Priapismo de alto flujo postraumático / Post-traumatic high-flow priapism

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Entrenamiento en laparoscopia y apendicitis / Training in laparoscopy and appendicitis

Introducción. Para la formación en laparoscopia, la apendicectomía es la intervención más utilizada, por su alta frecuencia y, habitualmente, escasa dificultad. Sin embargo, durante la curva de aprendizaje (las primeras 35 intervenciones), el número de complicaciones puede aumentar, con lo que el beneficio de la formación se puede convertir en perjuicio para algunos pacientes. Por ello hemos revisado las complicaciones graves de las apendicectomías laparoscópicas realizadas en nuestro Servicio antes y después de la curva de aprendizaje y las hemos comparado entre sí y con las de las apendicectomías abiertas. Material y métodos. Se han revisado las complicaciones graves (abscesos intraabdominales, oclusiones, hemorragias, etc..) de las 1.710 apendicectomías realizadas en nuestro centro desde 1997 hasta 2013, divididas en tres grupos: abiertas (AA, n = 1.258), laparoscópicas durante la curva de aprendizaje (LDC, n = 154) y laparoscópicas tras la curva de aprendizaje (LTC, n = 298). Se han dividido en apendicitis simples (n = 1.233) y peritonitis (n = 477). Resultados. En el grupo AA se detectaron 110/1.258 complicaciones graves (8,7%), en el grupo LDC 28/154 (18,2%) y en el grupo LTC, 19/298 (6,4%) (p< 0,05 LDC vs AA y LTC). En las apendicitis simples las complicaciones fueron 13/889 (1,5%), en las AA 3/115 (2,6%) en el grupo LDC, y 2/229 en el grupo LTC (0,9%) (p = ns LDC vs AA y LTC). En las peritonitis las complicaciones fueron 97/369 (26,3%) en las AA, 25/39 (64%) en el grupo LDC y 17/69 (24,6%) en el grupo LTC (p< 0,05 LDC vs AA y LTC). Conclusiones. La apendicectomía laparoscópica con fines formativos debería reservarse a los casos de apendicitis simples

Background. In order to improve laparoscopic skills, appendectomy is the most common procedure because of its high frequency and low difficulty. In spite of that, during the learning curve (each surgeon´s first 35 interventions) the incidence of complications may increase, so improvement in training means a bigger risk for some patients. Methods. We retrospectively reviewed major complications (intra-abdominal abscess, intestinal occlusion, hemorrhage) of 1,710 appendectomies performed at our service between 1997 and 2013. We divided them in three groups: open appendectomy (OA, n= 1,258), laparoscopic appendectomy during the learning curve (LDC, n= 154) and laparoscopic appendectomy after the learning curve (LAC, n= 298). In addition, we distinguish between simple appendicitis (n= 1,233) and peritonitis (n= 477). Results. In the OA group we detected110/1,258 major complications (8.7%), 28/154 major complications (18.2%) in the LDC group and 19/298 (6.4%) in the LAC group (p< 0.05 LDC vs OA and LAC). In the simple appendicitis group, we found 13/889 major complications (1.5%) in OA, 3/115 (2.6%) in LDC group and 2/229 (0.9%) in LAC group (p= ns LDC vs OA and LAC). In the peritonitis group, 97/369 (26.3%) major complications were found in OA group, 25/39 (64%) in LDC group and 17/69 (24.6%) in LAC group (p< 0.05 LDC vs OA and LAC). Conclusions. Educational purpose laparoscopic appendectomy must be used in simple appendicitis cases

Infarto omental: caso clínico y breve reseña de esta entidad / Omental infarction: a case report

El infarto omental es una causa muy poco frecuente de dolor abdominal agudo en la edad pediátrica. Se debe a una oclusión vascular y un infarto posterior del tejido isquémico. Su diagnóstico es todavía un desafío para el cirujano, ya que, pese al cada vez mejor diagnóstico radiológico, suele ser un hallazgo incidental durante la intervención quirúrgica por sospecha de una apendicitis aguda. Actualmente su tratamiento es controvertido. Presentamos el caso clínico de una niña de 5 años de edad con un diagnóstico intraoperatorio de infarto omental y posterior resección quirúrgica, con una evolución postoperatoria favorable (AU)

Omental infarction is an uncommon cause of abdominal pain in children. Due to a vascular occlusion, the omentum develops ischemia and infarction. Its diagnosis is still a challenge for surgeons. Despite the better results of radiologic tests, it's still a usual intraoperative finding in the course of laparotomy secondary to a suspected appendicitis. Nowadays its treatment remains controversial. We present a clinical case of a five years old girl with an intraoperative diagnosis of omental infarction. A surgical resection was performed and subsequent postoperative course was uneventful (AU)

[Training in laparoscopy and appendicitis]. / Entrenamiento en laparoscopia y apendicitis.

