Laparoscopic radical hysterectomy with the use of a modified uterine manipulator for the management of stage IB1 cervix cancer.

We prospectively collected data on all patients with stage IB1 cervical cancer, who underwent total laparoscopic radical hysterectomy with the use of a modified uterine manipulator. From January 2000 to December 2005, 54 patients met the study criteria. The mean age was 41.8 +/- 7.47 years. Average BMI (kg/m(2)) was 27.38 +/- 3.13. Squamous carcinoma and adenocarcinoma were found in 88.88% and 11.11% of the cases, respectively. The average surgical time was 265 +/- 70.8 min. The mean estimated blood loss was 276.11 +/- 123.03 ml. The average patient lymph node count was 19.64 +/- 5.08. Positive malignant lymph nodes were identified in 11.11% of the cases. Surgical margins were free of disease in all patients. The mean hospital stay was 1.5 +/- 1 days. There was no mortality. Total laparoscopic radical hysterectomy can be considered a safe alternative to laparotomy. The use of a uterine manipulator does not pose an increased surgical risk and allows for a simpler and more feasible procedure.

Incidence and predictive factors for cytomegalovirus infection in renal transplant recipients.

BACKGROUND: Cytomegalovirus (CMV) infection is a common cause of morbidity, graft loss, and mortality among kidney recipients due to its direct and indirect influences on organs and systems, namely, immunomodulation, which favors the appearance of opportunistic infections, vasculopathy, and decreased graft and patient survival. In Mexico the dimensions of this infection are unknown in kidney transplant recipients. We evaluated the incidence and predictive factors for CMV infection among renal transplant recipients of the Mexican Institute of Social Security in Guadalajara. METHODS: This prospective cohort analysis of patients >or=16 years of age of both genders, included transplantations from May 2006 to July 2007. Two hundred twenty-five patients were followed over 6 months to evaluate CMV infection or disease. We evaluated demographic, clinical, and paraclinical aspects, such as total lymphocyte count and quantitative CMV polymerase chain reactions (PCR). RESULTS: The overall incidence of CMV infection was 17.8%. CMV infections were associated with lymphopenia (relative risk [RR] 14.75; confidence interval [CI] 95%, 3.46-62.77), serostatus D+/R- (RR 5.53; CI 95%, 2.18-14.05), and fever (RR 4.57; CI 95%, 1.50-13.95). Receiver-operating characteristic (ROC) curves for lymphopenia versus PCR showed a sensitivity of 27% and a specificity of 98%. CONCLUSION: In our study, lymphopenia, serostatus D+/R-, and fever were good predictors of CMV infections among renal transplant recipients.

A cost-effectiveness analysis of tension-free versus shouldice inguinal hernia repair: a randomized double-blind clinical trial.

BACKGROUND: The use of open tension-free techniques in hernia surgery seems to be superior to those techniques that apply tension to the suture line. However, the cost-effectiveness of tension vs. tension-free repairs has not been investigated before. METHODS: This study is a cost-effectiveness analysis within a randomized controlled clinical trial that compared open-tension (OT) versus mesh-plug tension-free (MPTF) hernia repair, with a 2-year follow-up for each patient. Between July 2002 and June 2003, 106 patients with inguinal hernia were randomized to either procedure. Main outcome measures included average surgical time, time to full recovery, pain visual analog scale, amount of analgesics required, off-work time, hospital stay, and heath-care costs. RESULTS: The average cost was $885.15 (95% CI $843.56-$926.74) and $837.66 (95% CI $796.42-878.89) USD for the OT and the MPTF herniorrhaphy, respectively (P < 0.05). Average yearly savings with the MPTF repair were calculated as $7,598.84 USD. Surgery time, time to full recovery, pain visual-analog scale, use of analgesics, off-work time, and hospital stay were significantly lower for the MPTF repair. Disability-adjusted life-years were reduced 56% with the MPTF repair, which represented a total savings of $12,656.60 USD with this procedure. CONCLUSION: This controlled clinical trial demonstrates that the MPTF technique significantly decreases care costs in patients operated on for inguinal hernias.

Direct trocar insertion without pneumoperitoneum and the Veress needle in laparoscopic cholecystectomy : a comparative study.

