[Choice of therapeutic approach in acute cholecystitis in the elderly]. / Elección de la conducta terapéutica en la colecistitis aguda del anciano.

BACKGROUND: Acute cholecystitis in elderly patients is a common disease characterized by a high mortality rate and serious complications. AIM: To compare conservative vs. surgical therapy for acute cholecystitis in the elderly. METHODS: This is a retrospective study including patients 70 years-old or older with the diagnosis of acute cholecystitis (AC) treated between 2003 and 2009. Epidemiological and clinical data, diagnostic approach, surgical variables and cost-effectiveness were analyzed. According to the first therapeutic intent, the analysis was performed among final treatment groups and among older than 80 years and younger cases. p < 0.05 was considered significant. Statistical analysis was performed with StatView(©) 5.0. RESULTS: During the six-year period 173 episodes of acute cholecystitis were treated on 147 patients (52% females), with a mean age of 80.6 years (range 70-101). In 103 cases medical treatment was taken, with 82 cases of resolution of the clinical picture, 15 unexpected operations and 6 deceases. Other 70 cases were undergone surgery as first option, 78.5% of them through laparoscopy with a conversion rate of 19.7%. CONCLUSIONS: In our study, surgery and medical treatment get similar outcomes, making better progress those who underwent early laparoscopic cholecystectomy. We recommend performing emergency surgery in high-risk elderly patients rather than conservative therapy due to a tendency to increase morbidity with later approach.

[New diagnostic and surgical approach to Mirizzi syndrome]. / Nuevas posibilidades diagnósticas y terapéuticas en el síndrome de Mirizzi.

Mirizzi's syndrome is an unusual complication of gallstone disease, in which a stone impacting in the neck of the gallbladder (Hartmann s pouch) compresses the common bile duct. This mechanical obstruction leads to obstructive jaundice frequently followed by inflammatory changes and several complications. We present two patients affected by Mirizzi's syndrome whose diagnosis was correct in the preoperative period and approached by laparoscopy. A case was converted to open procedure due to adhesions in the Calot's triangle, and therefore, treated with subtotal cholecystectomy and choledochorrhaphy over a T tube. In the other case the laparoscopy access became successful. Both postoperative courses were uneventful. In this article, suitable diagnostic techniques are analyzed. On the other hand, we discuss what is the best therapeutic option, with a special attention to the relevance of endoscopic retrograde cholangiopancreatography and laparoscopic approach in the management of those patients.

Nuevas posibilidades diagnósticas y terapéuticas en el síndrome de Mirizzi / New diagnostic and surgical approach to Mirizzi syndrome

El síndrome de Mirizzi es una variante poco frecuente de colelitiasis en la que un cálculo impactado en la bolsa de Hartmann comprime la vía biliar desencadenando una ictericia obstructiva, frecuentemente seguida de fenómenos inflamatorios y de diversas complicaciones (colecistitis, colangitis, fístulas etc). Presentamos dos pacientes con síndrome de Mirizzi, correctamente diagnosticados en el preoperatorio e intervenidos por vía laparoscópica. Un caso fue convertido por adherencias en el triángulo de Calot y tratado con colecistectomía subtotal y coledocorrafia sobre tubo en T de Kher. En el otro enfermo se pudo completar con éxito el procedimiento. Ambos postoperatorios cursaron con normalidad. En el presente artículo, se analizan las técnicas diagnósticas que ayudan a una identificación precoz del síndrome y se discuten las opciones terapéuticas más adecuadas en el momento actual, prestando una especial atención al papel de la colangiopancreatografía endoscópica y del abordaje laparoscópico en el manejo de estos pacientes