BACKGROUND: In order to improve laparoscopic skills, appendectomy is the most common procedure because of its high frequency and low difficulty. In spite of that, during the learning curve (each surgeon´s first 35 interventions) the incidence of complications may increase, so improvement in training means a bigger risk for some patients. METHODS: We retrospectively reviewed major complications (intra-abdominal abscess, intestinal occlusion, hemorrhage) of 1,710 appendectomies performed at our service between 1997 and 2013. We divided them in three groups: open appendectomy (OA, n= 1,258), laparoscopic appendectomy during the learning curve (LDC, n= 154) and laparoscopic appendectomy after the learning curve (LAC, n= 298). In addition, we distinguish between simple appendicitis (n= 1,233) and peritonitis (n= 477). RESULTS: In the OA group we detected110/1,258 major complications (8.7%), 28/154 major complications (18.2%) in the LDC group and 19/298 (6.4%) in the LAC group (p<0.05 LDC vs OA and LAC). In the simple appendicitis group, we found 13/889 major complications (1.5%) in OA, 3/115 (2.6%) in LDC group and 2/229 (0.9%) in LAC group (p= ns LDC vs OA and LAC). In the peritonitis group, 97/369 (26.3%) major complications were found in OA group, 25/39 (64%) in LDC group and 17/69 (24.6%) in LAC group (p<0.05 LDC vs OA and LAC). CONCLUSIONS: Educational purpose laparoscopic appendectomy must be used in simple appendicitis cases.

INTRODUCCION: Para la formación en laparoscopia, la apendicectomía es la intervención más utilizada, por su alta frecuencia y, habitualmente, escasa dificultad. Sin embargo, durante la curva de aprendizaje (las primeras 35 intervenciones), el número de complicaciones puede aumentar, con lo que el beneficio de la formación se puede convertir en perjuicio para algunos pacientes. Por ello hemos revisado las complicaciones graves de las apendicectomías laparoscópicas realizadas en nuestro Servicio antes y después de la curva de aprendizaje y las hemos comparado entre sí y con las de las apendicectomías abiertas. MATERIAL Y METODOS: Se han revisado las complicaciones graves (abscesos intraabdominales, oclusiones, hemorragias, etc..) de las 1.710 apendicectomías realizadas en nuestro centro desde 1997 hasta 2013, divididas en tres grupos: abiertas (AA, n= 1.258), laparoscópicas durante la curva de aprendizaje (LDC, n= 154) y laparoscópicas tras la curva de aprendizaje (LTC, n= 298). Se han dividido en apendicitis simples (n= 1.233) y peritonitis (n= 477). RESULTADOS: En el grupo AA se detectaron 110/1.258 complicaciones graves (8,7%), en el grupo LDC 28/154 (18,2%) y en el grupo LTC, 19/298 (6,4%) (p<0,05 LDC vs AA y LTC). En las apendicitis simples las complicaciones fueron 13/889 (1,5%), en las AA 3/115 (2,6%) en el grupo LDC, y 2/229 en el grupo LTC (0,9%) (p= ns LDC vs AA y LTC). En las peritonitis las complicaciones fueron 97/369 (26,3%) en las AA, 25/39 (64%) en el grupo LDC y 17/69 (24,6%) en el grupo LTC (p>;0,05 LDC vs AA y LTC). CONCLUSIONES: La apendicectomía laparoscópica con fines formativos debería reservarse a los casos de apendicitis simples.

[Biodegradable catheters for fistula prevention in hypospadias. Experimental preliminary study]. / Sondas biodegradables para la prevención de las fístulas de hipospadias. Estudio preliminar experimental.

