Bowel ischaemia and cocaine consumption; case study and review of the literature.

BACKGROUND: Amongst others, cocaine consumption has a detrimental effect in the vascular supply to the mesenteric area causing abdominal ischemic changes. Early recognition of these changes and adequate treatment are essential to avoid serious complications and possible death of the patient from sepsis. CASE REPORT: In this case study, the subject is a 40-years-old gentleman presenting with acute abdominal pain due to multiple ischemic changes in both small bowel and sigmoid loops. The patient required emergency surgical intervention consisting of bowel resection and anastomosis. The pathologic analysis of the segment showed transmural necrosis and necrotizing phlebitis caused by the ingestion of drugs or toxic agents. The patient later confirmed the habitual consumption of cocaine. DISCUSSION: The increase in cocaine consumption and other recreational toxins substructed from erythroyilon coca alkaloids amongst young people have generated a large number of admissions to Hospital Accident and Emergency Departments with patients complaining of acute abdominal pain. In many of these cases, surgical intervention is required and in some cases patients will sadly die without a proper diagnosis. Some of the most common effects of cocaine and its compounds includes; hollow viscus perforation, gastro-intestinal bleed, and other vascular problems such as enteritis and ischemic colitis. It appears clear that there is a great need for an advance history taking of these patients and their habit to cocaine and other drugs together with a urine test for drug screening. These together with a suspicion of a non- occlusive ischemic bowel caused by the effects of cocaine in young adults with no cardiac risk factors will guide clinicians and establish, and plan the correct treatment for these categories of patients.

Isquemia intestinal y consumo de cocaína; presentación de un caso y revisión de la literatura / Bowel ischaemia and cocaine consumption; case study and review of the literature

Introducción: entre los efectos nocivos del consumo de cocaína se incluyen los producidos a nivel de la vascularización mesentérica, instaurándose en forma de cuadros abdominales isquémicos de potencial gravedad que, si no son diagnosticados y tratados adecuada y precozmente, conllevan complicaciones serias e incluso a la muerte por sepsis. Caso clínico: presentamos el caso de un hombre de 40 años que fue intervenido de urgencias por abdomen agudo secundario a isquemia segmentaria múltiple de asas de delgado y sigmoides. Se realizó resección intestinal y anastomosis. La anatomía patológica del segmento describió hallazgos compatibles con necrosis transmural y flebitis necrotizante producida por el efecto de drogas o tóxicos; el paciente confirmó el consumo previo y habitual de cocaína. Discusión: la difusión entre la población generalmente joven, del consumo de este y de otros tóxicos derivados de los alcaloides de la Erythroyilon coca, ha condicionado un incremento de las consultas en urgencias por dolor abdominal agudo; generalmente, en muchos de estos casos, los pacientes se intervienen quirúrgicamente sin diagnóstico o lo que es más grave, fallecen sin el mismo. Entre los efectos adversos a nivel gastrointestinal de la cocaína y sus derivados, se encuentran la perforación de víscera hueca, la hemorragia digestiva, y los problemas vasculares en forma de enteritis y colitis isquémica. Sería aconsejable un interrogatorio minucioso sobre el consumo de cocaína y otras drogas o la solicitud de su presencia en orina, y la sospecha clínica de una isquemia intestinal no oclusiva originada por cocaína en aquellos adultos jóvenes sin factores de riesgo cardiovascular, sobre todo con vistas a planificar el correcto tratamiento (AU)

