Embolia cerebral cálcica: presentación de una serie de 9 casos y revisión de la literatura / Calcified cerebral embolism: a 9 case series and review of the literature

Objetivo: Las embolias cerebrales cálcicas (ECC) representan una causa de ictus poco descrita e infradiagnosticada, que puede ser la primera manifestación de una enfermedad vascular o cardíaca. El objetivo del presente trabajo es describir las características de las ECC en una serie de casos y revisar la literatura. Pacientes y métodos: Tres centros hospitalarios aportaron casos al trabajo. Se evaluaron los métodos diagnósticos, las características de neuroimagen, la fuente embólica, el tratamiento y el pronóstico de los pacientes con ECC. Resultados: Se recogieron un total de 9 casos con ECC espontánea como causa de ictus isquémico agudo. Todos afectaron a la arteria cerebral media y se estudiaron mediante TC. Se encontró una posible fuente cálcica en 6 pacientes (66,6%): carotídea en 3 (33,3%) y cardíaca en otros 3 (33,3%) pacientes. Solo un paciente se trató en la fase aguda mediante trombectomía y solo un 11% tuvieron un mRS ≤ 2 a los 3 meses. Conclusiones: Las ECC son más frecuentes de lo que se creía en el pasado y, aunque siguen siendo comúnmente infradiagnosticadas, tienen una gran relevancia pronóstica a la hora de dirigir el estudio etiológico del ictus. (AU)

Objective: Calcified cerebral embolism (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. Our purpose is to describe the characteristics of CCE in a series of 9 cases and review the literature on the subject. Patients and methods: We included patients with CCE from 3 different hospitals. We described the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients. Results: We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originated in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified ranking scale scores ≤ 2 at 3 months. Conclusions: CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke. (AU)

Calcified cerebral embolism: a 9-case series and review of the literature.

OBJECTIVE: Calcified cerebral embolus (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. We describe the characteristics of CCE in a series of 9 cases and review the literature on the subject. PATIENTS AND METHODS: We included patients with CCE from 3 different hospitals. We describe the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients. RESULTS: We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originating in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified Ranking Scale scores ≤ 2 at 3 months. CONCLUSIONS: CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke.

Calcified cerebral embolism: a 9 case series and review of the literature. / Embolia cerebral cálcica: presentación de una serie de 9 casos y revisión de la literatura.

OBJECTIVE: Calcified cerebral embolism (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. Our purpose is to describe the characteristics of CCE in a series of 9 cases and review the literature on the subject. PATIENTS AND METHODS: We included patients with CCE from 3 different hospitals. We described the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients. RESULTS: We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originated in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified ranking scale scores ≤ 2 at 3 months. CONCLUSIONS: CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke.

Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer.

BACKGROUND: Abdominal perineal excision (APE) was originally described with levator ani removal for rectal cancer. An even wider, more aggressive extralevator resection for APE has been proposed. Although some surgeons are performing a very wide 'extralevator APE (ELAPE)', there are few data to recommend it routinely. This multicentre study aimed to compare outcomes of APE and ELAPE. METHODS: A multicentre propensity case-matched analysis comparing two surgical approaches (APE and ELAPE) was performed. All patients who underwent abdominoperineal resection of a rectal tumour were considered for the analysis. Tumour height was defined by magnetic resonance imaging measurement and patients with stage II-III tumours had neoadjuvant radiochemotherapy. Involvement of the circumferential resection margin (CRM) and intraoperative tumour perforation were the main outcome measures. A logistic regression model was used to study the relationship between the surgical approaches and outcomes. RESULTS: From January 2008 to March 2013 a total of 1909 consecutive patients underwent APE or ELAPE, of whom 914 matched patients (457 in each group) formed the cohort for analysis. Intraoperative tumour perforation occurred in 7.9 and 7.7 per cent of patients during APE and ELAPE respectively (P = 0.902), and there was CRM involvement in 13.1 and 13.6 per cent (P = 0.846). There were no differences between APE and ELAPE in terms of postoperative complication rates (52.3 versus 48.1 per cent; P = 0.209), need for reoperation (7.7 versus 7.0 per cent; P = 0.703), perineal wound problems (26.0 versus 21.9 per cent; P = 0.141), mortality rate (2.0 versus 2.0 per cent; P = 1.000) and local recurrence rate at 2 years (2.7 versus 5.6 per cent; P = 0.664). CONCLUSION: ELAPE does not improve rates of CRM involvement, intraoperative tumour perforation, local recurrence or mortality.

