Colocutaneous fistula due to polypropylene mesh.

Fistulae due to polypropylene mesh are known to occur if the prosthetic mesh is placed close to a hollow viscus. Some cases of enterocutaneous fistula have been reported but there are few cases of fistula affecting the large bowel. It is important to recognize these cases because they are severe complications of the prosthesis and difficult to manage. We present a case of colocutaneous fistula caused by fragmentation of polypropylene mesh and erosion into the sigmoid colon after recurrent incisional hernia repair.

Postoperative textilomas: review of 14 cases.

BACKGROUND: Textile materials of surgical origin are found in the abdominal cavity in between 1/1300 and 1/1500 laparotomies, in spite of preventive measures. It is very difficult to ascertain the exact incidence due to the lack of descriptions in the literature. METHODS: Fourteen cases of postoperative foreign bodies or textilomas are reported. The cases were collected from two hospital centers between 1985 and 1997. RESULTS: There were 12 intra-abdominal cases, 1 thoracic and 1 paravertebral. In 8 (57.1%) diagnosis was made preoperatively by radiological techniques. The mortality rate was 14.2% with 2 deaths due to multiorganic failure in one case and sepsis in the other. Both patients were over 70, with malignant pathology. The morbidity rate was 21.4%, wall abscesses which evolved favorably being the most frequent cause of complications. CONCLUSIONS: Prevention of this complication is the best treatment. It is advisable to use textile material with radiopaque contrast, to count the pieces of material to be used and perform an X-ray before the laparotomy is closed specially in emergency (bleeding and trauma patients) because in these complex cases the possibility of material being left behind is more advisable.

Self-expanding prostheses as a palliative method in treating advanced colorectal cancer.

AIM: This work presents the results of the use of self-expanding prosthesis as a definitive palliative method for eliminating colorectal obstructions caused by advanced and unresectable tumours. PATIENTS: A total of 41 cases were included (29 men, 12 women) with an average age of 70.12 years (range 46-95 years). All cases were showed symptoms of acute intestinal obstruction. Wallstent prostheses were inserted. RESULTS: Locally unresectable colorectal tumours were disseminated in five cases, metastasis in 28 cases and other tumours in eight cases. In all patients the appropriate insertion was performed, eliminating the obstruction in 38 (92.6%) cases in 24-96 h. The morbidity rate was 6/41 cases (14.6%) with slight rectal discomfort in five and one case of bleeding. Posterior tolerance of the prostheses was good. FOLLOW-UP: Two spontaneous rejections, three episodes of subocclusion because of faecal impact and two obstructions caused by an invasion of tumours occurred. Overall, 33 cases (80.4%) died within 1-18 months, average of 4.5 months survival. CONCLUSIONS: Wallstent endoprostheses is a good alternative avoiding a colostomy and providing a good tolerance and comfort for the patient until death.

Tissucol application in dermolipectomy and incisional hernia repair.

Biological adhesives have a lot of applications in surgical procedures. Here we present a prospective study with the aim of analyzing results of the application of Tissucol between the muscle layers and subcutaneous tissue after incisional hernia repair with polypropylene mesh and associated dermolipectomy. We assess clinical and technical parameters, local morbidity, and hospital stay. Fifty-six patients were divided into two groups. Patients with whom we used fibrin glue were older, with more obesity (P < 0.005) with associated diseases, and their incisional hernias were larger and more complicated to repair. Patients in the Tissucol group developed less local morbidity (hematomas or abscesses; P < 0.01), had a shorter mean hospital stay (P < 0.01), and required less wound care. The use of Tissucol improves the results of surgical repair of large abdominal incisional hernias repaired by mesh placement and dermolipectomy, and it decreases global morbidity and hospital stay are reduced.

[Desmoid tumor: a simple problem with severe sequelae]. / Tumor desmoide: un problema banal de graves secuelas.