Background: Amongst others, cocaine consumption has a detrimental effect in the vascular supply to the mesenteric area causing abdominal ischemic changes. Early recognition of these changes and adequate treatment are essential to avoid serious complications and possible death of the patient from sepsis. Case report: In this case study, the subject is a 40-years-old gentleman presenting with acute abdominal pain due to multiple ischemic changes in both small bowel and sigmoid loops. The patient required emergency surgical intervention consisting of bowel resection and anastomosis. The pathologic analysis of the segment showed transmural necrosis and necrotizing phlebitis caused by the ingestion of drugs or toxic agents. The patient later confirmed the habitual consumption of cocaine. Discussion: The increase in cocaine consumption and other recreational toxins substructed from erythroyilon coca alcaloids amongst young people have generated a large number of admissions to Hospital Accident and Emergency Departments with patients complaining of acute abdominal pain. In many of these cases, surgical intervention is required and in some cases patients will sadly die without a proper diagnosis. Some of the most common effects of cocaine and its compounds includes; hollow viscus perforation, gastro-intestinal bleed, and other vascular problems such as enteritis and ischemic colitis. It appears clear that there is a great need for an advance history taking of these patients and their habit to cocaine and other drugs together with a urine test for drug screening. These together with a suspicion of a non- occlusive ischemic bowel caused by the effects of cocaine in young adults with no cardiac risk factors will guide clinicians and establish, and plan the correct treatment for these categories of patients (AU)

[Application of new technologies to the teaching of surgery in the school of medicine]. / Aplicación de las nuevas tecnologías en la enseñanza de la cirugía en la licenciatura de medicina.

INTRODUCTION: The new methods of teaching, based on new technologies, already available in other educational and professional fields are gradually being introduced in our Medical Schools. The aim of our study is to present our initial experience in the introduction of a subject on the principles of surgery in our university. MATERIAL AND METHODS: The subject was offered voluntary to undergraduate students, with a maximum of 65 students per course during two consecutive academic years, while maintaining the traditional teaching with a formal lecture program with a different lecturer. The subject was designed with 60% virtuality on a WebCT platform and later in Moodle. The virtual subject was structured into teaching units, academically directed activities and communication tools. The subject was assessed in a report prepared by Cadiz University Department of Evaluation and Quality. RESULTS: There were 32 students in the 2005-2006 course and 62 in the following course. The mean activity of the students was: 602 accesses, 13 subjects for discussion forums and 20 e-mails between students and teachers. The students who participated in the Virtual subject have remarked that virtualisation make it more attractive and is an aid in the acquisition of knowledge. The data obtained from the report showed better results than the mean obtained in other subjects of the Department, School of Medicine and Cadiz University. CONCLUSIONS: The virtual subject of principles of surgery has been well evaluated in our university campus. We believe that the provision of teaching tools and new communication models make an effective contribution to the teaching of surgery as a subject in the school of medicine curriculum.

Aplicación de las nuevas tecnologías en la enseñanza de la cirugía en la licenciatura de medicina / Application of new technologies to the teaching of surgery in the school of medicine

Introducción: Los nuevos métodos de enseñanza, basados en las nuevas tecnologías, ya adoptados en otros ámbitos educativos y profesionales, se van introduciendo progresivamente en las facultades de medicina. El objetivo de nuestro estudio es presentar nuestra experiencia inicial en la implantación de una asignatura de carácter semipresencial de fundamentos de cirugía. Material y métodos: La asignatura se ha ofrecido con carácter voluntario a los estudiantes, y mantiene el grupo de enseñanza tradicional con un profesor responsable distinto. La asignatura se planificó con un porcentaje de virtualidad del 60% en la plataforma virtual WebCT y, posteriormente, en la plataforma Moodle. La asignatura virtual se estructuró en unidades temáticas, actividades académicamente dirigidas y herramientas de comunicación. En la valoración de la asignatura se presentan los informes realizados por la Unidad de Calidad de la Universidad de Cádiz (UCA). Resultados: Se matricularon 32 alumnos en el curso 2005¿2006 y 62 alumnos en el siguiente curso. El promedio de actividad en el aula virtual por alumno fue: 602 accesos, 13 temas de discusión propuestos en los foros y 20 correos intercambiados entre alumnos y profesores. Los alumnos que han cursado la asignatura han señalado que la virtualización de la asignatura la convierte en más atractiva y contribuye a la adquisición de conocimientos. Los datos del informe sobre la docencia han sido mejores que la media del departamento, la facultad de medicina y la UCA. Conclusiones: La asignatura virtual de fundamentos de cirugía ha sido muy bien valorada dentro de nuestro ámbito universitario. Pensamos que las herramientas docentes ofrecidas y los nuevos modelos de comunicación contribuyen eficazmente a la enseñanza de la cirugía como disciplina dentro de la licenciatura de medicina (AU)

