Recurrence and virulence of colonic diverticulitis in immunocompromised patients.

BACKGROUND: To evaluate the probability of recurrence and the virulence of colonic diverticulitis correlated with immunocompromised status. METHODS: Nine hundred thirty-one patients admitted in a single tertiary referral university hospital over a 14-year period were included. Patients were divided into 2 groups: group 1, 166 immunosuppressed patients, and group 2, 765 nonimmunosuppressed patients. The variables studied were sex, age, American Society of Anesthesiologist status, reasons of immunosuppression (eg, chronic use of corticosteroids, transplant recipients, and diseases affecting the immune system), severity of the diverticulitis episode, recurrence, emergency and elective surgery, and morbidity and mortality rates. RESULTS: Two hundred thirteen patients underwent an emergency operation during the first hospitalization and 26 patients in further episodes. One hundred thirty-six patients developed 1 or more recurrent episodes of diverticulitis. The overall recurrence rate was similar in both groups. Patients in group 1 with a severe first episode presented significantly higher rates of recurrence and severity without needing more emergency surgery. Mortality after emergency surgery was 33.3% in group 1 and 15.9% in group 2 (P = .004). CONCLUSIONS: After successful medical treatment of acute diverticulitis, patients with immunosuppression need not be advised to have an elective sigmoidectomy.

Generalized peritonitis due to perforated diverticulitis: Hartmann's procedure or primary anastomosis?

PURPOSE: Hartmann's procedure (HP) still remains the most frequently performed procedure for diffuse peritonitis due to perforated diverticulitis. The aims of this study were to assess the feasibility and safety of resection with primary anastomosis (RPA) in patients with purulent or fecal diverticular peritonitis and review morbidity and mortality after single stage procedure and Hartmann in our experience. METHODS: From January 1995 through December 2008, patients operated for generalized diverticular peritonitis were studied. Patients were classified into two main groups: RPA and HP. RESULTS: A total of 87 patients underwent emergency surgery for diverticulitis complicated with purulent or diffuse fecal peritonitis. Sixty (69%) had undergone HP while RPA was performed in 27 patients (31%). At the multivariate analysis, RPA was associated with less post-operative complications (P < 0.05). Three out of the 27 patients with RPA (11.1%) developed a clinical anastomotic leakage and needed re-operation. CONCLUSIONS: RPA can be safely performed without adding morbidity and mortality in cases of diffuse diverticular peritonitis. HP should be reserved only for hemodynamically unstable or high-risk patients. Specialization in colorectal surgery improves mortality and raises the percentage of one-stage procedures.

Valor de los índices de Charlson y la escala de riesgo quirúrgico en el análisis de la mortalidad operatoria / Charlson index and the surgical risk scale in the analysis of surgical mortality

Introducción: Existe controversia sobre cómo valorar los riesgos de mortalidad quirúrgica tras distintas intervenciones. El objetivo de este estudio es valorar los factores operatorios que influyeron en la mortalidad quirúrgica y la capacidad de los índices de Charlson y la Escala de Riesgo Quirúrgico (SRS) en determinar los pacientes de bajo riesgo. Material y métodos: Se incluyeron todos los pacientes que fallecieron en el periodo 2004–2007. Se recogió la puntuación de ambos índices. Se escogió el punto de división entre baja y alta probabilidad de muerte una puntuación de «0» para el índice de Charlson y de «8» para el SRS. Se han establecido tres grupos de riesgo: bajo, cuando el Charlson fue=0 y el SRS fue <8 intermedio cuando el charlson fue 0 y SRS <8 o charlson y srs 8805 8 alto cuando el fue 0 y el SRS ≥8. Se han comparado los factores de riesgo pre-intra-postoperatorios entre los grupos. Resultados: Se intervinieron 72.771 pacientes, de los cuales 7.011 lo fueron en régimen de urgencia. Fallecieron uno de cada 1.455 pacientes en el intraoperatorio y 1 de cada 112 pacientes durante su ingreso hospitalario. Trece (2%) pacientes fallecidos pertenecían al grupo bajo riesgo, 199 (30,7%) al de riesgo intermedio y 434 (67,2%) al de riesgo alto. Se asoció enfermedad cardiaca al grupo de alto riesgo. La urgencia fue un factor determinante que se asoció a la complejidad quirúrgica. En el grupo de bajo riesgo predominó la reintervención y la sepsis como causa de muerte; para el resto de grupos predominó la causa cardiaca. Conclusiones: La combinación del índice de Charlson y el SRS, detectó aquellos pacientes de bajo riesgo de muerte siendo una herramienta útil para auditar los resultados operatorios (AU)