PURPOSE: The purpose of this study is to compare the safety and complications of direct trocar insertion without pneumoperitoneum (DTI) with Veress needle (VN) in laparoscopic cholecystectomy (LC). METHODS: We studied 84 patients admitted to our hospital for LC, in a random simple blind design, 42 patients were assigned to DTI and 42 to VN. The variables analysed were : procedure complications, laparoscope insertion time and duration of surgery. RESULTS: Complication percentages between the groups were significantly different (DTI 2.3% versus VN 23.8%, p = 0.009). The duration of surgery between the two groups was also significantly different (DTI 56+/-31 versus VN 71+/-28 minutes, p < 0.02). Finally, laparoscope insertion time between the two techniques was significantly different (DTI 1.5+/-0.5 versus VN 3.0+/-0.4 minutes p < 0.001). CONCLUSIONS: Our results show DTI to be a safe, efficient, rapid and easily-learned alternative technique, reducing the number of procedure-related complications.

Fibrin glue as adjuvant treatment for gastrocutaneous fistula after gastrostomy tube removal.

Gastrocutaneous fistulas are infrequent after gastrostomy tube removal. However, if the fistulous tract remains permeable, even low-volume output can produce significant cutaneous burns. The use of biodegradable adhesives has been described, where fibrin glue is applied directly over the fistulous tract or under the guidance of procedures such as upper or lower gastrointestinal endoscopy or fistuloscopy. We studied the use of fibrin glue in five consecutive adult patients with gastrocutaneous fistulas after gastrostomy tube removal, with no complications that might impede spontaneous closure. A comparison group included seven patients treated during the preceding 2 years with conservative medical management, who were not treated with fibrin glue. There was no difference between the two groups with regard to age and gender, nor with regard to type of gastrostomy (surgical or endoscopic). The mean output volume from the fistulas was 151.4 +/- 146.1 ml/24 h in the study group and 115.0 +/- 42.7 ml/24 h in the control group, which was not significantly different ( P = 0.80). The duration of previous conservative treatment was 93.8 +/- 85.1 days for the study group and 95.8 +/- 80.7 days for the control group and this also did not differ significantly ( P = 0.93). The time to achieve total fistula closure was 7.0 +/- 3.1 days in the study group and 32.7 +/- 15.7 days in the control group. This difference was statistically significant ( P < 0.004). The time required before oral feeding could be recommenced after spontaneous or induced closure was similar in the two groups, at 2.8 +/- 1.3 days and 4.71 +/- 2.36 days, respectively. Endoscopic guidance allows direct instillation of fibrin glue via the external opening through the whole fistulous tract. This procedure reduces the time required for the closure of gastrocutaneous fistulas.

The role of MAP kinases in trauma and ischemia-reperfusion.

Mitogen-activated protein kinases (MAPKs) have been the focus of a number of studies, as these compounds are involved in a number of important inflammatory cell signaling mechanisms. Recent studies have further elucidated the role of MAPKs in the inflammatory response, as a result of trauma and/or ischemia-reperfusion (I/R) injury. There are three major classes of MAPKs that may be involved in the inflammatory response: extracellular signal-regulated kinases (ERKs), stress-activated protein kinases (SAPKs)/c-Jun NH(2)-terminal kinases (JNKs), and p38 MAPKs (p38). This is clinically relevant, because these pathways may be a possible target for anti-inflammatory drug intervention. This review studies the role of MAPKs in trauma and/or I/R.

Combined transurethral prostatectomy and mesh-based tension-free inguinal hernia repair.

Previous reports have recognized the benefits of combining prostatic resection and inguinal hernia repair. This study reports the surgical management of bladder-outlet obstruction with simultaneous transurethral prostatectomy and mesh-based tension-free inguinal hernia repair. A prospective study was undertaken of 31 consecutive patients seen from January 1993-December 1998 at the Western Medical Center. All surgery was performed electively under epidural anesthesia, and prophylactic antimicrobial agents were given routinely. Two hernia repair techniques were used: the mesh-plug technique and the Lichtenstein repair. Written informed consent was obtained from all patients. Over a 5-year period, in 31 consecutive patients without urinary tract infection, 36 groin hernias were diagnosed. The mean+/-SD age of patients was 65.9+/-6.3 years. Twenty-four (66.7%) hernias were direct, and 12 (33.3%) were indirect; 61.1% (22) were primary hernias, and 38.8% (14) were recurrent. The mesh-plug and Lichtenstein repair techniques were used to treat 22 (61.1%) and 14 (38.8%) hernias, respectively. Wound hematoma developed after three hernioplasties (8.3%) and wound infection in one (2.7%). Hospital stays ranged between 2 and 4 days. The mean follow-up period was 69 months. The recurrence rate was 2.7% (one hernia). Simultaneous mesh-based tension-free herniorrhaphy and transurethral prostatectomy is a reliable and safe alternative for patients with both prostate enlargement and groin hernia. Hospital stay is not affected by the combined procedure, and the infection rate is acceptably low.

Esophagopericardial fistula attributed to a barogenic rupture of the esophagus. Report of a case and review of the literature.

