Tratamiento quirúrgico de las hemorroides según técnica Milligan-Morgan comparando disección mediante diatermia versus sellado vascular / Surgical treatment of hemorrhoids according to Milligan-Morgan technique comparing diathermy dissection versus vascular sealing

Antecedentes: La prevalencia de patología hemorroidal está entre el 5-36 %, aunque solo en un 5-10 % se va a requerir cirugía. Objetivo: Comparar la hemorroidectomía según la técnica Milligan-Morgan mediante diatermia versus sellado vascular en pacientes con hemorroides grado III-IV, en cuanto a dolor y otras complicaciones postoperatorias. Material y métodos: Se realizan dos grupos, uno en que se lleva a cabo la disección del paquete hemorroidal con diatermia, y el otro con sellado vascular. En ambos, la cirugía es realizada con sedación profunda e infiltración plexo pudendo con ropivacaína, en régimen de Cirugía Mayor Ambulatoria. Al alta, se les entrega un protocolo con pauta analgésica y a las 24 horas se realiza una revisión telefónica. Al mes se revisan en consulta y rellenan un cuestionario con diferentes variables. Resultados: Entre el año 2007 y 2011 se han intervenido por patología hemorroidal un total de 1.010 pacientes en nuestra unidad, realizándose 362 hemorroidectomías mediante la técnica de Milligan-Morgan. El 52,8 % eran varones, edad media 48 años (17-82), 71,5 % disección mediante diatermia vs. 28,5 % sellado vascular. No hubo diferencias en cuanto a características de las hemorroides y patología anal acompañante, ni de dolor ni otras complicaciones. Sí se encontró significación estadística en una más rápida recuperación por parte del grupo de sellado vascular. Conclusiones: Ambas técnicas obtienen resultados similares, notándose recuperación más pronta en pacientes a los que se les realiza sellado vascula (AU)

Background: The prevalence of hemorrhoidal disease is between 5-36 %, although only 5-10 % will require surgery. Aims: To compare the hemorrhoidectomy according to Milligan-Morgan technique by diathermy vs. sealed in patients undergoing vascular grade III-IV hemorrhoids, in terms of pain and other postoperative complications. Methods: For this, there are two groups, one that is held hemorrhoidal Package dissection with diathermy and the other vessel sealing. In both, the surgery is performed with sedation and infiltration with ropivacaine pudendal plexus, under Ambulatory Surgery. At discharge, they are given a protocol with analgesic regimen, and 24 hours is a review phone. At month are reviewed in consultation and fill out a questionnaire with different variables. Results: Between 2007 and 2011, have been seized by hemorrhoidal disease a total of 1010 patients in our unit, performing 362 hemorrhoidectomies by Milligan-Morgan technique. 52.8 % were male, average age 48 years (17-82). Diathermy dissection 71.5 % vs. 28.5 % vascular sealing. There were no differences in characteristics of hemorrhoids and anal pathology companion. There were no differences in pain or other complications. Yes statistical significance was found in faster recovery by vascular sealing group. Conclusions: Both techniques give similar results, noting more rapid recovery in patients who underwent vascular sealing (AU)

[What happens in the liver during artificial feeding?]. / Qué sucede en el hígado durante la alimentación artificial?

The livers of healthy individuals, where different products are synthesized and metabolized, carries out a series of complex metabolic functions. Furthermore, there is an important relationship with the digestive apparatus, such as for the secretion, excretion and re-circulation of bile, and also with the various hormonal systems or the bacterial microflora of the intestine. When artificial feeding (AF) is used, this may lead to changes in the functionality and structure of the liver, which may or may not be reversible depending on the base situation of the patient and the type of AF administered. This would be enough to bring about a series of changes followed by adaptive phenomena in the liver itself. The degree of hepatic damage triggered by artificial feeding will depend on the interaction of all these elements and the specific characteristics of each case.

¿Qué sucede en el hígado durante la alimentación artificial? / What happens in the liver during artificial feeding?

En las personas sanas el hígado, como lugar de síntesis y metabolización de diferentes productos, realiza una serie de funciones metabólicas complejas. Asimismo mantiene una importante relación con el aparato digestivo, tales como la secreción, excreción y recirculación biliar, o la relación con diferentes sistemas hormonales o con la microflora bacteriana intestinal. Cuando utilizamos alimentación artificial (AA), ésta puede originar cambios en la funcionalidad y en la estructura hepática, que podrán ser irreversibles o no según la situación de base del paciente y el tipo de AA administrada. Esta provocará por sí misma una serie de cambios, que vendrán seguidos de fenómenos adaptativos por parte del propio hígado. De la interación de todos ellos y de las características concretas de cada caso dependerá el grado de daño hepático que pueda originar la alimentación artificial (AU)

The livers of healthy individuals, where different products are synthesized and metabolized, carries out a series of complex metabolic functions. Furthermore, there is an important relationship with the digestive apparatus, such as for the secretion, excretion and re-circulation of bile, and also with the various hormonal systems or the bacterial microflora of the intestine. When artificial feeding (AF) is used, this may lead to changes in the functionality and structure of the liver, which may or may not be reversible depending on the base situation of the patient and the type of AF administered. This would be enough to bring about a series of changes followed by adaptive phenomena in the liver itself. The degree of hepatic damage triggered by artificial feeding will depend on the interaction of all these elements and the specific characteristics of each case (AU)

[Parenteral nutrition-associated cholestasis: the effect of diets free of taurine and its metabolic precursors on bile composition and liver structure]. / Colestasis asociada a nutrición parenteral: influencia de las dietas exentas de taurina y de sus precursores metabólicos sobre la composición biliar y la estructura hepática.