Mirizzi’s syndrome is an unusual complication of gallstone disease, in which a stone impacting in the neck of the gallbladder (Hartmann’s pouch) compresses the common bile duct. This mechanical obstruction leads to obstructive jaundice frequently followed by inflammatory changes and several complications. We present two patients affected by Mirizzi’s syndrome whose diagnosis was correct in the preoperative period and approached by laparoscopy. A case was converted to open procedure due to adhesions in the Calot’s triangle, and therefore, treated with subtotal cholecystectomy and choledochorrhaphy over a T tube. In the other case the laparoscopy access became successful. Both postoperative courses were uneventful. In this article, suitable diagnostic techniques are analyzed. On the other hand, we discuss what is the best therapeutic option, with especial attention to the relevance of endoscopic retrograde cholangiopancreatography and laparoscopic approach in the management of those patients

[Focal peritonitis as a form of clinical presentation of listeriosis]. / Peritonitis focal como forma de presentación clínica de una listeriosis.

Infections by germs of Listeria genus can occur sporadically or in epidemic outbreaks and have different clinical presentations. Abdominal origin is very unusual among them, especially in no immunocompromised patients or without concurrent liver illness. We present a young healthy man who is lacking in underlying diseases, suffering from focal peritonitis caused by Listeria monocytogenes. The patient had to be operated on, requiring immediate colectomy and evacuation of a retroperitoneal abscess. The postoperative evolution was favorable under antibiotic treatment with amoxicillin and clavulanic acid during 3 weeks. The clinical-epidemiological and therapeutic aspects of listeriosis are analysed in the discussion, giving special attention to abdominal infective episodes.

Peritonitis focal como forma de presentación clínica de una listeriosis / Focal peritonitis as a form of clinical presentation listeriosis

Las infecciones por gérmenes del género Listeria pueden ser esporádicas o en brotes epidémicos y cursar con múltiples formas de presentación clínica. Entre ellas, la listeriosis de origen abdominal es una de las menos frecuentes, especialmente en aquellos individuos sin un compromiso previo del sistema inmune o una enfermedad hepática concurrente.Presentamos el caso de un varon joven, sano y sin factores predisponentes, con una peritonitis focal causada por Listeria monocytogenes. El paciente fue intervenido de urgencia, practicándose una colectomía derecha y la evacuación de un absceso retroperitoneal. La evolución pos toperatoría fue favorable, mediante un tratamiento antibiótico consistente en una pauta de amoxicilina y ácido clavulánico durante tres semanas.En la discusión, se analizan los diversos aspectos epidemiológicos, clínicos y terapéuticos de la listeriosis, con una especial atención por los episodios infectivos abdominales

Infections by germs of Listeria genus can occur sporadically or in epidemic outbreaks and have different clinical presentations. Abdominal origin is very unusual among them, especially in no immunocompromised patients or without concurrent liver illness. We present a young healthy man who is lacking in underlying diseases, suffering from focal peritonitis caused by Listeria monocytogenes. The patient had to be operated on, requiring immediate colectomy and evacuation of a retroperitoneal abscess. The postoperative evolution was favorable under antibiotic treatment with amoxicillin and clavulanic acid during 3 weeks. The clinical-epidemiological and therapeutic aspects of listeriosis are analysed in the discussion, giving special attention to abdominal infective episodes

Esclerosis de microvarices. Expectativas y realidades / Treatment of spider veins with sclerotherapy. The expectations and realities

