Incontinencia urinaria: frecuencia y factores asociados / Incontinence: frequency and associated factors

Objetivo: Describir la frecuencia, características y factores asociados a la incontinencia urinaria en pacientes mayores de 25 años que son remitidos al Servicio de Fisioterapia del Hospital de Talavera de la Reina por motivos independientes a la IU. Material y método: estudio descriptivo transversal en 506 sujetos consecutivos en los que se utilizó el Cuestionario corto de calidad de vida de la International Consultation on Incontinence Questionnaire (ICIQ_IU_SF), validado para diagnosticar la IU y sus tipos. Resultados: La frecuencia de IU fue de 15,6% (IC 95% 10,7-20,5) en hombres y 55,6% (IC 95% 49,8-61,9) en mujeres. En los hombres, se encontró asociación significativa de la IU con la edad (OR > de 65 años = 66,91; IC 95% 8,6-526,8; p < 0,001) y tener problemas de próstata (OR ajustada por edad = 4,2; IC 95% 1,54-11,69; p = 0,005). Los factores asociados a la IU en mujeres (ajustados por edad), fueron el sobrepeso (OR = 2,7; IC 95% 1,47-4,92; p = 0,001) y la obesidad (OR = 2,5; IC 95% 1,28-4,67; p = 0,007), el estreñimiento crónico (OR = 2,3; IC 95% 1,20-4,32; p = 0,01), las infecciones urinarias de repetición (OR = 2,26; IC 95% 1,01-5,09; p = 0,048), los desgarros durante el parto (OR = 1,9; IC 95% 1,03-3,65; p = 0,039), y la menopausia (OR = 2,3; IC 95% 1,06-5,09; p = 0,036). Conclusiones: La incontinencia urinaria es mucho más frecuente en mujeres. Los factores asociados son diferentes en ambos sexos, siendo en los hombres la edad y problemas de próstata y en las mujeres la obesidad, estreñimiento, infecciones urinarias, factores relacionados con el parto y la menopausia

Objective: To describe frequency, characteristics and factors associated with urinary incontinence in patients over 25 who are referred to the Hospital Talavera de la Reina Physiotherapy Service for reasons other than UI factors. Material and methods: A cross-sectional study that included 506 consecutive subjects in whom the ICIQ_IU_SF questionnaire validated for diagnosing UI and their types was performed. Results: The frequency of UI was 15.6% (95% CI 10.7 to 20.5) in men and 55.6% (95% CI 49.8 to 61.9) in women. A significant association of UI with age (OR > 65 = 66.91, 95% CI 8.6 to 526.8, p < 0.001) and prostate problems (OR adjusted for age = 4.2, 95% CI 1.54 to 11.69, p = 0.005). was found in men. The factors associated with UI in women (age adjusted) were overweightness (OR = 2.7, 95% CI 1.47 to 4.92, p = 0.001) and obesity (OR = 2.5, 95% 1.28 to 4.67, p = 0.007), chronic constipation (OR = 2.3, 95% CI 1.20 to 4.32, p = 0.01), recurrent urinary tract infections (OR = 2, 26, 95% CI 1.01 to 5.09, p = 0.048), tears during delivery (OR = 1.9, 95% CI 1.03 to 3.65, p = 0.039), and menopause (OR = 2.3, 95% CI 1.06 to 5.09, p = 0.036). Conclusions: Urinary incontinence is more common in women. Associated factors are different in both sexes. In men, these were age and prostate problems and for women obesity, constipation, urinary tract infections, factors related to childbirth and menopause

Caracterización de una población con discapacidad visual (baja visión y ceguera) atendida en dos instituciones prestadoras de salud de Medellín / Characterization of a population with visual disabilities (low vision and blindness) attended in two health institutions from Medellín / Caracterização de uma população com incapacidade visual (baixa visão e cegueira) atendida em duas instituições prestadoras de saúde de Medellín

Objetivo: caracterizar, en los ámbitos clínico y sociodemográfico, una población de pacientes con discapacidad visual atendidos en dos instituciones de salud de la ciudad de Medellín (departamento de Antioquia/Colombia), con énfasis en la etiología del déficit visual irreversible. Metodología: estudio observacional descriptivo. Estudio macro sobre deficiencias visuales unilaterales y bilaterales en 1 742 registros de historias clínicas para identificar pacientes con baja visión o ceguera. Aplicación de un formato de investigación orientado a validar los pacientes con discapacidad visual y se seleccionaron 107 historias clínicas. Resultados: el 56.6% presenta discapacidad visual tipo baja visión y el 43.4% discapacidad visual tipo ceguera. El déficit visual responsable de la discapacidad visual fue del 39% por causas oftalmológicas, 20% por alteraciones neuro-oftalmológicas y 17% por trastornos neurológicos de cortezas visuales. Además de la agudeza visual, se encontraron otras deficiencias de la función visual: atrofia óptica, alteración electrofisiológica de la conducción visual y encefalomalacia en cortezas visuales. El 82% de los pacientes tiene al menos una comorbilidad no oftalmológica. Conclusiones: es fundamental un adecuado registro de las características biológicas, sociales, psicológicas y de las actividades de rehabilitación de los pacientes con baja visión y ceguera, para entender en forma integral no sólo la discapacidad sino el impacto que produce.

