Perfiles hormonales de gastrina y secretina en pacientes sometidos a cirugía biliar / Gastrin and secretin hormone profiles in patients undergoing biliary surgery

Introducción. La pancreatitis postoperatoria es una complicación temida tras la intervención quirúrgica sobre la región biliopancreática. Entre los mecanismos patogénicos de la pancreatitis sigue especulándose alrededor de los secretagogos y, en concreto, sobre el papel de las hormonas estimuladoras de la secreción pancreática. Pacientes y método. Se realizó un estudio prospectivo en pacientes que iban a ser sometidos a cirugía biliar electiva por procesos benignos, determinándose la gastrina y secretina en el preoperatorio, a las 24 y 48 h del postoperatorio por técnicas de radioinmunoanálisis. Resultados. Quedaron incluidos 98 pacientes, 72 mujeres y 26 varones, con una edad media de 59 años. El perfil de la gastrinemia fue de 177 pg/ml en el preoperatorio, 186 pg/ml a las 24 h del postoperatorio y 172 pg/ml a las 48 h de éste; el perfil de la secretinemia proporcionó esta secuencia: 87, 86 y 84 pg/ml. Conclusiones. La cirugía sobre la vía biliar no modifica significativamente los valores hormonales de gastrina y secretina; aunque su liberación se sigue produciendo en concentraciones similares a las preoperatorias (AU)

Current management of colonic volvulus. Results of a treatment protocol.

Colonic volvulus affects mainly the geriatric population and is associated with a high number of complications when treated by emergency surgery. The development of alternative methods has replaced and reduced the number of traditional surgical procedures. We present the results of treatment of colonic volvulus in a surgical service in Alicante, Spain. Between 1993 and 1997 a total of 17 cases in 15 patients were diagnosed, 16 in the sigmoid colon and 1 in the cecum. In 9 (60%) patients endoscopic devolvulation was successful. In 2 (22%) of these patients the problem recurred, and was resolved by a second endoscopic treatment. Three patients (20%) required surgery, and 3 others (20%) were treated with radiological reduction (barium enema) and rectal catheter. The average hospital stay of patients treated with endoscopy and barium enema was 2-3 days, being 7 days in patients who underwent surgery. Management with endoscopy is initially effective in most cases of volvulus of the sigmoid colon. This procedure affords decompression and adequate preparation of selected patients for surgical resection, which is the treatment of choice and provides the greatest guarantee against subsequent recurrence.

[An experimental study of the efficacy of politetrafluoroethylene grafts in tracheal surgery]. / Estudio experimental de la eficacia de injertos de politetrafluoroetileno en cirugía traqueal.

We studied the efficacy of polytetrafluoroethylene (PTFE) grafts in the surgical correction of extensive tracheal defects in rabbits. Results showed anastomotic stenosis in 100% of the animals after primary reconstruction when a total of six complete rings were resected. We did not appreciate tracheal stenosis in no animal when we applied a PTFE prosthesis placed around the anastomotic site. Results were not satisfactory upon repairing partial tracheal defect by means of a spindle of PTFE prosthesis. We concluded that the external tutor is useful for the surgical correction of the tracheal stenosis induced after resection of six rings in the cervical tracheal of the animal.

[Management of colostomies with plug: clinical aspects and patient evaluation]. / Manejo de las colostomías mediante obturador: aspectos clínicos y evaluación de los pacientes.

AIM: To assess the effectiveness of the one-piece disposable plug device Conseal (Coloplast A/S, Espergaerd, Denmark) in colostomy patients, considering clinical and social aspects. PATIENTS AND METHODS: Twenty patients with definitive (perineal-abdominal amputation 17 cases) or transitory (Hartmann in 3 cases) colostomy were studied prospectively. No patient used self-irrigations. All of them completed the study. After obtaining the patient's consent, we analyzed for comfort, leaks, security, easy handling and skin conditions by means of personal interview and clinical examination. RESULTS: Sixteen patients (80%) had previously used conventional colostomy bags, 4 (20%) started to use the plug device during the postoperative period (average 8.7 days). Fifteen patients (75%) preferred to use the plug, whereas 5 (25%) considered the plug was insecure. CONCLUSIONS: Our study suggests that the one-piece disposable plug device improves the quality of life in patients with colostomy, although adequate selection of patients and previous training are mandatory.

Effect of atropine and truncal vagotomy on the exocrine pancreatic function in dogs stimulated with intraduodenal tryptophan.