Introduction: There is controversy over how to assess surgical mortality risks after different operations. The purpose of this study was to assess the surgical factors that influenced surgical mortality and the ability of the Charlson Index and The Surgical Risk Scale (SRS) to determine low risk patients. Material and methods: All patients who died during the period 2004–2007 were included. The score of both indices (Charlson and SRS) were recorded. A score of «0» for the Charlson Index and «8» for the SRS were chosen as the cut-off point between a low and high probability of death. Three risk groups were established: Low when the Charlson was =0 and SRS was <8 intermediate when the charlson was 0 and the SRS <8 or charlson and srs 8805 8 high when the was 0 and the SRS ≥8. The risks factors before, during and after surgery were compared between the groups. Results: A total of 72,771 patients were surgically intervened, of which 7011 were urgent. One in every 1455 patients died during surgery and 1 in every 112 died during their hospital stay. Thirteen (2%) patients who died belonged to the low risk group, 199 (30.7%) to the intermediate risk group, and 434 (67.2%) to the high risk group. Heart disease was associated with the high risk group. The urgency of the operation was a determining factor associated with surgical complexity. Re-intervention and sepsis predominated as a cause of death in the low risk group, and in the rest of the groups a cardiac cause was the predominant factor. Conclusions: The combination of the Charlson Index and SRS detected those patients with a low risk of death, thus making it a useful tool to audit surgical results (AU)

[Charlson index and the surgical risk scale in the analysis of surgical mortality]. / Valor de los índices de Charlson y la escala de riesgo quirúrgico en el análisis de la mortalidad operatoria.

INTRODUCTION: There is controversy over how to assess surgical mortality risks after different operations. The purpose of this study was to assess the surgical factors that influenced surgical mortality and the ability of the Charlson Index and The Surgical Risk Scale (SRS) to determine low risk patients. MATERIAL AND METHODS: All patients who died during the period 2004-2007 were included. The score of both indices (Charlson and SRS) were recorded. A score of «0¼ for the Charlson Index and «8¼ for the SRS were chosen as the cut-off point between a low and high probability of death. Three risk groups were established: Low when the Charlson was =0 and SRS was <8; Intermediate when the Charlson was >0 and the SRS <8 or Charlson=0 and SRS ≥8; and high when the Charlson was>0 and the SRS ≥8. The risks factors before, during and after surgery were compared between the groups. RESULTS: A total of 72,771 patients were surgically intervened, of which 7011 were urgent. One in every 1455 patients died during surgery and 1 in every 112 died during their hospital stay. Thirteen (2%) patients who died belonged to the low risk group, 199 (30.7%) to the intermediate risk group, and 434 (67.2%) to the high risk group. Heart disease was associated with the high risk group. The urgency of the operation was a determining factor associated with surgical complexity. Re-intervention and sepsis predominated as a cause of death in the low risk group, and in the rest of the groups a cardiac cause was the predominant factor. CONCLUSIONS: The combination of the Charlson Index and SRS detected those patients with a low risk of death, thus making it a useful tool to audit surgical results.

Factores de riesgo de mortalidad de los pacientes quirúrgicos en un hospital terciario: estudio del registro de pacientes en el periodo 2004¿2006 / Mortality risk factors in surgical patients in a tertiary hospital: a study of patient records in the period 2004¿2006