Objective: to characterize the clinical and socio-demographical characteristics of a population of patients with visual impairment attended at two health institutions in Medellín (Antioquia, Colombia), with an emphasis on the etiology of irreversible vision loss. Methodology: Observational, descriptive study of unilateral and bilateral visual impairment in 1 742 medical records to identify patients with low vision or blindness. A research form was used to validate patients with visual impairment, and 107 medical records were selected. Results: 56.6% presented low vision and 43.4% presented blindness. Vision loss was due to ophthalmic causes in 39% of cases, 20% were caused by neuro-ophthalmic alterations and 17% by neurological disorders of the visual cortex. In addition to visual acuity, other visual impairments were found, such as optic atrophy, electrophysiological alteration of the visual pathway, and encephalomalacia in visual cortices. 82% of patients had at least one nonophthalmic comorbidity. Conclusions: Adequate registration of rehabilitation activity, biological, social, and psychological characteristics of patients with low vision and blindness is essential in order to fully understand both the impairment and its impact.

Objetivo: caracterizar, nos âmbitos clínico e sócio-demográfico, uma população de pacientes com incapacidade visual atendidos em duas instituições de saúde da cidade de Medellín (departamento de Antioquia/Colômbia), com énfase na etiologia do déficit visual irreversível. Metodologia: estudo observacional descritivo. Estudo macro sobre deficiências visuais unilaterais e bilaterais em 1 742 registros de histórias clínicas para identificar pacientes com baixa visão ou cegueira. Aplicação de um formato de investigação orientado a validar os pacientes com incapacidade visual e se selecionaram 107 histórias clínicas. Resultados: 56.6% apresenta incapacidade visual tipo baixa visão e 43.4% incapacidade visual tipo cegueira. O déficit visual responsável da incapacidade visual foi de 39% por causas oftalmológicas, 20% por alterações neuro-oftalmológicas e 17% por transtornos neurológicos de córtex visual. Ademais da agudeza visual, se encontraram outras deficiências da função visual: atrofia óptica, alteração eletrofisiológica da condução visual e encefalomalácia em córtex visual. 82% dos pacientes têm pelo menos uma comorbilidade não oftalmológica. Conclusões: é fundamental um adequado registro das características biológicas, sociais, psicológicas e das atividades de reabilitação dos pacientes com baixa visão e cegueira, para entender em forma integral não só a incapacidade senão o impacto que produz.

Simultaneous pancreas-kidney transplantation: is the failure of the grafts also simultaneous?

INTRODUCTION: It is well known that after a simultaneous pancreas and kidney transplantation (SPKT) there is a higher incidence of pancreatic graft loss in the acute period, due to technical problems. However, there is little information about the survival of pancreatic and kidney grafts 1 year after transplantation. AIMS: To analyze the causes of long-term graft loss of SPKT in our hospital and to determine if this loss occurs simultaneously or is isolated. PATIENTS AND METHODS: We analyzed the data of 63 SPKTs performed between February 1983 and October 2005, including the cases with normal renal and pancreatic function after 1 year of transplantation, and with a loss of one or two organs during the follow-up period (8 +/- 4 years). We defined simultaneous SPKT failure as failure that occurs at the same time or when the period between pancreatic and renal graft failure is shorter than 9 months. RESULTS: In 28 patients (44%), there was a simultaneous graft failure, whereas in 35 (56%) the loss of function occurred in only one organ or in both, but separately. Death was responsible for 75% (21/28) of simultaneous graft losses, representing 25% (9/35) of isolated graft failures. Cardiovascular disease was the leading cause of death. In 14 of 35 isolated graft failures, there was loss of renal and pancreatic function (11/14 kidney failed first) with a 2.9 +/- 2.3 years of interval. In 12 cases there was only loss of pancreatic function, whereas in nine cases the affected organ was the kidney. Graft chronic nephropathy and chronic rejection in the pancreas were the main causes of graft failure. CONCLUSIONS: The main cause of simultaneous SPKT failure is patient death; however, among isolated or separated SPKT failures, the kidney failed first, more frequently.

Macrovascular events after kidney-pancreas transplantation in type 1 diabetic patients.

