120-hour 5-fluorouracil (5-FU) continuous infusion (CI) plus BCNU in advanced colorectal cancer.

Seventy-five previously untreated patients with measurable advanced colorectal cancer were treated with 5 fluorouracil 1,000 mg/m2 as a 24-hour intravenous (i.v.) continuous infusion during days 1-5 and 28-32 every cycle, plus 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU), 200 mg/m2 i.v. bolus on day 1, all given every 8 weeks up to 6 cycles. Median Karnofsky performance status (KPS) was 100. Sites of disease at entry were mainly the abdomen (45%) and liver (33%). All patients were evaluable for response and survival. There were two complete responses and seven partial responses (PR) for an overall response rate of 12% (95% confidence limits: 5-20%). Four out of 25 patients with liver metastases alone had PR. Stabilization was seen in 40 patients (53%). Median time to progression was 9.3 months and overall median survival was 12.5 months, whereas median survival for patients with liver metastases alone was 16 months. Toxicity was mild except for 8% with WHO grade 4 mucositis. Only KPS had statistical significance in the multivariate analysis of prognostic factors. It is concluded that this regimen is relatively active and well tolerated in patients with advanced colorectal cancer.

[Size of breast cancer at the time of initial diagnosis]. / Extensión del cáncer de mama en el momento del diagnóstico inicial.

BACKGROUND: To observe whether patients with breast cancer of an epithelial strain consult physician with a less advanced disease, the patients attended by the Valencian Interhospital Group were studied between January 1981 and December 1990. METHODS: The same diagnosis of disease spread (anamnesis, physical examination, blood analysis and imaging techniques of the thorax, bones and liver) was carried out in all cases. Surgical techniques and histopathologic criteria were homogenous throughout the study. The classification used was that of the International Union Against Cancer of 1987. Histopathologic correlations were studied. RESULTS: Seven hundred seventy-nine patients with a mean age of 57.3 years (range: 24-85) were studied. A statistically significant (S) progressive reduction in the size of the tumor was observed (p less than 0.003) with the percentage of stage II progressively increasing and stage IIIa (more advanced disease than stage II) parallelly diminishing (p less than 0.0019) (S). In patients over the age of 55 this diminution was not observed. To the contrary, more advanced stages (stage IIIb--locally advanced, and stage IV--metastatic disease) were presented than in younger women (p = 0.000) (S). There is a direct correlation between the size of the tumor, the degree of tumoral differentiation and lymphatic metastases. CONCLUSIONS: Patients under the age of 55 spontaneously and progressively consult the physician with a less advanced breast cancer. This is expected to have beneficial effects on survival. It is suggested that primary medicine may play a fundamental role in making women more aware of breast cancer, particularly those over 55 years of age regardless of early detection campaigns.

Pulmonary function and complications after laparoscopic cholecystectomy.

OBJECTIVE: To investigate the impairment of pulmonary function and complications after laparoscopic compared with open cholecystectomy through an upper midline incision. DESIGN: Prospective randomised trial. SETTING: Teaching hospital, Spain. SUBJECTS: 40 patients, 20 in each group. INTERVENTIONS: Clinical examination, spirometry, arterial blood gas analysis, and chest radiographs before and after operation. RESULTS: 48 hours postoperatively FVC and FEV1 had decreased to 56.7% and 53%, respectively, in the patients who had had open cholecystectomy, compared with 85.3% and 84.8% in the laparoscopic group (p < 0.0001). The mean (SD) postoperative percentage reductions in both PaO2 (86.1 (11.1) compared with 98.3 (11.3)) and SatO2 (98.6 (1.3) compared with 100 (1.5)) were also greater in the open group (p < 0.005 in both cases). CONCLUSIONS: Laparoscopic cholecystectomy causes less impairment of lung function than cholecystectomy through an upper midline incision.

Home treatment of deep vein thrombosis: a two-years experience of a single institution.