Objetivo: Determinar los factores de riesgo de mortalidad de los pacientes quirúrgicos. Material y métodos: Se incluyó a todos los pacientes operados que fallecieron en el curso del procedimiento peroperatorio en el periodo 2004¿2006. Se realizó un estudio de corte transversal. Se analizaron variables preoperatorias, intraoperatorias y postoperatorias. Se han analizado los factores de riesgo de muerte en los pacientes intervenidos de urgencia y en los intervenidos electivamente. Se ha realizado un análisis multivariable correlacionando las diferentes variables mediante la prueba de la χ2 de Pearson con un intervalo de confianza del 95%. Resultados: Durante el periodo que abarca el estudio fueron intervenidos 38.815 pacientes con ingreso hospitalario: 6.326 de urgencia y 32.489 de forma electiva. Durante el ingreso hospitalario murió un total de 479 pacientes; 36 intraoperatoriamente y 443 tras la intervención quirúrgica. La hipertensión arterial, la diabetes mellitus y el diagnóstico de neoplasia tuvieron significación estadística con la muerte. Las complicaciones quirúrgicas resultaron significativas para los pacientes que fallecieron en el intraoperatorio. La cirugía de urgencia es un factor de riesgo independiente de mortalidad (5,5% de mortalidad en relación con el 0,4% para la cirugía electiva). Las complicaciones postoperatorias fueron los principales factores de riesgo de mortalidad, en especial la sepsis, los problemas cardíacos y los respiratorios. Conclusiones: La prevención y el correcto tratamiento de todos los factores de riesgo preoperatorios, intraoperatorios y postoperatorios se presume disminuirían de forma significativa los índices de mortalidad y morbilidad de los pacientes intervenidos quirúrgicamente, en especial en aquellos intervenidos de urgencia (AU)

Objective: To determine mortality risk factors in surgical patients. Material and method: A cross-sectional study was carried out on all surgical patients who died while in hospital, over a period of three years (2004¿2006). Pre, intra and postoperative variables were analysed. Comparisons were made between patients operated on as emergencies and elective surgery patients. Multivariate analysis was performed on the pre, intra and postoperative variables, using χ2 of Pearson correlation with a confidence interval of 95%. Results: Surgery was performed on a total of 38 815 patients, of which 6 326 were emergency procedures and 32 489 as elective. There were 479 deaths registered: 36 occurred in the operating theatre and 443 died after the operation. Arterial hypertension, diabetes mellitus and cancer were significant causes of death. Intraoperative complications were associated with mortality during the surgical procedure. Emergency surgery was an independent risk factor (mortality, 5.5% vs. 0.4% for elective surgery). Sepsis, cardiac and respiratory related deaths were the main risk factors for postoperative death. Conclusions: Prevention and adequate treatment of perioperative risk factors should significantly reduce morbidity and mortality rates, mainly in those patient operated as emergencies (AU)

[Mortality risk factors in surgical patients in a tertiary hospital: a study of patient records in the period 2004-2006]. / Factores de riesgo de mortalidad de los pacientes quirúrgicos en un hospital terciario: estudio del registro de pacientes en el periodo 2004-2006.

OBJECTIVE: To determine mortality risk factors in surgical patients. MATERIAL AND METHOD: A cross-sectional study was carried out on all surgical patients who died while in hospital, over a period of three years (2004-2006). Pre, intra and postoperative variables were analysed. Comparisons were made between patients operated on as emergencies and elective surgery patients. Multivariate analysis was performed on the pre, intra and postoperative variables, using chi(2) of Pearson correlation with a confidence interval of 95%. RESULTS: Surgery was performed on a total of 38 815 patients, of which 6 326 were emergency procedures and 32 489 as elective. There were 479 deaths registered: 36 occurred in the operating theatre and 443 died after the operation. Arterial hypertension, diabetes mellitus and cancer were significant causes of death. Intraoperative complications were associated with mortality during the surgical procedure. Emergency surgery was an independent risk factor (mortality, 5.5% vs. 0.4% for elective surgery). Sepsis, cardiac and respiratory related deaths were the main risk factors for postoperative death. CONCLUSIONS: Prevention and adequate treatment of perioperative risk factors should significantly reduce morbidity and mortality rates, mainly in those patient operated as emergencies.

Mutations in TP53 are a prognostic factor in colorectal hepatic metastases undergoing surgical resection.

The aim of this study was to analyze the prognostic value of TP53 mutations in a consecutive series of patients with hepatic metastases (HMs) from colorectal cancer undergoing surgical resection. Ninety-one patients with liver metastases from colorectal carcinoma were included. Mutational analysis of TP53, exons 4-10, was performed by single-strand conformation polymorphism and sequencing. P53 and P21 protein immunostaining was assessed. Multivariate Cox models were adjusted for gender, number of metastasis, resection margin, presence of TP53 mutations and chemotherapy treatment. Forty-six of 91 (50.05%) metastases showed mutations in TP53, observed mainly in exons 5-8, although 14.3% (n = 13) were located in exons 9 and 10. Forty percent (n = 22) were protein-truncating mutations. TP53 status associated with multiple (> or =3) metastases (65.6%, P = 0.033), advanced primary tumor Dukes' stage (P = 0.011) and younger age (<57 years old, P = 0.03). Presence of mutation associated with poor prognosis in univariate (P = 0.017) and multivariate Cox model [hazard ratio (HR) = 1.80, 95% confidence interval (CI) = 1.07-3.06, P = 0.028]. Prognostic value was maintained in patients undergoing radical resection (R0 series, n = 79, P = 0.014). Mutation associated with a worse outcome in chemotherapy-treated patients (HR = 2.54, 95% CI = 1.12-5.75, P = 0.026). The combination of > or =3 metastases and TP53 mutation identified a subset of patients with very poor prognosis (P = 0.009). P53 and P21 protein immunostaining did not show correlation with survival. TP53 mutational status seems to be an important prognostic factor in patients undergoing surgical resection of colorectal cancer HMs.