BACKGROUND: There are few studies concerning the effect of kidney-pancreas transplantation (KPTx) on the progression of macrovascular disease in type 1 diabetic patients. The aim of our study was to retrospectively evaluate the incidence of macrovascular events after functioning KPTx. MATERIALS AND METHODS: We studied 146 patients (96 men and 50 women) who had undergone KPTx from February 1983 to September 2001, with more than 1 year of evolution of both grafts functioning normally. The mean follow-up of the patients after KPTx was 5+/-3 years. RESULTS: Before KPTx, 29 patients displayed 42 macrovascular events. During the follow-up after transplantation, intermittent claudication remained in 25 patients (86.2%) with 11 new macrovascular events (1 stroke, 1 angina pectoris, 1 myocardial infarction, and 8 minor amputations) in 10 patients (34%). Among the 117 patients without antecedent macrovascular events prior to KPTx, 38 (32.5%) experienced a total of 63 macrovascular events (26 intermittent claudication, 4 stroke, 8 angina pectoris, 7 myocardial infarction, 11 minor amputations, and 7 major amputations). Before transplantation, 88.4% of the patients presented with hypertension, 42.5% a history of smoking, and 14.4% previous treatment for dyslipidmia. After transplantation, we observed an important reduction in the percentage of patients with hypertension (48.6%) and smoking (25.5%), without a change in the prevalence of dyslipemia (19.9%). Hypertension after transplantation was clearly associated with the appearance or persistence of macrovascular events. CONCLUSION: In our experience, 43% of the transplant recipients present with macrovascular events. It is important to note the elevated prevalence of cardiovascular risk factors in the patients who underwent KPTx.

Laparoscopic pancreatic surgery in patients with chronic pancreatitis.

BACKGROUND: In recent years, technological advances and technical refinements to laparoscopic instruments have encouraged some surgeons to explore the application of laparoscopic methods to benign disorders of the pancreas. The aim of this report was to evaluate the feasibility and outcome of laparoscopic pancreatic surgery in patients with chronic pancreatitis. METHODS: One group of five patients with disease of nonalcoholic origin localized in the body-tail of the pancreas underwent distal pancreatectomy with preservation of the splenic vessels; a second group of six patients with symptomatic pancreatic pseudocysts (alcoholic origin in four cases and idiopathic in two cases) underwent laparoscopic transgastric drainage. For distal pancreatectomy and spleen salvage, the patient's positioning was half-lateral decubitus with the left side up. Four ports were used. A comparison was made with 41 patients with chronic, pancreatitis who underwent conventional open distal pancreatectomy. For the patients with laparoscopic distal pancreatectomy, the mean operative time was 4 h (range 3-5). RESULTS: There were no pancreatic-related complications, but one patient was reoperated for perforation of duodenal ulcer. The mean hospital stay was 6 days and the mean time to resume normal daily activities was 3 weeks. Laparoscopic pseudocyst drainage was performed in four patients via laparoscopic anterior gastrostomy and two patients via laparoscopic intraluminal cystogastrostomy. The mean operative time was 100 min (range 60-160). There was no morbidity. The mean hospital stay was 5 days, and the mean time to resume normal daily activities was 2 weeks. CONCLUSION: This study provides information about the possibilities of performing laparoscopic surgery in patients with chronic pancreatitis. Laparoscopic distal pancreatectomy with preservation of the splenic vessels and laparoscopic transgastric drainage are feasible and safe techniques. They offer obvious advantages, such as reduction of the parietal damage to the abdomen, a shorter hospital stay, and an earlier postoperative recovery than can be obtained with conventional open pancreatic resection.

Outcome of laparoscopic pancreatic surgery: endocrine and nonendocrine tumors.

Laparoscopic pancreatic surgery (LapPS) for management of benign pancreatic tumors has still not been defined. This paper evaluates the feasibility and outcome of LapPS in patients with endocrine pancreatic tumors (EPTs) and cystic neoplasms of the pancreas (CyNP). Eighteen patients with benign pancreatic tumors underwent LapPS between January 1998 and May 2001. The indications were 10 EPTs (6 sporadic insulinomas, 1 multiple insulinoma of multiple endocrine neoplasia type 1, 2 nonfunctioning tumors, 1 VIPoma) and 8 CyNPs (3 serous cystadenomas, 5 mucinous cystic neoplasms). The laparoscopic procedure was performed using four ports with patients in the half-lateral position. Laparoscopic ultrasonography (LapUS) was used in all cases. Laparoscopic enucleation (LapE) was planned in five patients and performed in four (one conversion for tumor not found during laparoscopy). Laparoscopic pancreatic resection (LapPR) with spleen salvage was planned in 13 patients and performed in 12 (one conversion for metastatic VIPoma), with splenic vessel preservation in 11 patients and short gastric vessel preservation in 1. The average operating time was 3.5 hours after enucleation, 4.0 hours after distal pancreatectomy, and 5.0 hours after subtotal pancreatectomy. Pancreatic fistula was observed in two patients after LapE and in three patients after LapPR. Splenectomy for splenic abscess was performed 1 week after surgery in a patient with short gastric vessel splenic preservation. The average hospital stay was 5 days. We concluded that LapPS is a safe method for removing EPTs and CyNPs, although the incidence of pancreatic fistulas remains high. In selected patients LapPS offers significant benefit to patients: reduced trauma to the abdominal wall, short hospital stay, and a quick postoperative recovery.