Sacral nerve stimulation for the treatment of faecal incontinence following low anterior resection for rectal cancer.

AIM: The aim of this study was to assess the effectiveness of sacral nerve stimulation (SNS) in the management of faecal incontinence following neoadjuvant therapy and low anterior resection (LAR) for rectal cancer. METHOD: In a prospective single-centre study, 15 patients (12 men, median age 72 years) were enrolled between 2005 and 2008. All had severe incontinence after total mesorectal excision, and 14 had received preoperative full-course chemoradiotherapy. The patients were followed up for a median of 50 (range: 24-144) months. There was no recurrence (local or distal). Incontinence was evaluated using the Cleveland Clinic Florida Fecal Incontinence (CCF-FI) scoring system. Quality of life (QoL) was evaluated using the Fecal Incontinence Quality of Life (FIQL) questionnaire. SNS was performed in three stages. RESULTS: During percutaneous nerve evaluation (PNE), a good response was observed in seven patients, all of whom received a permanent implant. The median follow up was 12 (range: 1-44) months. The mean CCF-FI score was reduced from 19.2 [standard deviation (SD) 1.2] to 6.2 (SD 1.7) (P < 0.01). The mean number of days per week with an incontinent episode decreased from 7 (SD 0) to 0.2 (SD 0.3) (P < 0.01), and the mean number of defaecations per week decreased from 42.5 (SD 13.7) to 13.2 (SD 7.4) (P < 0.01). In the five patients with a permanent implant who were followed up for longer than 6 months, all FIQL scores improved. An increase in the mean resting and squeeze pressures was seen in four patients with a permanent implant. CONCLUSIONS: SNS is a treatment option for faecal incontinence after LAR for rectal cancer.

Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano.

BACKGROUND: The aim of this randomized study was to compare the results of anal fistula plug and endorectal advancement flap in the treatment of high fistula in ano of cryptoglandular origin. METHODS: Consecutive patients with high trans-sphincteric fistula in ano of cryptoglandular aetiology were randomized to treatment with either an anal fistula plug or endorectal advancement flap. Patients agreed to participate in a follow-up programme, which included scheduled visits at 2, 4, 8, 12 and 24 weeks and at 1 year after surgery. The primary endpoint was effectiveness in fistula healing. Recurrence was defined as the presence of an abscess arising in the same area, or obvious evidence of fistulation. RESULTS: A large number of recurrences in the fistula plug group led to premature closure of the trial. After 1 year, fistula recurrence was noted in 12 of 15 patients treated with an anal fistula plug compared with two of 16 treated with an endorectal advancement flap (relative risk 6.40 (95 per cent confidence interval 1.70 to 23.97); P < 0.001). CONCLUSION: Contrary to other published studies, an anal fistula plug was associated with a low rate of fistula healing, particularly in patients with a history of fistula surgery.

Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano.

BACKGROUND: The length of follow-up required after surgical repair of cryptoglandular fistula in ano has not been established. This prospective study determined the follow-up time needed to establish that an anal fistula has been cured after elective fistulotomy or fistulectomy associated with endorectal advancement flap (ERAF) repair. METHODS: Between January 2001 and June 2004, consecutive patients with anal fistula of cryptoglandular aetiology were included provided that they lived within the catchment area of the hospital and agreed to participate in a follow-up programme, which comprised scheduled visits every month until complete wound healing and annually thereafter. RESULTS: Some 206 of 219 eligible patients were evaluable; fistulotomy was performed in 115 and ERAF repair in 91. Median follow-up was 42 (range 24-65) months. Eighteen patients had recurrence of the fistula during follow-up, with a median time to relapse of 5.0 (range 1.0-11.7) months. There were no recurrences after 1 year. CONCLUSION: Recurrence of fistula in ano of cryptoglandular origin treated by means of fistulotomy or ERAF repair occurs within the first year of operation.