The purpose of this experimental study was to analyze the effect of different doses of atropine and bilateral transthoracic truncal vagotomy on pancreatic secretion. We chose the dog as our experimental model and used the modified Thomas method to obtain gastric juice, removing the gastric acid with a gastric cannula. An additional duodenal cannula was used for the selective intubation of the greater pancreatic duct in order to obtain pure pancreatic juice. To stimulate pancreatic secretion the pancreas was stimulated with intravenous secretin at a constant dose and intraduodenal tryptophan at gradually increasing doses. The juice was collected at 10-min intervals and volume, output of bicarbonate and protein were determined. The results obtained show that low doses of atropine (0.65, 1.25 and 5 micrograms/kg/h) strengthen the suppressive effect of truncal vagotomy on the hydrobicarbonate secretion. Greatest suppression was found in the highest dosage of atropine in response to the intraduodenal tryptophane at gradually increasing doses. The above results suggest the possible existence of local enteropancreatic cholinergic reflexes that are readily suppressed by atropine and vagotomy. Suppression is not global though, since there is no significant reduction in the pancreatic protein secretion, which shows a dosage-effect curve in response to the gradually increasing doses of intraduodenal tryptophan released by the action of endogenous cholecystokinin. Our hypothesis is that there exists a nonvagal enteropancreatic cholinergic reflex.

[Hepatocarcinoma: a rare form of presentation]. / Hepatocarcinoma: forma infrecuente de presentación.

A case of acute abdomen presenting with pain in the right upper abdomen, pyrexia and leukocytosis is presented. At laparotomy, hepatocarcinoma with necrosis and associated acute cholecystitis was found. This is apparently an unusual report of hepatocarcinoma presenting as acute cholecystitis.

[The effects of verapamil in experimental acute pancreatitis in the rat]. / Efectos del verapamil en la pancreatitis aguda experimental de la rata.

Experimental studies have shown that verapamil inhibits pancreatic exocrine secretion. In order to determine whether verapamil has any effect on acute pancreatitis (AP), we undertook an experimental study in Wistar rats. We used 72 animals divided into two groups. In all animals of both experimental groups, AP was induced by ligation of the biliary duct at its entrance in the duodenum. Animals were given saline (NaCl 0.9%), or 0.30 mgrs/hour verapamil. Subgroups of 9 animals, were treated for 6, 12, 18 and 24 hours; 6 animals group were then sacrificed, for biochemical studies (serum amilase, lipase, and calcium; and trypsin and chemotrypsin in the homogenized pancreas); the other 3 animals were used for morphologic study of the pancreas. Verapamil treatment decreased significantly tissue activity of trypsin (p less than 0.001) and chemotrypsin (p less than 0.0001) and increased serum lipase (p less than 0.05), and calcium. There was no statistical difference in serum amylase. Morphological findings include oedema, acinar necrosis, hemorrhage and vasculitis in non treated animals. Only oedema was observed in animals treated with verapamil. These results suggest a beneficial effect of verapamil on experimental AP induced by ligation of the bile duct in the rat.

[Absence of effect of atropine on exocrine pancreatic secretion stimulated by cerulein]. / Ausencia de efecto de la atropina en la secreción pancreática exocrina estimulada con ceruleína.

The effect of atropine, 0.9, 1.8, 7 and 29 nmol/kg-1/h-1, on pancreatic exocrine secretion has been measured in seven dogs with gastric and pancreatic fistula in response to IV administration of increasing doses of cerulein (3.7 to 118 pmol/kg-1/h-1). Secretin was perfused continuously, at a rate of 20.5 pmol/kg-1/h-1, starting one hour before perfusion of cerulein. The administration of atropine, 7 and 29 nmol/kg-1/h-1, significantly (p less than 0.05) decreased the protein response to secretin. Only the injection of 29 nmol/kg-1/h-1 of atropine produced a significant decrease in the secretion of bicarbonate in response to secretin. The administration of 3.7 pmol./kg-1/h-1 and larger doses of cerulein significantly increased the secretion of bicarbonate and protein, compared to the levels obtained with the administration of secretin alone. None of the atropine doses showed a significant effect on the pancreatic response to the administration of cerulein. Only the highest dose of atropine, 29 nmol/kg-1/h-1, modified cardiac rate. These findings are consistent with the hypothesis that cholinergic innervation does not modify the effect of cerulein, a CCK analogue, on the pancreatic secretion of protein and bicarbonate in the dog.