Treatment and outcome of pancreatic venous graft thrombosis after kidney--pancreas transplantation.

BACKGROUND: Pancreas venous graft thrombosis after transplantation is the main non-immunological cause of graft failure and usually results in pancreatectomy. Duplex Doppler ultrasonography is the primary imaging technique for monitoring vascular patency after pancreas transplantation. This study reports the results of rescue treatments for pancreas graft thrombosis after simultaneous pancreas--kidney transplantation. METHODS: One hundred and ninety-six patients with insulin-dependent diabetes mellitus received a simultaneous pancreas--kidney transplantation. Venous graft thrombosis was diagnosed in 25 of these patients based on Doppler ultrasonographic findings. RESULTS: Total venous graft thrombosis was diagnosed in 20 symptomatic patients, of whom 14 required graft pancreatectomy. Surgical thrombectomy was attempted in six patients with preserved arterial supply and was successful in four. Partial venous graft thrombosis was diagnosed in five asymptomatic patients; one also had partial splenic artery thrombosis. Rescue graft procedures included systemic anticoagulation (one patient), arterial thrombolysis (one) and venous thrombolysis and/or mechanical venous thrombectomy (four episodes in three patients). Graft rescue was achieved in three patients treated by venous thrombolysis/thrombectomy. CONCLUSION: Doppler ultrasonography allows the appropriate selection of rescue treatment based on the findings of total or partial thrombosis.

Coledocolitiasis no sospechada: abordaje laparoscópico durante la colecistectomía / Laparoscopic exploration of the common bile duct for unsuspected stones during cholecystectomy

Introducción. En los pacientes con colelitiasis sintomática, la colangiografía intraoperatoria transcística durante la colecistectomía laparoscópica puede mostrar la presencia de cálculos no sospechados en la vía biliar principal entre el 1 y el 9 por ciento, según las distintas series publicadas. El objetivo de este estudio es valorar la utilidad y los resultados del abordaje transcístico laparoscópico de la coledocolitiasis no sospechada, diagnosticada durante la colecistectomía laparoscópica, en una serie de pacientes con antecedentes de pancreatitis aguda biliar y coledocolitiasis tratada por colangiopancreatografía retrógrada endoscópica (CPRE).Pacientes y métodos. Desde enero de 1997 hasta abril de 2001, en 349 pacientes que fueron sometidos a colecistectomía laparoscópica (201 pacientes pospancreatitis aguda biliar, 75 pacientes post-CPRE y 73 pacientes con colelitiasis sintomática), la realización de colangiografía objetivó la existencia de coledocolitiasis en 34 pacientes (10 por ciento). De ellos, 19 eran mujeres y 15 eran varones con una edad media de 67 años. El abordaje de la vía biliar principal mediante extracción transcística fue utilizado en 15 pacientes (44 por ciento), la dilatación neumática de la papila en 12 (35 por ciento) y coledocotomía laparoscópica en tres (9 por ciento).Resultados. Todos los pacientes fueron tratados por laparoscopia de forma satisfactoria sin necesidad de conversión. El número de cálculos extraídos varió de uno a ocho, y el tamaño de 2 a 8 mm. El tiempo operatorio medio fue de 79 min (límites, 35125) para la extracción transcística, 82 min (límites, 50-105) para la dilatación neumática de la papila y de 105 min (límites, 90-120) para la coledocotomía laparoscópica. Cuatro pacientes requirieron la realización de una CPRE postoperatoria (12 por ciento) por coledocolitiasis residual. La morbilidad asociada a la cirugía fue del 15 por ciento.Conclusiones. La colangiografía transcística durante la colecistectomía laparoscópica es necesaria para el diagnóstico de la coledocolitiasis no sospechada (10 por ciento). El abordaje por vía transcística o por coledocotomía es posible y consigue eliminar la litiasis de la vía biliar principal en el 91 por ciento de nuestros pacientes. Ambas técnicas laparoscópicas son reproducibles si se dispone de la experiencia y del material adecuado, evitando un número importante de conversiones y CPRE postoperatorias. (AU)

[Schistosomiasis of the spinal cord. Case report]. / Esquistosomiasis medular. Presentación de un caso clínico.

The authors report a case of a 34 year-old woman who, in the last four years, had travelled to Africa frequently, and developed a progressive clinical (about three months) dysfunction of the conus medullaris mainly consisting in sensitive disturbances. The MRI showed an intramedullary spinal cord lesion, and specific laboratory tests were negative. A biopsy for histologic diagnosis, showed a granulomatous tissue with eggs of S. Hematobium. After this diagnosis she was treated with praziquantel. We emphasize the relative frequency of the spinal cord location of schistosomiasis in endemic countries, and the importance of the laboratory diagnosis to start an early and effective antischistosomal treatment. Spinal cord schistosomiasis is uncommon but we must bear in mind this possibility in patients with a progressive spinal cord afectation.