Desmoid tumours are rare benign lesions with an important local invasive potential and high risk of recurrence. The reported incidence is low, and the diagnosis is made in young women with an abdominal mass. Estrogen levels, a history of trauma and Gardner's syndrome have been incriminated. The defect of the entire thickness of the abdominal wall was reconstructed with a graft of marlex in three cases. The aggressive behavior of these three cases, and diagnosis of eight extraperitoneal cases in a short period of two years prompted us to review the features of the disease.

[Mucoprotein secretion in calculous gallbladder]. / Secrección de mucoproteínas en la vesícula biliar con cálculos.

Secretion of mucoproteins or mucine (MP) have been studied as possible markers in several pathological conditions of the digestive tract, such us colonic polyposis or gastric dysplasia. In the gallbladder (VB) it has been established that form the core of crystalization for the calculi. A study in 100 gallbladders have been made based on the utility of the analysis of the qualitative and quantitative modifications of MP in lithogenesis. It was been determined by histochemical techniques the three main types of MP (neutral, low and high sulphated acid) to evaluate the alterations in the process of lithiasis. Results show a high production of the MP in VB with lithiasis, presenting in 97% a mixed composition of MP (48.9% of 2 types, and 3 types in 46%), without a predominating type in this pathology.

[Appendiceal disease caused by Enterobius vermicularis. Presentation of 3 cases]. / Apendicopatía por Enterobius vermicularis. Presentación de tres casos.

Three cases of acute abdominal pain in children are presented. The clinical diagnosis was acute appendicitis and emergency appendectomy was performed. The histopathological study showed the presence of Enterobius vermicularis and chronic inflammatory changes in the appendix.

[Correlation between dysplasia and malignization risk of Crohn disease]. / Correlación entre displasia y riesgo de malignización de la enfermedad de Crohn.

The malignancy risk in Crohn's disease is less than that of ulcerative colitis, although it has not been so well studied. The possibility of an early detection of malignant changes during the long term follow-up of the patients induces to look for parameters which might be helpful in this respect. In the second surgical clinic of the Hospital Clinico in Madrid, the pathological findings of 11 patients with the diagnosis of Crohn's disease have been analyzed and correlated with the clinical findings. The evaluation of the degree of dysplasia was done on 15 samples obtained by endoscopy and compared with the findings of the surgical specimens in 6 operated patients. The degree of dysplasia increases with age of the patients and years of evolution of the disease with a significant correlation (p less than 0.001) between negative dysplasia and positive dysplasia grade I.

[Retroperitoneal hibernoma]. / Hibernoma retroperitoneal.

We report a new case of retroperitoneal hibernoma. Hibernoma is a rare, benign soft tissue tumor whose constituent cells resemble those of brown fat tissue, which is present in human fetus and newborn infant and it gradually diminishes in quantity throughout adult life. Retroperitoneal location is unusual. Differential diagnosis with the liposarcoma (the most frequent tumour on this location) is based on the high vascularity of the hibernoma. Total resection of the tumour can achieve complete cure without recurrence nor metastasis.

[Expandable stents in obstructive unresectable carcinoma of the gastric antrum]. / Prótesis autoexpandible en el cáncer obstructivo de antro gástrico inoperable.

We present a patient with obstructive unresectable carcinoma of the gastric antrum. An expandable stent was placed endoscopically along the tumor to paliate obstruction. Such a procedure allowed unrestricted oral feeding of the patient up to death six months later.

Treatment of left colon neoplasic obstruction by placement of self-expandable stents.