PURPOSE: To study the morphological and biliary alterations associated with taurine-free parenteral nutrition and its other precursors. EXPERIMENTAL GROUPS: One fed a standard taurine-free amino acid formula, a group fed without taurine or its metabolic precursors, and a control group. At the beginning and end of the experiment, analyses were made of nutritional parameters, hepatic enzymes, biliary composition, plasmatic aminogram and optical and electronic microscopy of the liver. RESULTS: Significant increases of threonine, glutamine, alanine, lysine, histidine and arginine, and insignificant increases of taurine, serine, isoleucine and leucine in groups with PN. Increased Non-conjugated AB, particularly lithocholic and taurolithocholic acid in groups without taurine precursors. Fat microsteatosis in area 3 of the acinus in the group without taurine, and in the three areas in the group without precursors. Standard taurine-free PN causes changes in the biliary composition and liver histology, which increase in the absence of taurine precursors.

Liver lipid composition and intravenous, intraperitoneal, and enteral administration of intralipid.

We studied the variations arising in plasma and liver lipids after intravenous (i.v.), intraperitoneal (IP), and intragastric (IG) administration of a fat overdose on the order of 4 g.kg-1 body wt.day-1 in the form of Intralipid (ITL) 20% to 33 New Zealand rabbits for 15 days. The control group was submitted for surgery but did not receive an ITL supplement. The results show weight gain in all animals and normal liver enzyme values. There was an increase in plasma lipids in groups supplemented by the parenteral route (i.v. and IP), and fatty acids showed a similar distribution, in terms of percentages, to that for ITL. In liver tissue, there was an increase in the fractions related to ethanolamine and a decrease in phospholipids of choline and serine. In the i.v. group, neutral lipids predominated compared with other groups. The livers of all supplemented animals (i.v., IP, and IG) showed a higher content of stearic and linoleic acid and a reduction in oleic acid. Study with optical microscopy showed a microvacuolization affecting the three areas of the hepatic acini in the i.v. group, seen with electron microscopy as vacuoles lacking membranes and surrounded by mitochondria. In conclusion, there is an increase in hepatic steatosis in parenteral groups and a greater deposit of neutral lipids in the i.v. group, related to the administration route, without biochemical signs of liver dysfunction.

[Interferences between nutrients in their absorption from the peritoneal cavity in rats]. / Interferencias entre nutrientes en su absorción desde la cavidad peritoneal de ratas.

With the aim of detecting possible interferences in the absorption of glucose, amino acids and fats we infused several combination of them into the peritoneal cavity of the Wistar rats. After intraperitoneal infusion of 2 mu Ci-L-glucose-C14 with 5 ml of D-glucose 5 per 100 and L-glucose-C14 with 5 ml of "16N" 3.5 per 100 in different groups of animals, we detected slight differences in plasma radioactivity one hour after infusion. We also found moderated differences in plasma radioactivity among the groups of animals infused with 1 mu Ci of fat radioactive amino acids plus 5 ml of D-glucose 5 per 100 and in the group infused with 1 mu Ci of 5-L-amino acid-C14 plus 5 ml of "16N" 3.5 per 100, after four hours of the infusion. We found no differences among those groups of animals infused with fat plus glucose and with fat plus amino acid with respect to those infused with fat alone. In summary, as glucose and amino acid absorption pathway are the same (capillary flow) seem reasonable that they interfere with each other when they are infused intraperitoneally. Fat infusion that not seem to interfere with other substrates possible due to the different absorption pathway (lymphatic channels) but further studies are needed to determine this.

[Nutrient absorption rate from the peritoneal cavity in rats]. / Velocidad de absorción de nutrientes desde la cavidad peritoneal de ratas.

A study has been done of the absorption/elimination kinetics of nutritive substances such as glucose, amino acids and fats from the peritoneal cavity. For this purpose, 48 male Wistar rats were administered an intravenous or intraperitoneal "bolus" of 2 microCi of L-glucose-C14/250 g of body weight, 3 microCi of D-alanine-L-C14/250 g and 0.4 g of Intralipid/250 g body weight. A two-compartment pharmacokinetic model was applied to determine the absorption, elimination and distribution constants among the different body compartments of each of these substrates, as well as the absorption and elimination halflife. When the areas under the curves were compared following intravenous and intraperitoneal infusion, the total physiological availability or fraction of dose absorbed over a given period of time were calculated. A higher absorption and elimination constant for glucose and amino acids as compared to fats was found. Higher than 90% absorption for all substrates was found, but since in the case of fats the elimination constant is lower and longer the elimination halflife, we must be cautious regarding its infusion rate.

[Intrahepatic cholestasis associated with parenteral nutrition: an experimental study in rats]. / Colestasis intrahepática asociada a nutrición parenteral: estudio experimental en ratas.

Intrahepatic cholestasis is a condition often observed in patients receiving parenteral nutrition, especially in new born babies who are underweight (< 1,000 g.) Some authors find an alteration in the amino acids transulphuration passage, which gives rise to a deficit of taurina. This makes it impossible to achieve a correct conjugation of toxic biliary acids. The access of nutrients to the liver may have an effect on this. An experimental study on rats was performed, administering an oral diet at the expense of lipids (20% Intralipid, 60% of caloric needs) and glucose (40% of caloric needs) in one group, another group received amino acid supplements to this diet (16N) at a proteic rate of 2 gr/kg of weight and day orally, with an identical diet to the above, except that the proteic intake was intraperitoneal. Two control groups were established. We found a microvacuolization in hepatic fat with the help of an electronic microscope in the groups lacking proteins and those with oral or intraperitoneal supplements of amino acids, as well as an increase in plasmatic AST.