[Pancreas and kidney transplantation: long-term metabolic results]. / Greffe de pancréas et de rein: résultats métaboliques à long terme.

STUDY AIM: Pancreas and kidney transplantation (PKTx) is indicated in uremic patients with insulin-dependent diabetes mellitus (IDDM). The aim of this study was to determine its long-term effect on metabolic control in order to establish the real efficacy of this treatment in diabetic patients. PATIENTS AND METHOD: Among a total experience of 191 pancreas and kidney transplantations, a metabolic control was performed in 80 patients who underwent PKTx in our center, with both grafts functioning for more than one year. Immunological markers of diabetes mellitus were also evaluated (ICA and GADab) in 50 patients. RESULTS: Basal glycemia and glycosylated hemoglobin (HbA1c) levels throughout follow-up were within the normal range. Hyperinsulinemia was present throughout follow-up till the fourth year. The oral glucose tolerance test (OGTT) was normal in 82.5% of the patients beyond one year after the graft. Over time, no differences were detected on basal glucose and insulin levels and areas under the curve (AUC) of glycemia and insulinemia. During the evolution, no differences were found in the fasting insulin resistance index (FIRI), in spite of increasing body weight. ICA were + in 2 patients before graft and + in 7 after graft (14%). GADab were + in 10 patients before graft and + in 11 after graft (22%). CONCLUSION: Pancreas and kidney transplantation provides without any insulin treatment and diet long-term normalization of glycemic control, assessed by HbA1c and OGTT, despite the existence of sustained hyperinsulinemia. Our results strongly suggest that pancreas and kidney transplantation is the most efficient treatment for uremic patients with insulin-dependent diabetes mellitus from a metabolic point of view.

Laparoscopic pancreatic surgery in patients with neuroendocrine tumours: indications and limits.

Laparoscopic pancreatic procedures are still at an evaluation stage with regard to their indications and techniques. Between January 1998 and December 2000, 13 patients with endocrine pancreatic tumours - 11 insulinomas and 2 non-functioning tumours-underwent laparoscopic surgery, laparoscopic ultrasonography being used in all the patients. Enucleation was performed in five patients. The operative time was 2-3 hours. Distal pancreatectomy was performed in six patients with insulinomas, and spleen preservation with intact splenic vessels was feasible in five. Splenectomy was necessary in one patient for technical reasons. Laparoscopic distal pancreatectomy with splenic vessel preservation was performed in two patients with a large (6 and 8 cm) non-functioning tumour. The mean operative time for all the patients undergoing distal pancreatectomy was 4 hours, ranging from 3 to 5 hours. A pancreatic fistula occurred in three patients after tumour enucleation and in two patients after distal pancreatectomy; the mean hospital stay for all patients was 5 days. Enucleation guided by laparoscopic ultrasonography thus allows safe tumour dissection and excision, laparoscopic distal pancreatectomy also being feasible and safe. Splenic salvage with splenic vessel preservation is technically possible. The laparoscopic approach allows a shorter hospital stay and an earlier return to normal activities.

Trasplante clínico de páncreas: resultados a largo plazo / Pancreatic transplantation: long-term results

Objetivo. Analizar a largo plazo la estabilidad de la función pancreática y la posible repercusión sobre ella de la reaparición de los marcadores inmunológicos de la diabetes tipo 1.Material y métodos. A partir de una experiencia global de 191 trasplantes de riñón y páncreas, se evaluó el control metabólico en 80 pacientes, con un correcto funcionamiento de ambos injertos, entre uno y 10 años. También se realizó el estudio de los marcadores inmunológicos, los anticuerpos contra la célula del islote (ICA) y los anticuerpos contra la glutámico ácido decarboxilasa (GADab).Resultados. Los valores de glucemia basal y hemoglobina glucosilada (HbA1c) se mantuvieron dentro de cifras normales a lo largo del estudio. La insulinemia basal se mantuvo elevada de forma significativa hasta el cuarto año postrasplante. El test de tolerancia oral a la glucosa (TTOG) fue normal en un 82,5 por ciento de los pacientes al año del trasplante, siendo la curva intolerante en un 14 por ciento y la curva diabética en un 3,5 por ciento; ningún paciente recibía insulina. Esta proporción se mantuvo hasta los 6 años del trasplante. Los ICA fueron positivos antes del trasplante en 2 pacientes (4 por ciento) y después del trasplante en siete (14 por ciento). El GADab fue positivo en 11 pacientes (22 por ciento) al año del trasplante, de los que 10 ya eran previamente positivos. Conclusiones. El trasplante de páncreas permite mantener la glucemia y la HbA1c dentro de la normalidad a largo plazo sin necesidad de insulina ni restricciones dietéticas. El estudio de los marcadores inmunológicos de la diabetes mellitus tipo 1 debería formar parte del seguimiento de los pacientes trasplantados (AU)

