Cushing's syndrome in pregnancy. Laparoscopic adrenalectomy during pregnancy: the mainstay treatment.

INTRODUCTION: Cushing's syndrome (CS) is a rare disease in pregnancy and its differential diagnosis is complicated. It is usually confused with complicated pregnancy cases, such us preeclampsia and gestational diabetes. This usually leads to a delayed diagnosis and is also associated with severe materno-foetal complications. PURPOSE: We present a case of a pregnant woman in her third trimester of pregnancy with CS secondary to an adrenal adenoma without response to medical treatment who underwent laparoscopic adrenalectomy without complications. DISCUSSION: Most authors consider adrenalectomy as the first-choice treatment, since it presents higher rate of successful pregnancies. However, previously published cases did not reflect this stance. These publications prefer to maintain medical treatment, allowing pregnancy to go to term and delaying adrenalectomy after childbirth. We consider that experience in laparoscopic surgery, obstetric knowledge and resources now available, all offer sufficient guarantees to carry out the laparoscopic procedure to treat CS in pregnancy even in the third trimester. Laparoscopic adrenalectomy for CS in pregnancy is a safe and efficacious procedure allowing stopping the disease and curbing the dreadful consequences it may have for both mother and foetus.

[Abdominal actinomycosis simulating Crohn's disease]. / Actinomicosis abdominal simulando enfermedad de Crohn.

Actinomycosis is a rare chronic infectious disease that usually develops abscesses and fistulas. It can also mimic other diseases such as cancer, inflammatory bowel diseases or diverticulitis. We present the case of a 67-year-old woman with an unusual form of actinomycosis. Clinically, the disease simulated an inflammatory bowel disease. Computerized axial tomography, intestinal transit and colonoscopy were performed and the suspected 1 diagnosis continued to be inflammatory bowel disease. The definitive diagnosis was made after histopathological study of the surgical specimen. We highlight the diagnostic difficulty of this rare disease and the importance of prolonged antibiotic treatment.

Laparoscopic choledochotomy in the management of choledocholithiasis. A report of 32 cases.

OBJECTIVE: we describe a choledochotomy technique for the laparoscopic removal of calculi in the management of choledocholithiasis, with an analysis of the results obtained in our first 32 patients. METHODS: a prospective study was made of all patients who underwent laparoscopic choledochotomy in our surgical service in the period between December 1993 and December 1996. A total of 112 patients diagnosed as having choledocholithiasis were operated on in our service in the course of the study. Of the 54 patients who initially underwent laparoscopic surgery, 32 underwent cholecystectomy, choledochotomy, extraction of stones and laparoscopic choledochorrhaphy. RESULTS: in 30 patients (93.75%) laparoscopic surgery could be completed without resorting to open surgery; in 5 of these patients primary choledochorrhaphy was performed, and in the remaining patients suturing was performed on a Kehr T-tube. Mean surgical time was 176 min. Two slight complications (one acute gastric dilatation and one small biliary fistula) and one severe complication (bowel fistula) were recorded. Mean hospital stay was 7 days. CONCLUSIONS: choledocholithiasis was successfully managed with laparoscopic choledochotomy and the extraction of stones, with no increase in morbidity or mortality in comparison to other therapeutic modalities.

Laparoscopic reconstruction of intestinal continuity following Hartmann's procedure.

Laparoscopy-guided reversal of Hartmann's procedure was performed in eleven patients who had been treated surgically for inflammatory disease or cancer of the colon. Restoration of intestinal continuity was achieved in ten of them. There were no postoperative complications. The mean surgical time was 144 minutes and the mean duration of postoperative ileus was 48 hours (range: 30 to 60 hours). The mean hospital stay was 7 days. Our results suggest that laparoscopic reversal of Hartmann's procedure is safer than and as effective as open surgery.

Early results of laparoscopic resection of colorectal cancer.

OBJECTIVE: To study the immediate and early postoperative results obtained in patients subjected to laparoscopic resection of colorectal cancer. PATIENTS AND METHOD: A prospective, observational cohort study was initiated in January 1993, involving 50 patients subjected to laparoscopic resection for colorectal adenocarcinoma (rectal amputation in 10 cases, lower rectal resection in 13, recto-sigmoidectomy in 18, and miscellaneous colectomies in 9 cases). Seventy-percent of the tumors were in IUCC stages II and III. Mean follow-up was 21 months. RESULTS: Conversion to open surgery was required in 18 cases (36%). Intraoperative problems were limited to a single urethral lesion, while postoperative complications were recorded in 11 patients (22%), and were managed conservatively: a urinary fistula secondary to the aforementioned urethral lesion; subclinical dehiscence of the anastomosis (2 cases); phlebitis (1 case); infection of the surgical wound (4 cases), and urinary and pulmonary infection (1 case each). There were no differences between converted surgery (i.e., conventional laparotomy) and those operations completed endoscopically (with a final assisted or combined minilaparotomy) in terms of the length of the surgical resection piece, the length of the distal margin of the specimen or the number of lymph nodes. Global hospital stay ranged from 9-12 days, versus 5-7 in the group without complications. Global survival is 78% at 42 months, with a disease-free interval of 53% at this time. CONCLUSIONS: Laparoscopic colorectal resection presents an incidence of intra- and postoperative complications characteristic of major surgery, with no differences in surgical specimen size with respect to those operations converted to laparotomy. Global survival is similar to that reported in the literature for open surgery.