Tratamiento de la enfermedad de Crohn perianal / Treatment of perianal Crohn’s disease

La afectación perianal por enfermedad de Crohn comprende un amplio espectro de lesiones de diferente manejo y pronóstico. Una exploración minuciosa del paciente, si es preciso bajo anestesia, una rectoscopia para valorar la posible afectación del recto por la enfermedad, y en ocasiones la valoración mediante ecografía endoanal o resonancia magnética, son las bases para un correcto enfoque diagnóstico y terapéutico. Farmacología y cirugía han de complementarse en el tratamiento de la enfermedad de Crohn perianal y perseguir un doble objetivo: aliviar la sintomatología del paciente y prevenir posibles complicaciones. Salvo en situaciones de urgencia por sepsis perianal, el tratamiento médico es el primer escalón en el manejo de la enfermedad de Crohn perianal, y en muchas ocasiones se controlará la enfermedad haciendo innecesaria la cirugía. Cuando se precisa de ésta, al propósito de un tratamiento definitivo de la lesión perianal, ha de contraponerse el riesgo de desarrollar complicaciones, muy especialmente incontinencia

Perianal affectation due to Crohn’s disease includes a wide spectrum of lesions involving different management and prognosis. A thorough exploration of the patient, under anaesthetic if necessary, a rectoscope to evaluate the possible affectation of the rectum by the disease, and on occasions evaluation through endoanal echography or magnetic resonance, are the bases for a correct diagnostic and therapeutic focus. Pharmacology and surgery must be complementary in the treatment of perianal Crohn’s disease and must pursue a double aim: to alleviate the symptomology of the patient and prevent possible complications. Except in situations of emergency due to perianal sepsis, medical treatment is the first step in managing perianal Crohn’s disease, and on many occasions it will control the disease, making surgery unnecessary. When surgery is required, with the aim of a definitive treatment of the perianal lesion, the risk of developing complications, especially incontinence, must be contrasted

[Treatment of perianal Crohn's disease]. / Tratamiento de la enfermedad de Crohn perianal.

Perianal affectation due to Crohn's disease includes a wide spectrum of lesions involving different management and prognosis. A thorough exploration of the patient, under anaesthetic if necessary, a rectoscope to evaluate the possible affectation of the rectum by the disease, and on occasions evaluation through endoanal echography or magnetic resonance, are the bases for a correct diagnostic and therapeutic focus. Pharmacology and surgery must be complementary in the treatment of perianal Crohn's disease and must pursue a double aim: to alleviate the symptomology of the patient and prevent possible complications. Except in situations of emergency due to perianal sepsis, medical treatment is the first step in managing perianal Crohn's disease, and on many occasions it will control the disease, making surgery unnecessary. When surgery is required, with the aim of a definitive treatment of the perianal lesion, the risk of developing complications, especially incontinence, must be contrasted.

Quality of life assessment in patients with chronic anal fissure after lateral internal sphincterotomy.

BACKGROUND: The aim of this study was to compare quality of life of patients with chronic anal fissure before and after open lateral internal sphincterotomy. METHODS: A prospective study was undertaken of 108 consecutive patients with a history of chronic anal fissure who underwent lateral internal sphincterotomy. Quality of life was measured before and 6 months after operation with the Short-Form 36 (SF-36) Health Survey. RESULTS: Quality of life improved significantly in six of the eight scales of the SF-36 questionnaire: physical functioning, role physical, bodily pain, energy, social functioning and mental health. There were no significant differences between the 70 patients who had no change in continence after operation and the 38 patients with continence disturbances after sphincterotomy. However, there were significant improvements in four scales in patients without changes in continence compared with improvements in only two scales in those with continence disturbances. CONCLUSION: Patients with chronic anal fissure showed an improvement in quality of life 6 months after internal lateral sphincterotomy. Patients with postoperative continence disturbances showed improvement in fewer scales of the SF-36 questionnaire than those without changes in continence.

Prospective study of artificial anal sphincter and dynamic graciloplasty for severe anal incontinence.