Complicaciones de la cirugía del cáncer de páncreas / Complications in pancreatic cancer surgery

La mortalidad de la duodenopancreatectomía, en la mayoría de centros con amplia experiencia en la técnica, no supera el 3 por ciento, habiéndose publicado series extensas sin mortalidad. Este descenso en la mortalidad operatoria es multifactorial: cirujanos con mayor experiencia, capaces de realizar la intervención en menos tiempo y con menor pérdida de sangre, mejores cuidados pre y postoperatorios, mejor técnica anestésica y soporte nutricional adecuado. En constraste con la reducción que se ha producido en la mortalidad operatoria la morbilidad de la duodenopancreatectomía continúa siendo muy elevada, y se han comunicado cifras de hasta un 52 por ciento. Las complicaciones pueden clasificarse como generales, o no quirúrgicas, derivadas del sistema cardiovascular, respiratorio o renal, y directamente relacionadas con la técnica quirúrgica. Las causas más frecuentes de morbilidad relacionada con la técnica son: vaciamiento gástrico retrasado, fístula pancreática, fístula biliar, fístula gastrointestinal, absceso intraabdominal, hemorragia, pancreatitis y úlcera marginal. La incidencia de complicaciones generales en la cirugía exerética del páncreas oscila entre un 9 y un 17 por ciento, y la de complicaciones relacionadas con la técnica entre un 25 y un 35 por ciento, que obligan a la reintervención en un 4-9 por ciento de los casos (AU)

Doble derivación, gástrica y biliar, por laparoscopia en pacientes con carcinoma de cabeza de páncreas irresecable / Laparoscopic gastric and biliary bypass in patients with unresectable pancreatic head carcinoma

Antecedentes. Un elevado número de pacientes con cáncer de páncreas irresecable presentan dificultades del vaciamiento gástrico y obstrucción biliar; en esta situación clínica debe ser planteada una intervención paliativa. El propósito de este estudio en pacientes con cáncer de páncreas irresecable fue la valoración de la seguridad y de la eficacia de la doble derivación biliar y gástrica al intestino delgado mediante el abordaje laparoscópico. Pacientes y método. Entre agosto de 1995 y julio de 1998 fueron intervenidos 12 pacientes consecutivos con carcinoma irresecable de páncreas mediante una derivación biliar (colecistoyeyunostomía) y gástrica (gastroyeyunostomía) transmesocólica simultáneas por laparoscopia. Se realizó en 8 varones y 4 mujeres, con una edad media de 72 años (rango, 50-82 años). En todos los pacientes la indicación de las derivaciones fueron ictericia obstructiva y obstrucción del vaciamiento gástrico. Se valoró la morbilidad relacionada con el procedimiento, la mortalidad, el tiempo operatorio, la estancia intrahospitalaria, la supervivencia y la capacidad de mantener la alimentación oral durante el período de supervivencia. Resultados. Todos los procedimientos fueron completa dos por abordaje laparoscópico, y el tiempo operatorio fue de 89 ñ 29,56 min (rango, 35-150 min). No hubo complicaciones intraoperatorias. La morbilidad postoperatoria consistió en infección de la herida en 2 pacientes y neumonía en otro enfermo. Un paciente con cirrosis falleció por fallo multiorgánico al segundo día del postoperatorio. La estancia hospitalaria promedio fue de 6,4 ñ 1,5 días (rango, 5-17 días). El tiempo de supervivencia hasta la muerte por la enfermedad subyacente fue de 85 ñ 32,46 días. Durante este período, la tolerancia a la alimentación oral fue adecuada y en ningún caso reapareció la ictericia. Conclusión. La doble derivación, biliar y gástrica, simultáneas, por vía laparoscópica son técnicas seguras y eficaces para el tratamiento de la obstrucción biliar y gástrica en pacientes con cáncer de páncreas irresecable (AU)

(99m)Tc-sestamibi scintigraphy and cell cycle in parathyroid glands of secondary hyperparathyroidism.