Introducción. La escleroterapia es el procedimiento terapéutico más difundido para el tratamiento de las microvarices. La valoración científica de los resultados que se obtienen no siempre es fácil, ya que depende de diversos factores técnicos, humanos y metodológicos. Objetivo. Analizar las complicaciones y resultados estéticos de la esclerosis de microvarices en las extremidades inferiores. Pacientes y métodos. Se realizó un estudio prospectivo, observacional y no aleatorizado a pacientes sometidos a esclerosis de microvarices entre septiembre de 2001 y abril de 2003. El esclerosante que se eligió fue el polidocanol, y la técnica, la francesa. Se registraron todas las complicaciones y se valoró estéticamente el resultado final, tanto desde el punto de vista del enfermo como del facultativo, mediante una escala subjetiva. Resultados. Se trataron 37 pacientes, todos del sexo femenino, con una edad media de 43,5 años. Un 46 por ciento habían recibido terapia hormonal anticonceptiva o sustitutiva y un 35 por ciento, tratamiento previo de sus microvarices. El número medio de sesiones fue de 5,3 (máximo 21) y no hubo abandonos. La complicación más frecuente fue la presencia de tenues hiperpigmentaciones postesclerosis (28 por ciento). Se revisó un 76 por ciento de los casos cuatro meses después, como mínimo, de la finalización de la terapia. Un 25 por ciento de estos casos presentaba microvarices subsidiarias de un nuevo tratamiento. Los resultados fueron buenos o muy buenos para un 82 por ciento de los pacientes que se encuestaron. Conclusión. La esclerosis es un buen tratamiento estético para las microvarices, con excelente tolerancia y baja morbilidad (AU)

Técnicas ambulatorias en el tratamiento quirúrgico de las microvarices / Ambulatory techniques for the surgical treatment of microvarices

INTRODUCCIÓN: Las microvarices (MV), telangiectasias y varices reticulares, son dilataciones patológicas de los vasos de pequeño calibre(0.1-5 mm.) en la dermis superficial. Representan la manifestación más frecuente de la enfermedad varicosa apareciendo, más tardeo más temprano, en todos los pacientes. También son un problema estético de primer orden en la mujer. OBJETIVOS: En el presente artículo exponemos la etiología, clasificación y tratamiento de las MV, revisando la experiencia de nuestro Servicio. PACIENTES Y MÉTODOS: Se estudian 26pacientes intervenidos de MV entre 2001 y 2003.Todos ellos fueron explorados con eco-Doppler color antes de la intervención y operados ambulatoriamente bajo anestesia local mediante técnicas microquirúrgicas de flebectomía, solas, o complementadas posteriormente con esclerosiso microcoagulación. RESULTADOS: No se registraron reingresos ni problemas de analgesia. Las complicaciones más frecuentes, todas ellas leves, se relacionaron con la patología de la cicatrización o pequeños hematomas, resueltos con tratamiento conservador. CONCLUSIÓN: Las diversas técnicas microquirúrgicas proporcionan buenos resultados estéticos con mínimas complicaciones y trastornos de la actividad socio-laboral de los enfermos. Los principales inconvenientes son la largaduración del tratamiento, cuando se precisan múltiples sesiones de esclerosis asociadas a la cirugía, y las recidivas tempranas de las MV. Ambas situaciones pueden causar el desánimo del paciente y el abandono de la terapia (AU)

INTRODUCTION: Microvarices (MV), telangiectasiae and reticular varicose veins, are pathologic dilations of minute veins (0.1-5 mm.) in the superficial dermis. They represent the most frequent manifestation of varicose disease which appears, sooner or later, in all patients. Moreover it is an important aesthetic problem in women. AIMS: In this article, we have studied the etiology, classification and treatment of MV by reviewing the experience of our Department. PATIENTS AND METHODS: We studied 26patients who had treatment with microsurgical techniques for their MV between 2001 and 2003.All of them were explored by colour echo-Doppler before the operation and underwent local anesthesia for microsurgical techniques, using phlebectomy on its own or combined therapy, associating it, later on, with sclerotherapyor microcoagulation. RESULTS: No readmissions were registered or any problems with analgesisa. All complications were minor and the majority were caused by pathological healing or small haematomas which were treated conservatively. CONCLUSION: The various microsurgical techniques existing provided patients with good aesthetic results without serious complications and minimal disturbance of their social and working life. Drawbacks are the length of the treatment when a course of sclerosis is necessary to complement the phlebectomy and the early recurrences of MV. Both situations can cause the patients to abandon the therapy (AU)

[Graves' disease with associated thyroid nodules (nodular Graves' disease). Clinical, diagnostic and therapeutic considerations]. / Enfermedad de Graves-Basedow con nódulos tioideos asociados (enfermedad de Graves-Basedow nodular). Consideraciones clínicas, diagnósticas y terapéuticas.