Anastomotic dehiscence after resection and primary anastomosis in left-sided colonic emergencies.

PURPOSE: There is no consensus about the risk factors for anastomotic failure after elective or emergency colorectal surgery. The purpose of this study was to analyze the factors that may contribute in anastomotic dehiscence. METHODS: A total of 208 patients who underwent left colonic resection and primary anastomosis for distal colonic emergencies were studied. Preoperative and operative variables analyzed for each patient were gender, age, American Society of Anesthesiologists score, comorbidities, indication for surgery, etiology of the disease, presence and grade of peritonitis, preoperative creatinine, hematocrit, hemoglobin, and leukocyte count, need for preoperative and operative transfusion. The end point was the clinical evident incidence of anastomotic leak. Bivariate comparisons of those patients with or without anastomotic leak were unpaired, and all tests of significance were two-tailed. A multivariate analysis, in which presentation of anastomotic leak was the dependent outcome variable, was performed by forward stepwise logistic regression model. RESULTS: One hundred five patients (50.4 percent) had one or more complications. Anastomotic leak was diagnosed in 12 patients (5.7 percent). Seventeen patients (8.2 percent) needed a reoperation for complication. The overall mortality was 6.2 percent (13 patients). Obesity was significant as a predictor of anastomotic leak. CONCLUSIONS: Obesity is a factor predicting anastomotic leak risk after resection and primary anastomosis for left-sided colonic emergencies.

A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer.

BACKGROUND: Although a significantly decreased long-term survival has been observed in patients undergoing surgery for complicated colorectal tumors compared with uncomplicated ones, the role of radical oncologic surgery on emergency colonic cancer is not defined clearly. The aim of this study was to analyze the efficacy of a curative emergency surgery in terms of tumor recurrence and cancer-related survival compared with elective colonic surgery. METHODS: Between January 1996 and December 1998, all patients with colonic cancer deemed to have undergone a curative resection were considered for inclusion in this prospective study. Patients were classified into 2 groups: group 1, after emergency surgery for complicated colonic cancer, and group 2, patients undergoing elective surgery. The main end points were cancer-related survival and the probability of being free from recurrence at 3 years. RESULTS: Of the 266 patients included in the study, 59 patients (22.2%) were in group 1 and 207 patients (77.8%) were in group 2. Postoperative mortality was higher in group 1 (P=.0004). After patients were stratified by the tumor node metastasis system, differences between the groups with respect to overall survival of stage II tumors (P=.0728), the probability of being free from recurrence (P=.0827), and cancer-related survival (P=.1071) of stage III cancers did not reach statistical significance. Differences were observed for the overall survival in stage III tumors (P=.0007), and for the probability of being free from recurrence (P=.0011) and cancer-related survival (P=.0029) in stage II cancers. When patients with elective stage II tumors presenting 1 or more negative prognostic factor were compared with emergency patients affected by a stage II colonic cancer, no differences were observed. CONCLUSION: Curative surgeries for complicated colonic cancer are acceptable in emergency conditions. Cancer-related survival and recurrence in patients with complicated colonic cancers may approach that of elective surgery if a surgical treatment with radical oncologic criteria is performed.