INTRODUCTION: Continuous technical innovations are not enough to resolve the high incidence of fistula after hypospadias repair. A urethral catheter-tutor made of reabsorbable polymeric biomaterial (RPB) which could be left in situ long enough could reduce the complications. TARGET: To investigate in an animal model differents RPB to be used in urology. METHODOLOGY: CRL Wistar rats, males, divided into 5 equal groups according to the used polymers: polylactide; lactic-coprolactone copolymer; lactic-glycolic copolymer; simulated; control silicones. Three individuals were sacrificed per group at 4th, 10th and 16th week. In all animals (exceptuating the simulated group), biomaterial was fixed to the bladder wall bylaparotomy. Animals remained in individual housing and kept under daily control of hematuria during the first 15 days and weekly weight and urine control for pH and lactate. After being slaughtered, remaining polymer was collected for chemical analysis and bladder tissue for hystologic study. RESULTS: There was no mortality, hematuria nor other clinical signs. The bladder wall showed a mild foreign body reaction. The values of lactate and pH in urine did not reach toxic levels. Lactic-glycolic was totally reabsorbed by the 10th week and had the lowest degree of calcification. Polylactide and lactic-coprolactone remained intact. CONCLUSION: The model of urinary bladder has proven useful for studying the degradation of bioresorbable polymers. The analyzed polymers have spent long time to be reabsorbed, so we will have to study new others.

Tratamiento y seguimiento del plastrón apendicular / Management of appendicular mass

Introducción. El tratamiento del plastrón apendicular continúa siendo controvertido. Hay autores que defienden un tratamiento conservador inicial seguido de una apendicectomía programada. Objetivos. Nuestro propósito ha sido analizar la utilidad de este tratamiento y el momento óptimo para la intervención. Material y métodos. Se trata de un estudio retrospectivo de los casos tratados en nuestro Hospital durante los últimos 8 años. Se han analizado: tasa de éxito del tratamiento conservador, tiempo de espera hasta la apendicectomía, dificultad técnica y complicaciones. Resultados. Nuestra serie incluye 19 casos. En todos ellos se administró antibioterapia intravenosa y, en 14 de ellos, además, se realizó drenaje peritoneal (estancia media de 11,5 días). En 3 pacientes (16%) fue necesario realizar la apendicectomía de manera precoz (a los 12, 30 y 40 días). En 16 (84%), el manejo conservador funcionó y la apendicectomía se realizó transcurridos entre 3 y 12 meses (media: 6,6 meses): cuatro por abordaje abierto y 12 mediante laparoscopia (siendo necesario reconvertirla en 3 casos). La estancia media fue de 1,8 días, con sólo una complicación (absceso de pared). De los 16 casos, en 11 la intervención fue sencilla (no adherencias o leves) y el tiempo medio de espera fue de 5,5 meses (rango 3-6). En 5 casos había muchas adherencias, la intervención fue difícil y la espera media de 9,4 meses (rango 9-12).Conclusiones. El manejo conservador es una opción eficaz de tra tamiento para el plastrón apendicular, con una tasa de éxito del 84% en nuestra serie. Según nuestra experiencia, la apendicectomía resulta más sencilla cuando se realiza entre 3-6 meses (AU)

Objectives. Our aim has been to revise the usefulness of this management and the optimal time to carry out the appendectomy. Methods. We made a retrospective review of all the appendicular mass cases treated in our hospital during the last 8 years. We analyzed the success rate of the non-operative approach, the interval until the delayed appendectomy was performed, difficulty found at surgery and the occurred complications. Results. Our series includes 19 appendicular mass cases managed initially by a non-operative approach. Intravenous antibiotics were administered to all of them and in 14 cases a peritoneal drainage was placed (the average length of stay was of 11.5 days). In 3 cases (16%) early appendectomy was performed (12, 30 and 40 days after the onset of the symptoms). In 16 (84%) the conservative approach succeeded and the appendectomy was delayed 3-12 months (average: 6.6 months). Four of them were performed by an open approach and 12 by laparoscopy (in 3 of which conversion was needed). The average length of stay was of 1.8 days, with only one complication (wound abscess). Of these 16 delayed appendectomies, 11 were not technically difficult to perform (average wait of 5.5 months) and in 5 cases the procedure was difficult due to multiple adhesions (average wait of 9.4 months).Conclusion: Conservative management of appendicular mass is useful, with a success rate of 84% in our series. The appendectomy was less hazardous if performed 3-6 months after the onset of the symptoms (AU)

Sondas biodegradables para la prevención de las fístulas de hipospadias. Estudio preliminar experimental / Biodegradable catheters for fistula prevention in hypospadias. Experimental preliminary study