BACKGROUND AND AIMS: Dynamic graciloplasty and artificial anal sphincter are two options for refractory incontinence, the efficacy of which was compared in a prospective study. PATIENTS AND METHODS: Between November 1966 and June 1998, 16 patients were operated on (artificial anal sphincter 8, dynamic graciloplasty 8). Four consecutive operations with each technique were performed by two colorectal surgeons (one initiated the study with the neosphincter and the other with dynamic graciloplasty). Two independent observers assessed postoperative results at 4-month intervals. Patients were followed up to January 2001, with a median (interquartile range) of 44 (13) months and 39 (15) months for the nesophincter and the dynamic graciloplasty, respectively. RESULTS: Fourteen patients had complications. In the immediate postoperative period; there were eight cases of wound healing-related problems (four in the graciloplasty group). Perineal infection occurred in one patient in the graciloplasty group. At follow-up there were 11 complications (6 in the neosphincter group). Four patients undergoing neosphincter implantation had erosion or pain at the cuff site and had the implant removed (a new device was reimplanted in one). Four patients undergoing dynamic graciloplasty had the stimulator removed. Postoperatively the neosphincter was associated with a significantly lower score on the continence grading scale of the Cleveland Clinic Florida than graciloplasty. CONCLUSION: The artificial anal sphincter is a more convenient technique than dynamic graciloplasty for institutions treating small number of patients. However, technical failures and complications during follow-up that require reoperation are very high in both types of treatments.

Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy.

BACKGROUND: The aim of this study was to compare the results of stapled haemorrhoidopexy (commonly called stapled haemorrhoidectomy) with those of conventional diathermy haemorrhoidectomy. METHODS: Fifty-five patients with symptomatic third- and fourth-degree haemorrhoids were randomized to either stapled haemorrhoidopexy (n = 27) or conventional diathermy haemorrhoid ectomy (n = 28). Operating time, postoperative pain, time to return to work, postoperative complications and effectiveness of haemorrhoidal symptom control were recorded. The mean follow-up was 15.9 months in the stapled haemorrhoidopexy group and 15.2 months in the conventional haemorrhoidectomy group. RESULTS: Mean pain intensity was significantly less in the stapled group (P = 0.001). There were no significant differences in the total number of complications, the length of absence from work or control of symptoms. Seven patients in the stapled group re-presented with prolapse compared with none in the conventional haemorrhoidectomy group (P = 0.004). This difference was also observed in the subset of patients with fourth-degree haemorrhoids (P = 0.003). CONCLUSION: The stapled operation was significantly less painful than conventional haemorrhoidectomy. However, the rate of recurrent prolapse was higher after stapled haemorrhoidopexy than after conventional diathermy haemorrhoidectomy.

Complications and functional outcome following artificial anal sphincter implantation.

BACKGROUND: The postoperative complications and functional outcome following 24 consecutive implantations of an artificial anal sphincter were assessed prospectively. METHODS: A total of 24 artificial anal sphincters (Acticon Neosphincter) were implanted in 22 patients (mean age 47 years). The mean follow-up period was 28 (range 6-48) months. Results were assessed prospectively by two independent observers at 4-month intervals. The cumulative probability of artificial anal sphincter removal was analysed by the Kaplan-Meier method. RESULTS: Five patients were free of complications. During the postoperative period, complications occurred in nine patients, two of whom required reoperation. During follow-up, complications developed in ten patients, nine of whom were reoperated. Definitive device explantation was necessary in seven patients. The cumulative probability of device explantation was 44 per cent at 48 months. The 15 patients with functioning implants were followed up for a mean of 26 (range 7-48) months. Continence grading improved from a mean of 18 (range 14-20) in the preoperative period to 4 (range 0-14) after operation (P < 0.001). Resting anal canal pressure in patients with a functioning implant increased from a mean of 35 (range 8-87) mmHg before operation to 54 (range 34-70) mmHg after implantation (P < 0.01). CONCLUSION: An artificial anal sphincter is a useful alternative for refractory faecal incontinence but the incidence of late postoperative complications is high.

Valoración por parte de los pacientes con incontinencia fecal de los resultados del biofeedback / Patient evaluation of the results of biofeedback in fecal incontinence