Proyecto nacional para la gestión clínica de procesos asistenciales. Tratamiento quirúrgico de la hernia inguinal / National project for the management of clinical processes. Surgical treatment of inguinal hernia

Introducción. La alta prevalencia del tratamiento quirúrgico de la hernia inguinal (procedimiento más frecuente en cirugía general) ha llevado a la Asociación Española de Cirujanos (AEC) a realizar un estudio a escala nacional dirigido a conocer los indicado-res más importantes. Objetivo. Análisis de la calidad asistencial en el tratamiento quirúrgico programado de la hernia inguinal, en el que se evalúa la calidad cientificotécnica, la eficiencia, la efectividad y la satisfacción del paciente. Material y métodos. Estudio prospectivo, longitudinal y descriptivo, desde el diagnóstico de la enfermedad hasta el seguimiento posterior. Se incluyó a pacientes intervenidos por hernia inguinal uni o bilateral, primarias o recidivas. Los criterios de exclusión fueron cirugía urgente y procedimientos quirúrgicos asociados. Se seleccionaron indicadores clínicos tras revisar la bibliografía científica. Resultados. Participaron 46 hospitales correspondientes a 16 comunidades autónomas que proporcionaron en total 386 casos. El seguimiento medio fue de 18 meses. La edad media de los pacientes fue de 56,33 años, el 88,3% varones. El 50,1% eran ASA I (grado marcado por la American Society of Anathesiologists). El 95,6% no cumplió las pautas del protocolo de pruebas preoperatorias de la AEC. Se empleó profilaxis antibiótica en el 75,39% y tromboembólica en el 40,04%. El 33,6% se intervino en régimen de (..) (AU)

Introduction. The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators. Objective. To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientifictechnical quality, efficiency, effectiveness, and patient satisfaction. Material and methods. A prospective, longitudinal, descriptive study from diagnosis to postoperative fo-llow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review. Results. Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was (..) (AU)

[National project for the management of clinical processes. Surgical treatment of inguinal hernia]. / Proyecto nacional para la gestión clínica de procesos asistenciales. Tratamiento quirúrgico de la hernia inguina.

INTRODUCTION: The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators. OBJECTIVE: To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientific-technical quality, efficiency, effectiveness, and patient satisfaction. MATERIAL AND METHODS: A prospective, longitudinal, descriptive study from diagnosis to postoperative follow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review. RESULTS: Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was performed in 33.6%. Local anesthesia and sedation only were used in 16.36% of the patients. The most frequently used surgical procedures involved mesh repair (Lichtenstein 50%, Rutkow-Robbins 17.1%), laparoscopy was used in 5.2% of the patients, and the Shouldice technique was used in 8.5%. The mean length of hospital stay was 47.5 hours in inpatients and was 11.65 hours in patients who underwent ambulatory surgery. Notable among the complications was hematoma in 11.6%. Ninety-six percent of the patients were satisfied or highly satisfied. The most highly scored items in the satisfaction survey were those related to information, personal dealings with staff, and the staffs kindness. The lowest scored items dealt with punctuality and accessibility. Follow-up at 18 months showed a recurrence rate of 4.11% with a total recovery time estimated by patients of 7.26 weeks. CONCLUSIONS: Analysis of the process revealed areas for improvement and strong points. Strong points consisted of up-to-date choice of surgical technique. The most frequently used techniques were tension-free procedures and the Shouldice technique. The following areas for improvement were identified: adherence to protocols for preoperative evaluation, increased use of ambulatory surgery, local anesthesia and sedation, appropriate use of antibiotic and thromboembolic prophylaxis in selected patients and a reduction in the length of hospital stay in inpatients. Patient satisfaction with the treatment was acceptable.

Large bowel obstruction: predictive factors for postoperative mortality.