BACKGROUND: Sometimes Graves disease (GD) can appear in association with thyroid nodules, which seems to increase the risk of carcinoma. In this article, we try to establish clinical characteristics, diagnostic means and appropriate treatment for Graves patients with co-existent nodules. METHOD: A retrospective study was made of 153 consecutive patients who underwent operation for GD between 1967 and 2000. Each patient was subject to a regular protocol including physical examination, diagnostic test, total or subtotal thyroidectomy and follow-up in the long term with the purpose of making a valuation of the postsurgical morbidity, evolution and relapses. Data were processed through computing in order to get the statistical information. RESULTS: 28.1% of GD had thyroid nodules and carcinoma was diagnosed in four patients (9.3%), all of them belonging to papillary variety. Surgery consisted of 57 subtotal thyroidectomies (37.3%) and 94 total thyroidectomies. Parathyroid and recurrent morbidity was established in 4.6 and 3.9%, respectively, a year later since the operation, though it had a strong tendency to decrease from 1980. 96% of cases showed no relapse. CONCLUSIONS: Nodular GD is very common in our setting, especially in Graves patients with late beginning who wait for ages until they are undergone surgery. Initial treatment should be by means of braking therapy with antithyroid drugs and clinical, cytologic and ultrasonographic control. Surgery would be advised, from the outset or during the follow-up, in view of either any suspicion about cancer or presence of local growth. The procedure of choice is total thyroidectomy performed with low morbidity.

Enfermedad de Graves-Basedow con nódulos tiroideos asociados (enfermedad de Graves-Basedow nodular). Consideraciones clínicas, diagnósticas y terapéuticas / Graves' disease with associated thyroid nodules (Nodular Graves' Disease). Clinical, diagnostic and therapeutic considerations

Fundamento: La enfermedad de Graves-Basedow (EGB) puede presentarse en ocasiones asociada a nódulos tiorideos, lo que parece aumentar la posibilidad de padecer un carcinoma. En el presente artículo, intentamos establecer las particularidades clínicas, los medios diagnósticos y el tratamiento adecuado para los pacientes en los que coexisten ambas patologías. Método: Se estudiaron 153 EGB intervenidas consecutivamente entre los años 1967 y 2000. Todas ellas fueron sometidas a un protocolo uniforme que incluyó exploración, pruebas complementarias, tiroidectomía subtotal o total y seguimiento a largo plazo con el fin de valorar la evolución de la morbilidad postquirúrgica y las recidivas. Los datos obtenidos fueron registrados informáticamente para su posterior análisis estadístico. Resultados: Un 28.1 por ciento de las EGB se asociaban a nódulos y se diagnosticaron cuatro carcinomas (9,3 por ciento) todos ellos pertenecientes a la variedad papilar. Se practicaron 57 tiroidectomías subtotales (37,3 por ciento) y 94 totales. La morbilidad paratiroidea y recurrencial al año de la intervención se estableció en un 4,6 y 3,9 por ciento, respectivamente, aunque con una marcada tendencia a disminuir desde 1980. Un 96 por ciento de los casos no presentó ninguna recidiva. Conclusiones: El Graves-Basedow nodular es muy frecuente en nuestro medio, sobre todo en pacientes con EGB de inicio tardío y que esperan años hasta intervenirse. El tratamiento inicial debe ser mediante una terapia frenadora con antitiroideos de síntesis y control clínico, citológico y ultrasonográfico. La cirugía será indicada, de inicio o durante el seguimiento, ante cualquier sospecha de cáncer o la presencia de síntomas compresivos. La técnica idónea es una tiroidectomía total practicada con baja morbilidad (AU)