Introduction: The new methods of teaching, based on new technologies, already available in other educational and professional fields are gradually being introduced in our Medical Schools. The aim of our study is to present our initial experience in the introduction of a subject on the principles of surgery in our university. Material and methods: The subject was offered voluntary to undergraduate students, with a maximum of 65 students per course during two consecutive academic years, while maintaining the traditional teaching with a formal lecture program with a different lecturer. The subject was designed with 60% virtuality on a WebCT platform and later in Moodle. The virtual subject was structured into teaching units, academically directed activities and communication tools. The subject was assessed in a report prepared by Cadiz University Department of Evaluation and Quality. Results: There were 32 students in the 2005¿2006 course and 62 in the following course. The mean activity of the students was: 602 accesses, 13 subjects for discussion forums and 20 e-mails between students and teachers. The students who participated in the Virtual subject have remarked that virtualisation make it more attractive and is an aid in the acquisition of knowledge. The data obtained from the report showed better results than the mean obtained in other subjects of the Department, School of Medicine and Cadiz University. Conclusions: The virtual subject of principles of surgery has been well evaluated in our university campus. We believe that the provision of teaching tools and new communication models make an effective contribution to the teaching of surgery as a subject in the school of medicine curriculum (AU)

[Retroperitoneal sarcomas. Report of five new cases and review of the current situation]. / Sarcomas retroperitoneales. Aportación de cinco nuevos casos y revisión de la situación actual.

INTRODUCTION: Soft-tissue sarcomas represent a heterogeneous group of rare tumors arising from the mesenchymal cells of the connective tissue. Approximately 15% of these tumors arise in the retroperitoneum. These neoplasms are locally aggressive and the only curative treatment is surgical resection "en-bloc". The main cause of mortality is locoregional recurrence. Five-year survival is 3-58%, depending on the histologic subtype and grade. PATIENTS AND METHOD: Over a 5-year period (2001 to 2006), we performed surgery in five patients with retroperitoneal sarcomas. The mean age was 59 years (range, 46-76) with a male-to-female ratio of 3:2. The most frequent signs were abdominal pain and the appearance of a mass. In 2 patients, an incidental diagnosis was made during the surgical intervention. RESULTS: Surgical resection was performed in 5 patients but was incomplete in two patients. We removed 2 liposarcomas, 1 leiomyosarcoma, 1 chondrosarcoma and 1 fusocellular sarcoma arising in the kidney. Locoregional recurrence occurred in four patients, requiring between 1 and 2 new relaparotomies (using the retroperitoneal approach in 2 patients). There was one death. CONCLUSIONS: Retroperitoneal sarcomas are a heterogeneous group of tumors, in which the only common factor is the anatomical location. New randomized, prospective, multicenter trials are required to apply different therapeutic options according to the subtype of retroperitoneal sarcoma.

Sarcomas retroperitoneales. Aportación de cinco nuevos casos y revisión de la situación actual / Retroperitoneal sarcomas. Report of five new cases and review of the current situation