PURPOSE: The aims of this study were to assess the prognostic value for mortality of several factors in patients with colonic obstruction and to study the differences between proximal and distal obstruction. METHODS: Two-hundred and thirty-four consecutive patients who underwent emergency surgery for colonic obstruction were studied. Patients with an obstructive lesion distal to the splenic flexure were assessed as having a distal colonic obstruction. Resection and primary anastomosis was the operation of choice in selected patients. Alternative procedures were Hartmann's procedure in high-risk patients, subtotal colectomy in cases of associated proximal colonic damage, and colostomy or intestinal bypass in the presence of irresectable lesions. Obstruction was considered proximal when the tumor was situated at the splenic flexure or proximally and a right or extended right colectomy was performed. A range of factors were investigated to estimate the probability of death: gender, age, American Society of Anesthesiologists score, nature of obstruction (benign vs. malign), location of the lesion (proximal vs. distal), associated proximal colonic damage and/or peritonitis, preoperative transfusion, preoperative renal failure, and laboratory data (hematocrit < or = 30 percent, hemoglobin < or = 10 g/dl, and leukocyte count >15,000/mm3). Univariate and multivariate forward steptwise logistic regression analysis was used to study the prognostic value of each significant variable in terms of mortality. RESULTS: One or more complications were detected in 109 patients (46.5 percent). Death occurred in 44 patients (18.8 percent). No differences were observed between proximal and distal obstruction. Age (>70 years), American Society of Anesthesiologists III-IV score, preoperative renal failure, and the presence of proximal colon damage with or without peritonitis were significantly associated with postoperative mortality in the univariate analysis. Only American Society of Anesthesiologists score, presence of proximal colon damage, and preoperative renal failure were significant predictors of outcome in multivariate logistic regression. CONCLUSION: Large bowel obstruction still has a high of mortality rate. An accurate preoperative evaluation of severity factors might allow stratification of patients in terms of their mortality risk and help in the decision-making process for treatment. Such an evaluation would also enable better comparison between studies performed by different authors. Principles and stratification similar to those of distal lesions should be considered in patients with proximal colonic obstruction.

[Survival and recurrence in the multidisciplinary approach of colorectal cancer]. / Supervivencia y recidiva en el tratamiento multidisciplinario del carcinoma colorrectal.

BACKGROUND AND OBJECTIVE: Colorectal cancer is one of the most frequent causes of death in the general population. Our aim was to analyze our experience in the multidisciplinary approach of colorectal carcinoma during a three year period. PATIENTS AND METHOD: Between January 1996 and December 1998, we studied prospectively 807 patients with colorectal cancer. The epidemiology, treatment and outcome(recurrence and survival) were analyzed. The minimum follow-up was 3 years. RESULTS: There were 598 colon (65.5%) and 279 rectal (34.5%) tumors in all the series. Surgical treatment was elective in 84% and urgent in 16%, and was considered radical in 598 cases (74.1%). Chemotherapy or radiotherapy was administered in 49.6% and 18.3% patients, respectively. The overall 3-year survival was as follows: stage I 97.5%, stage II 90.6%, stage III 75.2%, and stage IV 12.6%. The 3-year free-disease survival was as follows: in colon cancer 97.8% for stage I, 87.3% for stage II, and 71.4% for stage III; and in rectal cancer 96.8% for stage I, 85.1% for stage II, and 75.4% for stage III. During the follow-up 124 patients (20.7%) developed recurrence: local (2.8%), systemic (15.9%) or both (2%). The three-year survival in operated patients with liver metastases was 61.9%. CONCLUSIONS: We have observed adequate survival and recurrence rates which are the result are of systematic protocols established by a multidisciplinary team.

Protective effects of exogenous fructose-1,6-biphosphate during small bowel transplantation in rats.

BACKGROUND: We assessed the effect of adding exogenous fructose-1,6-biphosphate (F16BP) to the preservation solution (University of Wisconsin storage solution) used during an experimental procedure of small bowel transplantation in rats. METHODS: We studied levels of the nucleotides hypoxanthine/xanthine and adenosine in tissue after cold ischemia, as well as histologic changes and associated deleterious processes such as bacterial translocation produced by the reperfusion associated with the transplantation. RESULTS: The groups of rats treated with F16BP showed the lowest levels of hypoxanthine/xanthine and uric acid, the highest levels of adenosine, and the lowest levels of histologic damage and lactate dehydrogenase release to the bloodstream. Consumption of intestinal hypoxanthine during reperfusion was lowest in the groups treated with F16BP, as was the incidence of bacterial translocation. CONCLUSIONS: This study shows a protective effect of exogenous F16BP added to University of Wisconsin solution during experimental intestinal transplantation in rats. This protective effect, reflected by decreased intestinal damage and bacterial translocation, was related to a decrease in adenosine triphosphate depletion during cold ischemia before intestinal transplantation, and to the reduced availability of xanthine oxidase substrates for free radical generation during reperfusion.

Haemophagocytic syndrome after liver transplantation in adults.

The haemophagocytic syndrome is defined as a proliferation of phagocytic macrophages in the bone marrow, lymph nodes and spleen. Clinically, it is characterised by fever and pancytopenia. We present here a case of haemophagocytic syndrome after liver transplantation in a 63-year-old man who had undergone transplantation for autoimmune hepatitis. One month after liver transplantation, he developed ascites, fever and progressive pancytopenia. Bone marrow biopsy showed proliferation of non-neoplastic histiocytes, demonstrating phagocytosis of haemopoietic cells. No infectious or neoplasm-associated disease was found. Several kinds of treatment were attempted, but the course was fatal. The haemophagocytic syndrome is uncommon after liver transplantation, but this diagnosis has to be kept in mind in cases of pancytopenia of unknown origin.

