Evisceración vaginal. Abordaje abdominal y reparación con malla sintética / Vaginal evisceration. Abdominal approach and synthetic mesh repair

La evisceración vaginal espontánea es un fenómeno raro en la práctica clínica diaria. Se han publicado más de 70 casos hasta la actualidad desde que McGregor comunicara el primer caso a comienzos del siglo pasado. La situación ocurre generalmente en pacientes posmenopáusicas con hipoestrogenismo asociado a cirugía ginecológica previa. Recientemente, se ha descrito también en situaciones no ginecológicas tras una proctectomía perineal. Presentamos un nuevo caso de evisceración vaginal espontánea en una mujer posmenopáusica con cirugía ginecológica previa. La reparación se efectuó con malla a través de una laparotomía convencional (AU)

Spontaneous vaginal evisceration is a rare phenomenon in daily clinical practice. Since McGregor reported the first case at the beginning of the past century, more than 70 cases have been reported to date. Spontaneous vaginal evisceration usually occurs in patients with postmenopausal hypoestrogenism associated with previous gynecologic surgery. This entity has recently been described in non-gynecological conditions after perineal proctectomy. We present a new case of spontaneous vaginal evisceration in a postmenopausal woman with previous gynecological surgery. Surgical mesh repair was performed through conventional laparotomy (AU)

Utilidad de la colangiografía por resonancia magnética previa a la colecistectomía en la pancreatitis aguda biliar / Utility of magnetic resonance cholangiography prior to cholecystectomy in acute biliary pancreatitis

Objetivo. Análisis del papel de la colangiografía por resonancia magnética (C-RM) en pacientes candidatos a colecistectomía profiláctica tras pancreatitis aguda (PA) biliar. Material y método. Estudio prospectivo de pacientes con PA moderada (criterios de Atlanta), ingresados en nuestro hospital entre enero 2004 y marzo 2005. Se diagnosticó PA biliar mediante clínica compatible, elevación de amilasa sérica mayor al triple del límite superior y ecografía de colelitiasis. Se practicó C-RM en todos los pacientes incluidos. El diagnóstico por C-RM de litiasis de vía biliar (LVB) fue seguido de colangiopancreatografía retrógrada endoscópica (CPRE) y esfinterotomía endoscópica (EE), y luego colecistectomía laparoscópica (CL). A la C-RM negativa siguió directamente una CL. No se realizó colangiografía intraoperatoria de forma sistemática. Resultados. De 31 pacientes ingresados se incluyó a 27 (edad media, 66,4 ± 18 años; un 78% mujeres). Cuatro pacientes fueron excluidos: 2 rechazaron colecistectomía y 2 por PA grave. El intervalo de espera media entre pancreatitis y colecistectomía fue de 1,7 ± 1,2 meses. Tres pacientes (11,1%) sufrieron recurrencia, todos en las primeras 4 semanas. Cuatro pacientes (14,8%) presentaron LVB en C-RM. La CPRE con EE extrajo la totalidad de cálculos en 3. En 1 caso se extrajeron 12 cálculos de vía biliar, pero fue imposible la litiasis en el conducto cístico. Hubo 1 caso de LVB precolecistectomía que presentó re-currencia a las 4 semanas de la colecistectomía. Otro paciente con C-RM negativa también sufrió una PA poscolecistectomía. Veinticinco de 27 pacientes (93%) han permanecido asintomáticos (mediana, 16 meses; rango, 8-22 meses). Conclusiones. La C-RM en pacientes con PA biliar previamente a la CL no debe practicarse de manera sistemática. Es un método adecuado para pacientes seleccionados con esta patología (AU)