In this case we describe a fatal condition of esophagopericardial fistula secondary to barogenic rupture of the esophagus. The review of the literature disclosed only one fatal case (reported in 1968) of esophagopericardial fistula attributed to barogenic rupture of the esophagus. Early diagnosis and adequate treatment including pericardiocentesis along with intermittent drainage of the pericardium, full-course antibiotic therapy and a timely, well-planned surgical intervention will substantially improve the prognosis in this type of pathology. Patients similar to our case should be treated with either surgical bipolar esophageal exclusion (conservative disconnection) or esophagectomy combined with large drainage of the pericardial and mediastinal spaces. This case report reinforces the complexity of the diagnosis, and perhaps the need for clinical awareness and the inclusion of this entity in a differential diagnosis.

Complications of central venous catheters.

Central vein catheterization is frequently employed for monitoring, administration of drugs and parenteral nutrition in a variety of medical and surgical illnesses. Despite the widespread use of central vein access, both catheter-related infections and mechanical complications remain unacceptably common. In the last few years, data have become available to show that technical innovations and catheter maintenance protocols can reduce both catheter related bloodstream infections as well as mechanical complications. Future developments should be aimed at both educational intervention and biomaterials research. The former incorporates case-based instruction, problem-solving examination, and database analysis; while the latter will probably lead to a new set of catheters that are more resistant to infection and thrombosis.

Dual blockade of P-selectin and beta2-integrin in the liver inflammatory response after uncontrolled hemorrhagic shock.

BACKGROUND: Neutrophil infiltration is a characteristic feature of the hepatic injury associated with prolonged hypotension. Previous work has already stressed the important contribution of neutrophil-endothelial cell interactions in the organ injury seen after hemorrhagic shock. Single-blockade strategies using monoclonal antibodies (MAbs) against either selectin or integrin receptors have been demonstrated to be effective in limiting the tissue inflammatory response observed in this clinical disorder. One unexplored topic is the additive effect(s) and the potential antiinflammatory properties of the combined blocking of P-selectin plus beta2-integrin in the liver inflammatory response after uncontrolled hemorrhagic shock in rats. STUDY DESIGN: Sprague-Dawley rats (n = 64) weighing 250-300 g were included in a three-phase model of uncontrolled hemorrhagic shock. A prehospital phase consisted of 90 minutes of fluid resuscitation with lactated Ringer's solution to reach a mean arterial pressure (MAP) of 40 mmHg; a hospital phase consisted of 60 minutes of hemostasis and fluid resuscitation with lactated Ringer's solution to reach a MAP of 80 mmHg; and the third phase was 3 days of observation. All rats had 3 mL/100 g of blood volume shed during the initial 15 minutes. At 30 minutes, 75% tail amputation produced uncontrolled hemorrhagic shock. Four groups were randomized (n = 16 per group), and treatment at the beginning of resuscitation included normal saline (group 1); anti-P-selectin MAb, RMP-1 (group 2); anti-beta2-integrin MAb, WT.3 (group 3); or anti-P-selectin plus anti-beta2-integrin MAbs (group 4). The following indices were evaluated: fluid requirements for resuscitation, liver injury tests, liver tissue myeloperoxidase, and liver histology. RESULTS: Dual blockade of P-selectin and beta2-integrin significantly reduced fluid requirements for resuscitation (p < 0.05). We also observed a statistically significant improvement (p < 0.05) in tests demonstrating hepatic injury, myeloperoxidase in hepatic tissue, and histology studies. Survival was increased from 40% in controls to 60% with the dual-blockade treatment. CONCLUSIONS: These results indicate that dual-blockade strategies aimed at P-selectin and beta-integrin provided a protective effect in the liver inflammatory response after uncontrolled hemorrhagic shock in rats. Although dual blockade was more effective than either individual blockade alone, questions remain about the possible redundancy in the inflammatory adhesion pathways after this clinical condition.

[Surgical revision and correction of choledochal cysts]. / Revisión y corrección quirúrgica de quistes del colédoco.

Choledochal cyst are a rare congenital abnormality, seldom treated by the General Surgeon. We report six cases of re-operation found on a eighth year period. Six cysts type I, and one type II (Todani's Classification) were found. On five of them, an internal derivation had been performed, in one patient only a celiotomy was performed, and in another one a colecistectomy. Complete resection of the cyst was performed in six cases. In one female patient, this was impossible, because a carcinoma was found, she died postoperatively. We recommend external bile duct drainage for those cases where a complete resection can not be performed. This option alleviates the symptoms, allows morphological studies and do not compromise the final procedure which must be the complete excision of the cyst.