BACKGROUND AND OBJECTIVE: Low molecular weight heparin (LMWH) is known to be safe and effective for the initial treatment of patients with acute deep-vein thrombosis (DVT). Moreover, LMWH allows patients to be treated at home. However, only limited data are available on the feasibility of LMWH treatment at home in daily clinical practice. DESIGN AND METHODS: We evaluated the feasibility, efficacy and safety of home treatment of DVT in a consecutive series of outpatients using LMWH over a two year period. The two main reasons for exclusion were concomitant pulmonary embolism and a high hemorrhagic risk. Patients were treated with 95 IU/kg bid of nadroparin for a minimum of 7 days. The study design allowed patients to go home immediately after diagnosis or to be discharged after a short hospital stay. Anticoagulation with acenocoumarol was started 2 days before discontinuing nadroparin. RESULTS: From 1995 to 1997, 71 consecutive outpatients with DVT were treated with nadroparin. Ambulatory treatment was feasible in 39 patients (24 patients did not require admission and 15 patients were discharged in less than 48 hours). The remaining 32 patients were treated in hospital. The main causes for admission were the presence of serious comorbid conditions, the severity of symptoms in the involved leg and the inability to obtain a diagnosis. None of the patients had clinical recurrent venous thromboembolism during the initial treatment with nadroparin. One patient receiving nadroparin at home had a non-fatal major bleeding. None of the patients to whom the possibility of home therapy was offered wished to remain at hospital. However, only 26% of the home-treated patients injected the drug by themselves. INTERPRETATION AND CONCLUSIONS: Home therapy of DVT with LMWH bid at doses adjusted to patient's body weight is feasible, efficient and safe. Over 50% of outpatients with DVT can be treated at home, either entirely or after a short stay in hospital. Nevertheless, before using this therapeutic alternative as a standard of practice, an adequate assessment of embolic and hemorrhagic risks, and comorbid conditions, should be made.

Prevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study.

OBJECTIVE: To investigate the efficacy of respiratory rehabilitation in preventing postoperative pulmonary complications (PPC) and to define which patients can benefit. DESIGN: A randomized clinical trial. SETTING: A public hospital. PATIENTS: Eighty-one patients who had upper abdominal surgery were distributed into two homogeneous groups: control (n = 41) and rehabilitation (n = 40). INTERVENTION: Breathing exercises in the rehabilitation group. MAIN OUTCOME MEASURES: Preoperative and postoperative clinical evaluation, spirometry, arterial gasometry, and simple chest X-rays. RESULTS: The incidence of PPC was 7.5% in the rehabilitation group and 19.5% in the control group; the control group also had more radiologic alterations (p = .01). Stratified PPC analysis did not reveal significant differences between groups. However, high- and moderate-risk patients in the rehabilitation group had fewer PPC. Multivariate analysis showed a greater PPC risk associated with pulmonary history (p = .02) and duration of surgery longer than 120 min (p = .03), while rehabilitation exerted a protective effect (p = .06). Significant postoperative decreases in pulmonary volumes and arterial gas values were recorded in both groups, without significant differences. CONCLUSIONS: Respiratory rehabilitation protects against PPC and is more effective in moderate- and high-risk patients, but does not affect surgery-induced functional alterations.

Effect of hydrocolloid dressings on healing by second intention after excision of pilonidal sinus.

OBJECTIVE: To assess the efficacy of hydrocolloid dressings in wound management after excision of pilonidal sinus. DESIGN: Prospective randomised trial. SETTING: District hospital, Spain. PATIENTS: 38 patients with chronic pilonidal sinus. INTERVENTIONS: Open excision with healing by second intention. Divided into three groups: conventional gauze dressing (control, n = 15), Comfeel (n = 12) and Varihesive (n = 11). MAIN OUTCOME MEASURES: Median healing time, infection rate, intolerance, pain, comfort, ease of management, leakage, and recurrence. RESULTS: Median healing time was 68 days (range 33-168) in the control group, compared with 65 days (range 40-137) in the two hydrocolloid groups combined. There were no differences between the hydrocolloid groups. There were no recurrences during the 74 months of follow-up. A third of the postoperative cultures in the control group grew pathogens compared with 1/23 of the patients treated with hydrocolloid dressings (p = 0.03). This was of no clinical relevance. 14/23 in the hydrocolloid group developed leaks. Pain was significantly less in the first four postoperative weeks among the patients in the hydrocolloid group than in the control group (p < 0.05). CONCLUSIONS: Hydrocolloid dressings lessen pain and increase comfort for patients after excision of pilonidal sinus, though time to healing is no shorten than when a conventional gauze dressing is used.