Double-phase parathyroid MIBI ((99m)Tc-sestamibi) was performed in 27 patients with secondary hyperparathyroidism (SPT). Focal areas of increased uptake were scored for intensity on a three-point scale. All patients underwent subtotal parathyroidectomy (SPTx), and a total of 78 glands were removed at operation. Blood was obtained from the jugular vein before and after SPTx to measure the parathyroid hormone (PTH) levels. The volume and weight of the glands were calculated. The tissue was divided, with one aliquot being used for cell cycle analysis. The nuclei were acquired by flow cytometry and analyzed using CELLEIT software. Cell viability was assessed by flow cytometry and analyzed with LYSIS II software. Positive MIBI uptake was observed in 88.8% of patients. Focal MIBI uptake of one, two, or three glands was observed in 6, 11, and 8 patients, respectively. All patients experienced an 86% decrease in PTH blood level after SPTx compared to that before excision. A correlation was found between the volume of glands and the blood levels of intact PTH (iPTH) (r = 0.5, p < 0.05). A positive correlation was observed between MIBI uptake and the iPTH levels before SPTx (p < 0.01) and between the uptake of MIBI in the parathyroid glands and the cell cycle phases; low-grade uptake correlated with the G(0) phase and higher uptake with G(2)+S phase (r = 7, p < 0.01). No correlation was observed between MIBI uptake and the weight of the glands. MIBI scintigraphy accurately reflects the functional status of the hyperplastic parathyroid glands: Higher uptake grades correlated with the active growth phase. MIBI uptake does not reveal parathyroid enlargement; rather, it identifies the presence of hyperfunctioning autonomous glands. SPTx and total parathyroidectomy with autografting (TPTx+A) are the most widely accepted surgical approaches for patients with SPT. Reoperation for recurrence is necessary in 6% to 15% of cases. MIBI is now considered to be the radionuclide of reference for parathyroid gland scanning, although it is widely accepted that it produces poor results when trying to detect hyperplastic glands.

Cirugía endoscópica de las glandulas suprarrenales / Endoscopic surgery of the adrenal glands

Introducción. El abordaje laparoscópico de la glándula suprarrenal ha demostrado ser seguro y reproducible, pero presenta múltiples aspectos controvertidos y pocas series superan los 100 casos. Objetivo. Evaluar los resultados del abordaje laparoscópico de la glándula suprarrenal. Pacientes y métodos. Desde mayo de 1992 hasta diciembre de 1999 hemos realizado 116 adrenalectomías en 106 pacientes. Las indicaciones de la cirugía fueron: incidentaloma (n = 20), tumor metastásico (n = 8), aldosteronoma (n = 30), adenoma de Cushing (n = 12), enfermedad de Cushing (n = 7), feocromocitoma esporádico (n = 26) y neoplasia endocrina múltiple tipo 2 (n = 3). Resultados. El tiempo operatorio en las adrenalectomías unilaterales fue de 89 ñ 22 min y de 272 ñ 46 min en las adrenalectomías bilaterales. La estancia hospitalaria fue de 3 ñ 0,7 días para las adrenalectomías unilaterales y de 6 ñ 1,6 días para las adrenalectomías bilaterales. En 9 pacientes se realizó conversión a cirugía abierta por diversas razones (tamaño [n = 3], adherencias perineoplásicas [n = 3], dificultad técnica [n = 2] y neoplasia malignas [n = 1]). Los abordajes intra y extraperitoneal son igualmente seguros con la colocación del paciente en decúbito lateral. La insuflación de CO2 es segura, pero la insuflación con helio sería recomendable para pacientes con feocromocitoma y aquellos con enfermedades car diorrespiratorias. Conclusión. El abordaje laparoscópico puede considerarse en la actualidad el tratamiento de elección para los tumores adrenales benignos (AU)

Esplacnicectomía toracoscópica en el tratamiento del dolor en pacientes con cáncer de páncreas irresecable / Thoracoscopic splanchnicectomy in the treatment of pain in patients with irresectable pancreatic cancer

Introducción. En los pacientes con una neoplasia de páncreas irresecable el dolor es uno de los síntomas de más difícil control, produciendo limitaciones en la actividad de los enfermos y empeorando claramente su calidad de vida. Las intervenciones que se realizan en estos pacientes son paliativas, con el único objetivo de aliviar los síntomas de su enfermedad. El objetivo de este estudio es determinar la eficacia y seguridad de la esplacnicectomía toracoscópica, para el control del dolor en pacientes con cáncer de páncreas irresecable. Pacientes y métodos. Desde mayo de 1995 a abril de 1998 hemos realizado 35 esplacnicectomías toracoscópicas en 24 pacientes consecutivos (14 varones y 10 mujeres), diagnosticados de cáncer de páncreas irresecable. Todos los pacientes eran dependientes de opiáceos para controlar su dolor e incapaces de realizar una actividad diaria normal. Se ha utilizado la escala visual analógica (EVA) como parámetro subjetivo de medida del dolor en estos pacientes. Además, se han evaluado el tiempo operatorio, la morbilidad y mortalidad relacionada con el procedimiento y la estancia hospitalaria. Resultados. Todas las esplacnicectomías se han completa do por toracoscopia, sin complicaciones intraoperatorias. El tiempo operatorio fue de 58 ñ 22 min en la esplacnicectomía izquierda y de 93,5 ñ 15,6 min en la esplacnicectomía bilateral. La determinación del dolor por la EVA en estos pacientes era de 8,5 (8-10) como valor medio preoperatorio. El dolor desapareció o mejoró durante el postoperatorio, consiguiendo en todos los pacientes una disminución de las necesidades de analgésicos, abandonando en todos los casos los opiáceos. Cuatro pacientes a quienes se les realizó la esplacnicectomía bilateral presentaron dolor intercostal relacionado con los orificios de los trocares, mientras que el dolor abdominal había desaparecido. Dos pacientes presentaron complicaciones relacionadas con la técnica quirúrgica, uno un derrame pleural y otro un neumotórax residual, que se resolvieron con tratamiento médico. La estancia media hospitalaria fue de 3 días (2-5). En 20 pacientes (84 por ciento) el dolor fue controlado con dosis bajas de analgésicos no opiáceos hasta el momento de su fallecimiento. Conclusión. En nuestra experiencia, la esplacnicectomía toracoscópica es un método seguro y eficaz para el tratamiento del dolor en pacientes afectados de cáncer de páncreas irresecable. Entre las ventajas, permite eliminar la necesidad de dosis de analgésicos cada vez mayores, evita los efectos colaterales de esta medicación y ofrece una mejora importante de la calidad de vida en estos pacientes con una corta esperanza de vida (AU)

Thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas.

BACKGROUND: Intractable pain is the most distressing symptom in patients suffering from unresectable pancreatic carcinoma. Palliative interventions are justified to relieve the clinical symptoms with as little interference as possible in the quality of life. The purpose of this study was to examine the efficacy and safety of thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas. METHODS: Between May 1995 and April 1998, 24 patients (14 men and 10 women) with a mean age of 65 years (range, 30-85) suffering from intractable pain due to unresectable carcinoma of the pancreas underwent 35 thoracoscopic splanchnicectomies. All patients were opiate-dependent and unable to perform normal daily activities. Subjective evaluation of pain was measured before and after the procedure by a visual analogue score. The following parameters were also evaluated: procedure-related morbidity and mortality, operative time, and length of hospital stay. RESULTS: All procedures were completed thoracoscopically, and no intraoperative complications occurred. The mean operative time was 58+/-22 min for unilateral left splanchnicectomy and 93.5+/-15.6 min for bilateral splanchnicectomies. The median value of preoperative pain intensity reported by patients on a visual analogue score was 8.5 (range, 8-10). Postoperatively, pain was totally relieved in all patients, as measured by reduced analgesic use. However, four patients experienced intercostal pain after bilateral procedures, even though their abdominal pain had disappeared. Complete pain relief until death was achieved in 20 patients (84%). Morbidity consisted of persistent pleural effusion in one patient and residual pneumothorax in another. The mean hospital stay was 3 days (range, 2-5). CONCLUSIONS: We found thoracoscopic splanchnicectomy to be a safe and effective procedure of treating malignant intractable pancreatic pain. It eliminates the need for progressive doses of analgesics, with their side effects, and allows recovery of daily activity. The efficacy of this procedure is of major importance since life expectancy in these patients is very short.

Simultaneous laparoscopic biliary and retrocolic gastric bypass in patients with unresectable carcinoma of the pancreas.

BACKGROUND: A substantial number of patients with unresectable pancreatic cancer eventually develop biliary or gastric outlet obstruction. In some cases, they present initially with both complications. These conditions contribute markedly to their discomfort and certainly justify palliative intervention. The purpose of this study was to examine the feasibility and safety of simultaneous laparoscopic biliary and gastric bypass in patients with unresectable carcinoma of the pancreas. METHODS: Between August 1995 and July 1998, simultaneous laparoscopic biliary and retrocolic gastric bypass was performed successfully in 12 consecutive patients with unresectable carcinoma of the pancreas. There were eight men and four women. Their median age was 72 years (range, 50-82). In all patients, the indications for gastrointestinal bypass were gastric outlet obstruction and obstructive jaundice. The following parameters were evaluated for each patient: procedure-related morbidity and mortality, operative time, length of hospital stay, overall survival, and ability to sustain oral nutrition during the survival period. RESULTS: All procedures were completed laparoscopically. The mean operative time was 89 +/- 29.56 min. There were no intraoperative complications. Postoperative morbidity consisted of wound infection in two patients and pneumonia in one patient. One patient died of multiorgan failure on postoperative day 2. The mean hospital stay was 6.4 +/- 1.5 days (range, 5-17). The mean survival time until death from underlying disease was 85 +/- 32. 46 days (range, 31-260). None of the patients had recurrent jaundice, and all of them were able to maintain oral nutrition. CONCLUSION: Simultaneous laparoscopic biliary and retrocolic gastric bypass is a safe and effective technique for the treatment of biliary and gastroduodenal obstruction in patients with unresectable pancreatic cancer.