Objetivo. Valoración subjetiva de los resultados inmediatos y a largo plazo del biofeedback para el tratamiento de la incontinencia fecal, y su correlación con los resultados objetivos logrados. Pacientes y métodos. Se incluyeron en el estudio 20 pacientes (16 mujeres y 4 varones, con una media de edad 62,05 ñ 13,84 años), con incontinencia fecal (idiopática 14, traumatismo de médula espinal 2, poscirugía de fisura anal 2, posresección anterior baja 1, colitis ulcerosa 1). Se han realizado cuatro sesiones con periodicidad quincenal. A todos se les ha valorado su continencia anal previa, al término de las sesiones y a largo plazo (media 23,1 meses; rango 12-41 meses) mediante una escala de cuatro grados: menos de una fuga al mes, más de una fuga al mes y menos de una a la semana, más de una fuga a la semana y menos de una al día, y fugas diarias. La valoración subjetiva se ha hecho con una escala analógica (0-10 puntos), y otra de sensación (empeoramiento, no empeoramiento). Resultados. Inmediatos: 10 (50 por ciento) reducen escapes; menos de una fuga al mes, 5 casos (25 por ciento); más de una fuga al mes y menos de una a la semana, 4 casos (20 por ciento); más de una fuga a la semana y menos de una al día 9 casos (45 por ciento), y fugas diarias 2 casos (10 por ciento); valoración subjetiva 6,35 ñ 2,5; 4 casos (20 por ciento) valoración de 9-10 puntos, 6 casos (30 por ciento) de 7-8 puntos, 6 casos (30 por ciento) de 5-6 puntos, y 4 (20 por ciento) inferior a 5 puntos. La valoración subjetiva se correlaciona con la frecuencia de escapes lograda: menos de un escape/semana (n = 9) 8,0 ñ 1,50, más de un escape/semana (n = 11) 5,0 ñ 2,53 (t -3,13; p < 0,006). Tardíos: 18 (90 por ciento) no han empeorado; menos de una fuga al mes 15 (75 por ciento); más de una fuga a la semana y menos de una al día 1 (5 por ciento), y fugas diarias 4 (20 por ciento); valoración subjetiva 5,05 ñ 2,8 (p < 0,01); en 2 casos (10 por ciento) la valoración fue de 9-10 puntos, en 4 casos (20 por ciento) fue de 7-8 puntos, en 5 casos (25 por ciento) fue de 5-6 puntos, y en 9 (45 por ciento) inferior a 5.La valoración subjetiva también se relaciona con la frecuencia de escapes: menos de uno/semana (n = 5) 5,86 ñ 2,5, más de un escape/semana (n = 15) 2,6 ñ 2,5 (t -2,53; p < 0,02). Diecinueve pacientes (95 por ciento) consideran no haber empeorado; 17 de los 18 que no han aumentado su frecuencia de escapes así lo han valorado. Conclusión. La valoración subjetiva de los resultados del biofeedback para el tratamiento de la incontinencia fecal, tanto inmediata como a largo plazo, coincide con los resultados objetivos logrados aunque sean moderados (AU)

Anastomosis coloanal con reservorio: ¿es una solución para el síndrome de la resección anterior? / Coloanal anastomosis with reservoir: a solution to anterior resection syndrome?

Introducción. La anastomosis coloanal con reservorio se ha propuesto como solución para mejorar la función defecatoria tras anastomosis rectales muy bajas. Objetivo. Evaluar los resultados funcionales de una serie consecutiva. Pacientes y métodos. Un total de 55 pacientes a los que se ha realizado una anastomosis coloanal con reservorio en "J". Para la evaluación funcional debe haber transcurrido por lo menos un año del cierre del estoma temporal. Resultados. Complicaciones: cuatro abscesos pélvicos/dehiscencias (7,2 por ciento), un absceso subhepático (1,8 por ciento), tres íleos (5,4 por ciento), dos disfunciones de la ileostomía (3,6 por ciento), 21 fallecimientos por embolismo pulmonar (1,8 por ciento). Funcionales: evaluados 36 pacientes. Frecuencia deposicional de 8 casos de 1,9/día; 20 problemas funcionales de forma global (56 por ciento): ocho tenesmos (22 por ciento), ocho dificultades evacuatorias (22 por ciento), cuatro urgencias (11 por ciento), 13 casos de incontinencia (36 por ciento) (gases en tres, heces en cinco y ensuciamiento en cinco). Conclusión. La anastomosis coloanal con reservorio mejora la frecuencia deposicional, pero no el resto de problemas funcionales. La evaluación de la cirugía conservadora de esfínteres deberá hacer más hincapié sobre la calidad de vida que sobre los resultados funcionales (AU)

El cirujano colorrectal como factor pronóstico de resultados / The colorectal surgeon as a prognostic factor of results

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Hemorroidectomía mediante máquina de sutura automática (técnica de Longo). ¿Son reproducibles los resultados de esta técnica? / Hemorrhoidectomy using stapled devices (Longo technique): are the results with this technique reproducible?