INTRODUCTION AND OBJECTIVE: Neoplasic stenoses of the left colon are most frequently caused by primary colon carcinoma, infiltration from an external tumour and great adenomatous polyps. These patients often develop obstruction as their first symptom, leading to emergency surgical procedures in adverse circumstances and without an appropriate intestinal preparation that might prevent primary anastomosis. Therapeutic options for this event, such as Hartmann's resection, subtotal colectomy or anterograde colon lavage are not always possible. In these patients a colostomy is performed that requires future reoperation for reconstruction of the intestinal transit. Transtumoral self-expandable stenting followed by elective surgery might be the best option in these cases, as well as an alternative to surgery in non-operable patients. PATIENTS AND METHODS: Twenty four patients treated with this procedure in the past four years were divided in two groups. In group 1 (14 patients), the stent was placed as a permanent and palliative measure for the management of the disease. In group 2 (10 patients), the stent was placed temporarily for the management of the intestinal obstruction and latter the patients underwent elective surgery with fully preoperative and extension study and an appropriate preparation of the colon in order to allow reliable primary anastomosis. RESULTS: There were no hospital mortality nor stent migrations. There was only one complication (perforation caused by the stent) that required emergency surgery, but with any further complications. Failure to place the stent occurred in one patient. CONCLUSIONS: Self-expandable stents relieve neoplasic colon obstructions and allow to complete the study protocol, followed by elective surgery associated to less morbi-mortality. In patients with advanced or irresectable cancer, they provide a palliative and safe alternative to surgery, with satisfactory results.

[Epithelioid hemangioendothelioma localized in the small intestine]. / Hemangioendotelioma epitelioide localizado en intestino delgado.

Epithelioid hemangioendothelioma is a unique tumor of adult life which is characterized by epithelioid or histiocytoid endothelial cells. These tumors are rare, and developed preferentially in the dermis and subcutaneous tissues of the distal extremities. They grow in a slowly progressive fashion, have a borderline biological behavior, and a good response to surgical treatment. The authors present a 63-years-old woman with an epithelioid hemangioendothelioma localized in small intestine. The patient had a history of abdominal pain and recurrent rectal bleeding being surgically treated.

[Pseudomyxoma peritonei]. / Seudomixoma peritoneal.

Pseudomyxoma peritonei is an infrequent clinical entity, characterized by peritoneal implantations organized in cyst of mucine or free peritoneal mucine. Most arise from cystadenoma or cystadenocarcinoma of the ovary and appendix, and fewer from other tumours and locations. It is more common in females, and it is usually diagnosed over the fifth decade. Three cases of pseudomyxoma peritonei are presented, two associated to appendicular carcinoma and one to carcinoma of the ovary, and the data published about this disease are reviewed.

[Diagnostic validity of signs and symptoms defining the diagnosis of acute appendicitis]. / Validez diagnóstica de los signos y síntomas que definen el diagnóstico de apendicitis aguda.

A prospective study of 810 consecutive cases submitted to emergency appendicectomy was performed to determine the predictive value of abdominal pain, nausea, vomiting, fever, abdominal tenderness and total and differential leucocyte count in the diagnosis of appendicitis. Age, sex, time of evolution and degree of inflammation were considered as conditioning factors. Most of the cases were diagnosed within the first 12 h. Pain demonstrated acceptable sensitivity (85.2%) and a high positive predictive value (95.7%) but with an important proportion of false negatives (14.8%). The predictive value of abdominal exploration was 97.6% with a sensitivity of 96.1%. Leucocytosis increased with the degree of inflammation and values above the cut off point established (12,500 leucocytes/dl and 85% segmented) significantly increased the strength of the association. Pain on palpation and leucocytosis with shift to the left increased the sensitivity to 98.1% with false positives of 1.3%. The percentage of acute perforated appendicitis increased from 5 to 15.3% when diagnosis was delayed more than 12 h. Once the clinical manifestations and analytical alterations were established (6 h after initiation of the clinical picture) these did not modify with the time of evolution. The greater the involvement of the appendix the earlier the presentation although, logically, the later the diagnosis the greater the percentage of perforated appendix. The classical criteria of pain, tenderness and leucocytosis with left deviation does not allow the diagnosis of 1.9% of the cases of appendicitis with 1.3% of false positives. Once the clinical manifestations are established, these do not modify with the time of evolution, but the percentage of perforations does increase with time. To reduce this percentage, diagnosis must be made within the first 24 h.