Introducción. Los sarcomas constituyen un grupo muy heterogéneo de tumores infrecuentes que se originan a partir de las células mesenquimales localizadas en el tejido conectivo. De éstos, el 15% es de localización retroperitoneal. Son tumores localmente agresivos cuyo único tratamiento curativo es la resección quirúrgica en bloque con márgenes libres. La principal causa de muerte es la recidiva locorregional. La supervivencia a los 5 años es de un 3-58%, y la evolución varía según el subtipo histológico y el grado de diferenciación del sarcoma. Pacientes y método. Desde 2001 hasta 2006, hemos operado 5 sarcomas retroperitoneales. La media de edad fue de 59 (46-76) años, con una proporción varones:mujeres de 3:2. El dolor y la masa abdominal fueron los signos iniciales más frecuentes. En 2 casos el diagnóstico se realizó incidentalmente en el acto quirúrgico. Resultados. Los 5 casos fueron resecados, si bien fue incompleta en 2. Resecamos 2 liposarcomas, 1 leiomiosarcoma, 1 condrosarcoma y 1 sarcoma fusocelular de origen renal; 4 pacientes refirieron recidiva local y precisaron entre 1 y 2 nuevas resecciones con intención curativa (en esa ocasión realizamos un abordaje retroperitoneal en 2 casos). Registramos una muerte. Conclusiones. Los sarcomas retroperitoneales constituyen un grupo muy heterogéneo de tumores que tienen como único dato común la localización. Creemos que deberían llevarse a cabo estudios prospectivos aleatorizados y multicéntricos para aplicar criterios terapéuticos distintos según el subtipo de sarcoma retroperitoneal (AU)

Introduction: Soft-tissue sarcomas represent a heterogeneous group of rare tumors arising from the mesenchymal cells of the connective tissue. Approximately 15% of these tumors arise in the retroperitoneum. These neoplasms are locally aggressive and the only curative treatment is surgical resection "en-bloc". The main cause of mortality is locoregional recurrence. Five-year survival is 3-58%, depending on the histologic subtype and grade. Patients and method. Over a 5-year period (2001 to 2006), we performed surgery in five patients with retroperitoneal sarcomas. The mean age was 59 years (range, 46-76) with a male-to-female ratio of 3:2. The most frequent signs were abdominal pain and the appearance of a mass. In 2 patients, an incidental diagnosis was made during the surgical intervention. Results. Surgical resection was performed in 5 patients but was incomplete in two patients. We removed 2 liposarcomas, 1 leiomyosarcoma, 1 chondrosarcoma and 1 fusocellular sarcoma arising in the kidney. Locoregional recurrence occurred in four patients, requiring between 1 and 2 new relaparotomies (using the retroperitoneal approach in 2 patients). There was one death. Conclusions. Retroperitoneal sarcomas are a heterogeneous group of tumors, in which the only common factor is the anatomical location. New randomized, prospective, multicenter trials are required to apply different therapeutic options according to the subtype of retroperitoneal sarcoma (AU)

Differences in polypropylene shrinkage depending on mesh position in an experimental study.

BACKGROUND: Polypropylene (PP) mesh is one of the most frequent materials used in hernia repair. We have experimentally evaluated the shrinkage of PP mesh depending on the place of implantation. METHODS: In 15 New Zealand rabbits a muscular defect measuring 3 x 3 cm was created in both pararectal sides of the abdominal wall. The defect was repaired using a PP mesh measuring 5 x 3.5 cm that was placed in the right side in the sublay location and in the left side in the onlay location. Five animals were killed on the 30th, 60th, and 90th postoperative days. Macroscopic measurement and microscopic study of the prosthesis-host tissue interfaces were performed. RESULTS: One rabbit was killed because of severe infection in the onlay mesh. Another 2 infections were tolerated in the onlay mesh side. All the prostheses were integrated in the host tissue at death. In the macroscopic evaluation the mesh areas were reduced by 25.92% on the 30th day, by 28.67% on the 60th day, and by 29.02% on the 90th day. The mesh shrinkage was greater in the onlay group than in the sublay group at the 3 time intervals. More inflammatory leukocyte and mononuclear responses also were seen in the onlay group. CONCLUSIONS: These observations support the theory of PP mesh shrinkage as a consequence of the incorporation of the biomaterial to the scarring tissue. This shrinkage is significantly more intense if the meshes are placed in the onlay position.