Pretransplantation risk factors for graft loss after liver transplantation in cirrhotic patients; effect of cytomegalovirus serologic status.

This study analyzes the effect of the preoperative variables of donors and recipients on graft survival after liver transplantation (LT). Preoperative data from a cohort of 122 cirrhotic patients who underwent primary LT were evaluated prospectively. The influence of these variables as risk factors for graft loss was assessed. During follow-up (median: 33 (19-59) months) there were 38 (31.1%) graft losses (22 deaths and 16 retransplantations). Variables that showed statistical association with graft loss on univariate analysis (P<0.150) were: positivity of the CMV serologic status of the donor (P=0.028), the UNOS score of recipient (P=0.048) and advanced donor age (P=0.124). When these variables were introduced into the multivariate study, the CMV serologic status of the donor was the only variable that was independently associated with graft loss (relative risk=2.97, 95% confidence interval=1.05-8.39; P=0.039). Donor CMV-seropositivity is a significant pretransplantation determinant for graft loss in liver transplant recipients.

Administration of nitric oxide with caspase inhibitors minimizes bacterial translocation in experimental intestinal transplantation.

BACKGROUND: Bacterial translocation (BT) has been suggested to be responsible for the high incidence of infections occurring after small-bowel transplantation (Trp). Nitric oxide (NO) and apoptosis could affect cell demise. The aim of this study was to asses whether supplementation of University of Wisconsin (UW) solution with NO donors and apoptosis inhibitors can abolish BT in Trp. METHODS: The following experimental groups were studied: sham, Trp, intestinal transplantation, Trp+spermine NONOate (NONOs), and Trp+NONOs+caspase inhibitor Z-Val-Ala-Asp(Ome)-fluoromethylketone(Z-VAD-fmk). Histologic analysis, caspase-3 activity, DNA fragmentation, and BT from graft to mesenteric lymph nodes, liver, and spleen were measured in tissue samples after transplantation. RESULTS: During intestinal transplantation, apoptosis and necrosis were increased, showing graft injury and high levels of BT. The rats treated with NONOs showed a histologic protection of transplanted graft and a decrease in BT despite caspase-3 and DNA fragmentation-inducing effects. Administration of caspase inhibitor Z-VAD to NONOs-treated rats reversed the NO apoptosis-inducing effects and showed the lowest levels of BT in all tissues. CONCLUSIONS: Exogenous administration of NO associated with the inhibition of apoptosis maintains the graft in optimal conditions in terms of BT and improves the histology of the graft after intestinal transplantation in rats.

Spanish experience in liver transplantation for hilar and peripheral cholangiocarcinoma.

OBJECTIVE: To assess the real utility of orthotopic liver transplantation (OLT) in patients with cholangiocarcinoma, we need series with large numbers of cases and long follow-ups. The aim of this paper is to review the Spanish experience in OLT for hilar and peripheral cholangiocarcinoma and to try to identify the prognostic factors that could influence survival. SUMMARY BACKGROUND DATA: Palliative treatment of nondisseminated irresectable cholangiocarcinoma carries a zero 5-year survival rate. The role of OLT in these patients is controversial, due to the fact that the survival rate is lower than with other indications for transplantation and due to the lack of organs. METHODS: We retrospectively reviewed 59 patients undergoing OLT in Spain for cholangiocarcinoma (36 hilar and 23 peripheral) over a period of 13 years. We present the results and prognostic factors that influence survival. RESULTS: The actuarial survival rate for hilar cholangiocarcinoma at 1, 3, and 5 years was 82%, 53%, and 30%, and for peripheral cholangiocarcinoma 77%, 65%, and 42%. The main cause of death, with both types of cholangiocarcinoma, was tumor recurrence (present in 53% and 35% of patients, respectively). Poor prognosis factors were vascular invasion (P < 0.01) and IUAC classification stages III-IVA (P < 0.01) for hilar cholangiocarcinoma and perineural invasion (P < 0.05) and stages III-IVA (P < 0.05) for peripheral cholangiocarcinoma. CONCLUSIONS: OLT for nondisseminated irresectable cholangiocarcinoma has higher survival rates at 3 and 5 years than palliative treatments, especially with tumors in their initial stages, which means that more information is needed to help better select cholangiocarcinoma patients for transplantation.