[Immuno-nutritional prognostic factors in acute cholecystitis]. / Estudio de factores pronósticos inmunonutricionales en la colecistitis aguda.

A set of parameters that could be used to identify possible immunonutritional disturbances and serve as clinical evolution markers were measured in 210 patients diagnosed of acute cholecystitis (136 females and 74 males, 64.8 and 35.2% respectively) who were admitted into the Surgery Service of the Hospital General de 1++Elche. The prognostic evaluation indices were: a) Nutritional: hematocrit, hemoglobin, total protein, albumin, transferrin; b) Immunological: total lymphocytes and delayed hypersensitivity reaction test. The results obtained were analyzed and compared to those of the literature in this field.

[Hospital activities of surgery undergraduates]. / La actividad hospitalaria del pregraduado en cirugía.

A teaching-learning system of practices in Surgery named "Hospital Activity of undergraduates in surgery" has been performed over the last five academic courses in Alicante's Medical School. It is based on the stay and participation of 10 students over a 4 weeks period in the assistance tasks of one of the Teaching Hospital Surgery Department in the areas of: hospitalization, external visits and operating rooms. In order to fulfill the proposed teaching objectives a series of clinical sessions and special practices are performed. The hospital activity of 4 academic courses has been evaluated through the performance of a test addressed to the students and a evaluation using a multiple choice test. This educative method is accepted by the students although there are some aspects susceptible to be modified. A significant increase of knowledge between a pretest and a posttest (p less than 0.05) is observed and a significant absence of lacking of knowledge regarding the cognitive objectives fulfilled. Thus, this model of teaching-learning is valid and applicable in our environment.

[Bacteriologic findings as a prognostic factor in the course of acute cholecystitis]. / Hallazgos bacteriológicos como factor pronóstico en la evolución de la colecistitis aguda.

We made a bacteriological study of bile in a consecutive study of 210 patients studied in the General Surgery Department of the General Hospital of Elche (Spain) who underwent cholecystectomy for acute lithiasic cholecystitis, as a prognostic factor in the clinical evolution of these patients. The results obtained led us to the following conclusions. 1. The presence of positive bile culture is a risk factor predisposing to postoperative septic complications. 2. Bile cultures were more frequently positive in patients over 60-years-old. 3. In the early stages of the disease, positive cultures were more frequent. 4. The organism most often isolated was E. coli, so antibiotic treatment should be directed mainly against this agent.

[Biochemical and functional changes in experimental acute pancreatitis in the rat]. / Alteraciones bioquímicas y funcionales de la pancreatitis aguda experimental de la rata.

To discover the biochemical alterations occurring in the first 24 hours of acute pancreatitis (PA), we made an experimental study using rats. We used 90 animals in which necrosis and hemorrhage were induced by closing the choledochus. Animals underwent evolutive periods of 1, 2, 3, 4, 5, 6, 12, 18 and 24 hours. They were sacrificed and plasma (to determine amylase, lipase, creatinine and calcium), urine (amylase and creatinine), ascitic and pleural liquid (amylase and lipase) were obtained from 6 animals of each evolutive period. We made a post-mortem study of the pancreas of three animals of each subgroup. There was a significant increase in the amylasemia from the third hour (p less than 0.005) and of plasmatic lipase from the first hour (p less than 0.0001). Creatinine values remained in normal range and calcemia fell after the sixth hour (p less than 0.001). There was an increase in amylase concentration in urine and in ascitic and pleural liquids, and of the lipase in the last two. These changes correlated with the duration of the disease and with the histologic changes of the gland, which consist in edema, acinar necrosis, vasculitis and hemorrhage, which are present from the first hour and increase as time passes.

[Primary adenocarcinoma of the duodenum]. / Adenocarcinoma primitivo del duodeno.

Two cases are presented of primitive adenocarcinoma of the duodenum diagnosed and treated in the General Surgery Department of General Hospital of Elche (Spain) during the 10 years of its existence. The two patients were women, one a 45-year-old who consulted for pain, epigastric discomfort and melenas, and the other a 76-year-old who consulted for paraneoplastic syndrome and a palpable mass in the right lower quadrant. Radical resection was performed, with cephalic duodenopancreatectomy in the first case and atypical local resection of the first and second duodenal portions, gastric antrum and gallbladder in the second case. Six and 4 years after operation, respectively, the two patients are alive and asymptomatic. We comment the most important aspects of this rare disease in relation to the pecularities of our cases. We insist on the appropriateness of surgical resection as an effective therapeutic option.