Video-laparoscopic staging of gastric cancer. A prospective multicenter comparison with noninvasive techniques.

BACKGROUND: The high proportion of gastric carcinomas present in an unresectable stage, together with the emergence of multimodal treatments, increases the usefulness of objective staging methods that avoid unnecessary laparotomies. METHODS: A prospective evaluation of the accuracy of laparoscopy in the staging of 71 patients with gastric adenocarcinoma is presented. Serosal infiltration, retroperitoneal fixation, metastasis to lymph nodes, peritoneal and liver metastasis, and ascites were determined in the staging workup. Sensitivity, specificity, and predictive values were calculated and compared with those obtained with ultrasonography (US) and computed tomography (CT). RESULTS: The diagnostic accuracy of laparoscopy in the determination of resectability was 98.6%. Consequently, over 40% of patients were spared unnecessary laparotomies. Laparoscopy yielded diagnostic indices superior to US and CT for all the tumoral attributes studied. Our technique permits accurate assessment and pathologic verification of liver and the peritoneal and retroperitoneal extent of tumor invasion in the majority of patients. CONCLUSIONS: Laparoscopy in gastric adenocarcinoma is a reliable technique that provides accurate assessment of resectability and stage, thus avoiding unnecessary laparotomies in patients in whom surgical palliation is not indicated. A stepwise diagnostic workup combining imaging and minimally invasive techniques is proposed.

Colitis por citomegalovirus y fístula rectovaginal en paciente no inmunocomprometida / Cytomegalovirus colitis and fistule rectumvaginal in immunocompetent person

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Leiomiomatosis peritoneal diseminada. A propósito de un caso y revisión bibliográfica / Leiomyomatosis peritonealis disseminata. Case report and review of the literature

Se presenta un caso clínico de leiomiomatosis peritoneal diseminada, en una paciente de 40 años, con antecedentes de miomas uterinos y múltiples tumoraciones intraabdominales detectadas mediante ecografía y TC. El tratamiento se realizó mediante cirugía hormonosupresora de estrógenos y progesterona y exéresis de las tumoraciones. Revisamos en la bibliografía la frecuencia, la técnicas diagnósticas y el diagnóstico diferencial, así como las posibilidades terapéuticas de esta rara enfermedad (AU)

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Utilidad de la vía laparoscópica en la resolución de problemas de los catéteres de diálisis peritoneal / Utility of laparoscopic surgery in resolving problems with peritoneal dialysis catheters

Objetivo. Describir la técnica y los resultados de la vía laparoscópica en la resolución de los problemas de los catéteres de diálisis peritoneal. Pacientes y método. En 13 pacientes se efectuaron 15 laparoscopias. En 6 pacientes se indicó la vía laparoscópica por una función inadecuada del catéter y en los 7 restantes como vía de implantación por presentar en 6 casos antecedentes de cirugía abdominal y en un caso peritonitis de repetición. Se utilizó un trocar de Hasson infraumbilical y, si eran necesarios otros actos quirúrgicos, una puerta accesoria de 5 mm. Resultados. Se detectaron 3 migraciones simples del catéter y 3 atrapamientos por epiplón. La recolocación en la pelvis del catéter migrado fracasó en los 3 casos, optándose por la retirada y nueva implantación (dos por técnica convencional y uno por vía laparoscópica). Se realizaron 3 omentectomías, una simple y en 2 casos con sustitución del catéter. Se consiguió la implantación en los 6 pacientes con cirugía abdominal previa y en el paciente con peritonitis de repetición, efectuándose en 3 de ellos lisis de adherencias. No hubo morbilidad de la técnica y todos los catéteres funcionan correctamente. Conclusión. La vía laparoscópica es útil en la resolución de los problemas de los catéteres de diálisis peritoneal malfuncionantes debido a que permite detectar la causa del obstáculo al flujo y realizar el acto quirúrgico necesario. Así mismo, facilita la implantación de catéteres peritoneales a pacientes con cirugía abdominal previa (AU)