Aim. To analyze the role of magnetic resonance cholangiography (MRC) in candidates for cholecystectomy after acute biliary pancreatitis (ABP). Methods. We performed a prospective study of patients with mild ABP (Atlanta criteria) admitted to our hospital from January 2004 to March 2005. Diagnosis of ABP was based on clinical features, serum amylase levels more than 3 times higher than the upper level of normality, and gallstones detected by ultrasonography. In all patients, MRC was performed preoperatively. If positive for common bile duct stones (CBDS), endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was performed, followed by laparoscopic cholecystectomy (LC). When MRC was negative, LC was performed directly. Intraoperative cholangiography was not routinely performed . Results. Of the 31 patients admitted, 27 were included (mean age 66.4 ± 18 years, 78% female). Four patients were excluded: 2 refused to undergo cholecystectomy and two had severe ABP. The mean interval between onset of ABP and cholecystectomy was 1.7 months ± 1.2. Three patients (11.1%) experienced recurrence within 4 weeks of the index admission. MRC revealed CBDS in four patients (14.8%). In 3 patients, all the gallstones were removed by ERCP and ES. In one patient, 12 gallstones were retrieved but attempts to remove a stone from the cystic duct were unsuccessful. One patient with preoperative CBDS was readmitted 4 weeks after cholecystectomy due to recurrence. Another patient with negative findings on preoperative MRC was also readmitted with postcholecystectomy ABP. Twenty-five of the 27 patients (93%) have remained asymptomatic after cholecystectomy (median follow-up: 16 months [8-22 months]). Conclusions. MRC should not be routinely used in the preoperative evaluation of patients with ABP but is an accurate tool in selected patients with this disease (AU)

[Utility of magnetic resonance cholangiography prior to cholecystectomy in acute biliary pancreatitis]. / Utilidad de la colangiografía por resonancia magnética previa a la colecistectomía en la pancreatitis aguda biliar.

AIM: To analyze the role of magnetic resonance cholangiography (MRC) in candidates for cholecystectomy after acute biliary pancreatitis (ABP). METHODS: We performed a prospective study of patients with mild ABP (Atlanta criteria) admitted to our hospital from January 2004 to March 2005. Diagnosis of ABP was based on clinical features, serum amylase levels more than 3 times higher than the upper level of normality, and gallstones detected by ultrasonography. In all patients, MRC was performed preoperatively. If positive for common bile duct stones (CBDS), endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was performed, followed by laparoscopic cholecystectomy (LC). When MRC was negative, LC was performed directly. Intraoperative cholangiography was not routinely performed . RESULTS: Of the 31 patients admitted, 27 were included (mean age 66.4 +/- 18 years, 78% female). Four patients were excluded: 2 refused to undergo cholecystectomy and two had severe ABP. The mean interval between onset of ABP and cholecystectomy was 1.7 months +/- 1.2. Three patients (11.1%) experienced recurrence within 4 weeks of the index admission. MRC revealed CBDS in four patients (14.8%). In 3 patients, all the gallstones were removed by ERCP and ES. In one patient, 12 gallstones were retrieved but attempts to remove a stone from the cystic duct were unsuccessful. One patient with preoperative CBDS was readmitted 4 weeks after cholecystectomy due to recurrence. Another patient with negative findings on preoperative MRC was also readmitted with postcholecystectomy ABP. Twenty-five of the 27 patients (93%) have remained asymptomatic after cholecystectomy (median follow-up: 16 months [8-22 months]). CONCLUSIONS: MRC should not be routinely used in the preoperative evaluation of patients with ABP but is an accurate tool in selected patients with this disease.

Effects of PEEP on residual vascularization in oesophageal substitution gastroplasty by surface oximetry-capnometry and photoplethysmography: an experimental study.

OBJECTIVE: To evaluate the effects of positive end-expiratory pressure (PEEP) on residual vascularization in gastric tubes for oesophageal replacement. DESIGN: Experimental open study. MATERIALS: Eleven mongrel dogs. METHODS: Intestinal parietal blood flow was evaluated by photoplethysmography (PPG) and measurement of surface oxygen (PsO(2)) and carbon dioxide (PsCO(2)) tensions under basal conditions. After Akiyama's tubular gastroplasty, three levels of PEEP were administered. At each level, fluids were infused to counter the drop in cardiac output. PPG, surface gas tensions, arterial pressure, cardiac output and arterial blood gas tensions were monitored. Control sections of the bowel were also monitored by PPG. RESULTS: Cardiac output dropped for each level of PEEP and returned to basal levels on volume restabilization and on removal of PEEP. Central venous pressure and pulmonary arterial and capillary pressures increased for each level of PEEP and only returned to basal levels on removal of PEEP. PsO(2) values dropped for each level of PEEP and returned to basal levels on volume restabilization and on removal of PEEP. PsCO(2) levels rose, and PPG wave amplitude dropped, for each level of PEEP; these two variables only returned to basal levels on removal of PEEP. PPG values for the control sections reflected those of the anastomotic area. CONCLUSIONS: PEEP affects surface oxygen values at the level of the gastroplasty by means of its effect on cardiac output. PEEP also creates a venous return compromise and PPG wave amplitude and surface carbon dioxide values are related to this compromise. All three variables could be significant in anastomotic wound healing.