Introducción. Recientemente, se ha propuesto el tratamiento de la enfermedad hemorroidal mediante la exéresis y sutura del prolapso mucoso mediante una máquina de autosutura circular, técnica con la que se han descrito resultados excelentes tanto en términos de curación de la enfermedad como de alivio del dolor postoperatorio. El objetivo de este trabajo prospectivo ha sido evaluar la simplicidad del procedimiento, el dolor en el postoperatorio y las complicaciones de esta intervención. Pacientes y método. Veinticinco pacientes consecutivos, 19 con hemorroides de grado III y seis de grado IV fueron tratados con la técnica descrita por Longo, utilizándose el dispositivo PPH (ethicon endo-surgery). En todos los casos se indicó la misma pauta analgésica y fueron dados de alta 2 días después de la intervención. Para evaluar el dolor se utilizó una escala analógica visual, con un rango de 0-10 puntos. Al alta se le entregaba al paciente un diario donde debía anotar cada día la intensidad del dolor, con la misma escala empleada durante la estancia hospitalaria, y el consumo de analgésicos. El tiempo operatorio se midió mediante un cronómetro. Se recogieron las complicaciones postoperatorias. Todos los pacientes fueron visitados en la consulta a las 6 semanas de la intervención, solicitándoles una valoración de su satisfacción con la operación mediante una escala de 0 a 10 puntos. Resultados. El tiempo medio del procedimiento fue 12,4 ñ 4,20 min (rango, 6,2-25,3). Tres pacientes presentaron complicaciones después del alta. Ninguno requirió ingreso ni tratamiento quirúrgico. La intensidad del dolor postoperatorio fue de 5,2 ñ 1,9 puntos (rango, 1-10) el primer día y 3,1 ñ 1,7 (rango, 0-6) el segundo. Todos los pacientes excepto uno requirieron quetorolaco. En 3 casos fue necesario emplear meperidina. La intensidad media más alta del dolor después del alta fue 4,6 ñ 1,8 puntos (rango, 1-8). La media de días que los pacientes tomaron analgésicos en su domicilio fue 9,4 ñ 6,3. Ningún paciente requirió más de 3 dosis de quetorolaco. A las 6 semanas el 92 por ciento de los pacientes se mostró muy satisfecho con la intervención. Conclusión. En conclusión, la intervención de Longo es una técnica sencilla y rápida, con una tasa de complicaciones baja. Sin embargo, el dolor postoperatorio no ha sido tan escaso ni tan infrecuente como cabría esperar de la mayoría de las publicaciones previas (AU)

Oclusión intestinal por actinomicosis abdominal. Una infrecuente forma de presentación de la enfermedad / Intestinal occlusion due to abdominal actinomycosis. A rare presentation of the disease

La actinomicosis abdominal es una enfermedad poco frecuente producida por Actinomyces israelii, un germen usual del tracto gastrointestinal alto. Produce lesiones tumorales con abscesos y fístulas. Su forma de presentación clínica es muy variada. El diagnóstico preoperatorio correcto es inferior al 10 por ciento. Presentamos un caso de actinomicosis abdominal que se inició como obstrucción intestinal y que obligó a la resección quirúrgica con el diagnóstico preoperatorio de cáncer de colon izquierdo ocluido. La actinomicosis abdominal es una enfermedad que, aunque poco frecuente, debe tenerse en cuenta en el diagnóstico diferencial de pacientes con masas-abscesos abdominales (AU)

Adenopatías axilares como primer síntoma de carcinoma oculto de mama / Axillary lymph nodes as the first symptom of an occult breast cancer

La metástasis axilar de un carcinoma de mama oculto es una particular forma de presentación del cáncer de mama que ocurre en menos del 1 por ciento de los casos. Su tratamiento todavía es controvertido. La mastectomía, considerada clásicamente el tratamiento de elección, va siendo sustituída por la radioterapia con o sin quimioterapia, con tasas de supervivencia a 5 y 10 años similares. Presentamos dos casos de carcinoma oculto de mama tratados en nuestro hospital. Ambos recibieron radioterapia y quimioterapia tras la linfadenectomía axilar y ambos permanecen asintomáticos y sin evidencia de enfermedad tras un seguimiento de 66 y 42 meses. (AU)