Variantes anatómicas del confluente safeno-femoral. Estudio prospectivo en 122 disecciones quirúrgicas consecutivas / Anatomic variants of the saphenofemoral junction. A prospective study of 122 consecutive surgical dissections

Introducción. El conocimiento exacto de la anatomía del confluente safeno- femoral y sus variantes anatómicas es imprescindible para el cirujano a la hora de evitar accidentes operatorios y prevenir recidivas varicosas. Métodos. Entre los años 1996 y 1998 se estudiaron prospectivamente 122 confluentes safeno-femorales pertenecientes a 106 pacientes intervenidos de manera consecutiva de varices. En los 114 cayados de la vena safena interna no operados previamente, se registraron las variantes anatómicas siguiendo la clasificación de Blanchemaison y Santos Gastón. En los 8 casos con recidivas varicosas, los hallazgos se clasificaron según Stonebridge. Resultados. En el grupo de 114 confluentes se contabilizaron 102 variantes, para un total de 52 exploraciones anatómicas (45,6 por ciento), 37 con una anomalía, 20 con dos y 5 con tres o más. En las 8 reexploraciones se hallaron: 4 venas crurales defectuosamente tratadas, 3 ligaduras incontroladas del cayado y un complejo safeno-femoral intacto. Conclusiones. El éxito en la cirugía del cayado de la vena safena interna se basa en un óptimo cartografiado preoperatorio de las varices, un buen campo operatorio y el conocimiento de las variantes anatómicas que puedan presentarse (AU)

Spontaneous pneumothorax: consecutive treatment of a series of 45 cases. Preliminary results of using therapeutic videothoracoscopy. / Neumotórax espontáneo: tratamiento consecutivo de una serie de 45 casos. Resultados preliminares del uso de la videotoracoscopia terapéutica.

The appearance of procedures derived from video assisted thoracoscopy (VAT) has fostered new breakthroughs in the treatment of spontaneous pneumothorax. Our early experience with a study protocol using this technique is described. Patients admitted to our hospital in 1995 with a diagnosis of spontaneous pneumothorax were enrolled consecutively. Diagnosis was based on symptoms and pneumothorax was quantified by measuring the interpleural distance observed on the chest film. The initial treatment was pleural drainage; VAT was ordered in cases of recurrence, when lung reexpansion failed or when air leakage was persistent. Forty-five cases (30 men, 15 women) are reported. Mean age was 29 years. Eleven (24%) patients had had earlier pleural drainage but were suffering recurrences. The right side was involved in 14 (54%) cases. Initial treatment was pleural drainage and in 32 cases no other treatment was given. VAT was performed on 11 patients. In 1 (9%) patient the procedure became a minithoracotomy, or video-assisted thoracoscopic surgery. In 2 patients conventional thoracotomy was performed. Mean time the procedure lasted was 80 min. Mean follow-up was 3 months. There were no recurrences among patients treated with VAT and surgery. Our initial experience demonstrates that VAT is the technique of preference for the definitive treatment of spontaneous pneumothorax. There is less postoperative pain, increased comfort, no noteworthy morbidity, shorter postoperative hospital stays and prompt return to normal activity for the patient; these advantages lead us to choose this treatment over open surgery.

[Spontaneous retroperitoneal hemorrhage induced by anticoagulation treatment]. / Hemorragia retroperitoneal espontánea inducida por tratamiento anticoagulante.

Contribution of one case of spontaneous retroperitoneal haemorrhage presented after therapy with anticoagulants. Review of causes of transperitoneal haemorrhage, relative frequency, as well as signs and symptoms, and diagnosis. The sparse number of haemorrhagic complications after anticoagulant therapy with heparin and urokinase-associated adjusted heparin are described. Treatment is instituted based on precipitating condition and, in the present case, with suppression of medication and volume replacement together with an strict evolutive monitoring by means of ultrasound, computerized axial tomography (CT) and magnetic nuclear resonance (MNR).