Seguimiento de la contracción de las mallas de polipropileno empleadas en la reparación de eventraciones / Surveillance of shrinkage of polypropylene mesh used in the repair of ventral hernias

Introducción. El polipropileno (PP) es uno de los biomateriales más empleados en la reparación quirúrgica de las eventraciones. Aunque se conoce bien su capacidad de integración tisular en el huésped, se discute si las mallas sufren un proceso de contracción que reduce su tamaño durante el mecanismo de incorporación al proceso de cicatrización del huésped. Objetivo. Cuantificar el proceso de contracción de las mallas de polipropileno. Pacientes y método. Se ha diseñado un estudio de seguimiento radiológico en 23 pacientes consecutivos operados de eventraciones de la línea media con un diámetro mínimo de 5 cm. Las mallas de polipropileno fueron marcadas con clips de titanio en sus ejes mayores transversal y longitudinal. Se realizaron radiografías seriadas el primer día del postoperatorio, al mes, y a los 3, 6 y 12 meses. Se midieron las distancias entre los clips y se calculó el área de la malla. Resultados. Se operó a 17 mujeres y 6 varones. En 9 pacientes la malla se colocó en el espacio supraponeurótico y en 14 en el espacio subaponeurótico. Se produjeron 4 seromas en los pacientes tratados con malla en situación supraponeurótica. La reducción del área calculada ha sido del 12% al mes, 24% a los 3 meses, 29% a los 6 meses y 34% a los 12 meses. Conclusiones. Las mallas de PP han ofrecido excelentes resultados clínicos. En el seguimiento radiológico se ha comprobado una contracción considerable de la malla, fundamentalmente, durante los primeros 3 meses tras el implante (AU)

Introduction. Polypropylene (PP) mesh is one of the most frequently used materials in the surgical repair of ventral hernias. Despite the widely recognized ability of PP to integrate into the host tissue, these meshes may shrink during the healing process in the patient. Objective. To quantify polypropylene mesh shrinkage. Patients and method. A radiological follow-up study was performed in 23 consecutive patients who underwent surgery for midline ventral hernias with diameters of at least 5 cm. PP meshes were marked with titanium clips at the ends of their longest transverse and longitudinal axes. X-rays were performed on the first postoperative day and at 1, 3, 6 and 12 months. The distances between clips were measured and the area of the mesh was calculated. Results. Seventeen women and six men underwent surgery. In nine patients the mesh was placed on the prefascial space (onlay) and in 14 in the subfascial space (sublay). There were four seromas in patients with mesh placed with the onlay technique. The reduction in the calculated area was 12% at 1 month, 24% at 3 months, 29% at 6 months and 34% at 12 months. Conclusions. PP mesh provided excellent clinical results. Radiological surveillance revealed substantial shrinkage, mainly in the first 3 months after implantation (AU)

[Surveillance of shrinkage of polypropylene mesh used in the repair of ventral hernias]. / Seguimiento de la contracción de las mallas de polipropileno empleadas en la reparación de eventraciones.

INTRODUCTION: Polypropylene (PP) mesh is one of the most frequently used materials in the surgical repair of ventral hernias. Despite the widely recognized ability of PP to integrate into the host tissue, these meshes may shrink during the healing process in the patient. OBJECTIVE: To quantify polypropylene mesh shrinkage. PATIENTS AND METHOD: A radiological follow-up study was performed in 23 consecutive patients who underwent surgery for midline ventral hernias with diameters of at least 5 cm. PP meshes were marked with titanium clips at the ends of their longest transverse and longitudinal axes. X-rays were performed on the first postoperative day and at 1, 3, 6 and 12 months. The distances between clips were measured and the area of the mesh was calculated. RESULTS: Seventeen women and six men underwent surgery. In nine patients the mesh was placed on the prefascial space (onlay) and in 14 in the subfascial space (sublay). There were four seromas in patients with mesh placed with the onlay technique. The reduction in the calculated area was 12% at 1 month, 24% at 3 months, 29% at 6 months and 34% at 12 months. CONCLUSIONS: PP mesh provided excellent clinical results. Radiological surveillance revealed substantial shrinkage, mainly in the first 3 months after implantation.