Adrenalectomía laparoscópica: causas de conversión, experiencia personal y revisión de la bibliografía / Laparoscopi adrenalectomy: causes of conversion, personal experience and literature review

Introducción. La adrenalectomía laparoscópica es una opción que ofrece garantías y, asumiendo ciertas limitaciones, es la técnica de elección para el tratamiento quirúrgico de la glándula suprarrenal. Objetivos. Revisión de nuestros resultados en 77 adrenalectomías laparoscópicas, sus complicaciones y las causas de conversión a laparotomía, a partir de la bibliografía de reciente publicación. Pacientes y método. Desde septiembre de 1995 a mayo de 2003, realizamos 77 adrenalectomías laparoscópicas en 71 pacientes, con una edad media de 51 años. Se practicó una adrenalectomía bilateral en 6 pacientes, derecha en 30 ocasiones e izquierda en 35. El abordaje fue transperitoneal lateral en todos los casos excepto en el primero. Las indicaciones fueron: 22 aldosteronomas, 16 feocromocitomas, 17 incidentalomas, 6 metástasis y 10 hipercortisolismos. Resultados. El tamaño medio glandular fue de 6,1 cm y el peso medio de 56 g. De las 77 adrenalectomías, hubo 7 conversiones (9 por ciento) por causas relacionadas con la dificultad de disección de la masa adrenal y por una fisura esplénica. Las complicaciones de esta técnica en nuestra serie afectaron a 7 pacientes (9 por ciento), y fueron fundamentalmente hemorrágicas y aéreas. El tiempo medio de estancia postoperatoria fue de 2,5 días, excluidas las conversiones. No hubo mortalidad. Revisamos la bibliografía en series de más de 30 adrenalectomías por equipo quirúrgico desde 1995 a 2002. Las causas descritas de conversión fueron: experiencia del equipo quirúrgico (más de 10 adrenalectomías), tamaño adrenal (más de 10 cm) y diagnóstico (feocromocitomas, confirmación de neoplasia adrenal).Conclusiones. La adrenalectomía laparoscópica es una técnica segura y eficaz que ofrece los beneficios de la cirugía mínimamente invasiva, y acepta un índice de complicaciones del 6-25 por ciento y de conversiones del 4-21 por ciento, según las series (AU)

La asignatura virtual. "Fundamentos de Cirugía en Internet" / The virtual lecture. "Fundamentals of surgery in the Internet"

Introducción: Internet permite desarrollar un nuevo modelo de clase teórica basado en la enseñanza no presencial y asincrónica. Objetivo: Publicación virtual de un tema de "Fundamentos de Cirugía" y evaluación de los resultados de uso y participación de los 80 alumnos matriculados. Material y Métodos: Se diseñaron tres partes: teoría, cuestionario de autoevaluación, y foro de preguntas. La teoría consistía en hipertexto y gráficos, con cuatro tipos de asistentes de aprendizaje: 1) remarcadores de información esencial; 2) información no esencial adicional; 3) mnemotécnicos; 4) ampliación conceptos complejos. El cuestionario consistía en diez preguntas. La pantalla de respuesta ofrecía las respuestas correctas comentadas, la puntuación del alumno, y los centiles de cada nota. El foro de preguntas se basaba en el servidor Ez-Board. El profesor sólo explicó el sistema y los aspectos principales de la lección. Los alumnos podían consultar el material indefinidamente y el foro de preguntas estuvo activo durante dos meses. Resultados: El sistema facilitó la clase por parte del profesor y fue muy bien recibida por los alumnos. Se contabilizaron 239 visitas en dos meses, originadas en la Universidad en 80 por ciento de los casos. 16 alumnos usaron el asistente interactivo explicativo. El cuestionario fue respondido por 52 alumnos: 36 alumnos 1 vez y 16 alumnos 2 o más veces. El foro recibió 337 visitas. Se hicieron 38 preguntas de alumnos y 46 respuestas del profesor y otros especialistas. Conclusiones: 1) Diseño y funcionamiento correcto; 2) Excelente acogida y participación; 3) Probable mejora en el aprendizaje y adquisición de conocimientos (AU)