INTRODUCCIÓN: Las continuas innovaciones técnicas no acaban de solucionar la alta incidencia de fístulas tras la reparación del hipospa-dias. Una sonda-tutor hecha de un biomaterial polimérico reabsorbible (BPR) que pudiera dejarse in situ el tiempo suficiente podría disminuir las complicaciones.Objetivo. Investigar en un modelo animal diferentes BPR para su uso en urología.Material y métodos. Ratas Wistar macho (N= 45) divididas en 5 grupos en función de los polímeros empleados: polilactida; copolímero láctico-coprolactona; copolímero láctico-glicólico; simulado; control de silicona. Se sacrificaron 3 individuos por grupo a las 4, 10 y 16 semanas. A todos los animales (excepto al grupo simulado) se les fijó el material a la pared vesical por laparotomía. Los animales perma-necieron en alojamiento individual, con control diario de hematuria y control semanal de peso y de orina para pH y lactato. Al sacrificio, se recogió el material remanente para estudio químico y tejido vesical para valoración histológica.Resultados. No hubo mortalidad, hematuria ni otros signos clí-nicos. La pared vesical presentó una leve reacción a cuerpo extraño. Los valores de pH y lactato en orina no alcanzaron niveles tóxicos. El láctico-glicólico se reabsorbió totalmente a la 10ª semana y el polilactida y el láctico-coprolactona permanecieron íntegros. El polilactida tuvo alto grado de calcificaciones a partir de la 16ª semana.Conclusiones. Este modelo ha demostrado su utilidad para el es-tudio de la degradación del BPR. Los polímeros estudiados tardan de-masiado tiempo en reabsorberse por lo que habrá que investigar nuevos compuestos

INTRODUCTION: Continuous technical innovations are not enough to resolve the high incidence of fistula after hypospadias repair. A urethral catheter-tutor made of reabsorbable polymeric biomaterial (RPB) which could be left in situ long enough could reduce the complications.Target. To investigate in an animal model differents RPB to be used in urology.Methodology. CRL Wistar rats, males, divided into 5 equal groups according to the used polymers: polylactide; lactic-coprolactone co-polymer; lactic-glycolic copolymer; simulated; control silicones. Three individuals were sacrificed per group at 4th, 10th and 16th week. In all animals (exceptuating the simulated group), biomaterial was fixed to the bladder wall by laparotomy. Animals remained in individual hous-ing and kept under daily control of hematuria during the first 15 days and weekly weight and urine control for pH and lactate. After being slaughtered, remaining polymer was collected for chemical analysis and bladder tissue for hystologic study.Results. There was no mortality, hematuria nor other clinical signs. The bladder wall showed a mild foreign body reaction. The values of lactate and pH in urine did not reach toxic levels. Lactic-glycolic was totally reabsorbed by the 10th week and had the lowest degree of calci-fication. Polylactide and lactic-coprolactone remained intact.Conclusion. The model of urinary bladder has proven useful for studying the degradation of bioresorbable polymers. The analyzed poly-mers have spent long time to be reabsorbed, so we will have to study new others

[Management of appendicular mass]. / Tratamiento y seguimiento del plastrón apendicular.

BACKGROUND: Management of appendicular mass is still controversial. Some authors plead for an initial non-operative approach followed by a delayed appendectomy. OBJECTIVES: Our aim has been to revise the usefulness of this management and the optimal time to carry out the appendectomy. METHODS: We made a retrospective review of all the appendicular mass cases treated in our hospital during the last 8 years. We analyzed the success rate of the non-operative approach, the interval until the delayed appendectomy was performed, difficulty found at surgery and the occurred complications. RESULTS: Our series includes 19 appendicular mass cases managed initially by a non-operative approach. Intravenous antibiotics were administered to all of them and in 14 cases a peritoneal drainage was placed (the average length of stay was of 11.5 days). In 3 cases (16%) early appendectomy was performed (12, 30 and 40 days after the onset of the symptoms). In 16 (84%) the conservative approach succeeded and the appendectomy was delayed 3-12 months (average: 6.6 months). Four of them were performed by an open approach and 12 by laparoscopy (in 3 of which conversion was needed). The average length of stay was of 1.8 days, with only one complication (wound abscess). Of these 16 delayed appendectomies, 11 were not technically difficult to perform (average wait of 5.5 months) and in 5 cases the procedure was difficult due to multiple adhesions (average wait of 9.4 months). CONCLUSION: Conservative management of appendicular mass is useful, with a success rate of 84% in our series. The appendectomy was less hazardous if performed 3-6 months after the onset of the symptoms.

Adaptación en el intestino corto: efecto de la nutrición enteral mínima y los probióticos sobre la proliferación y la apoptosis en la pared intestinal / Adaptation in the small intestine: effect of minimal enteral nutrition and probiotics on proliferation and apoptosis in the intestinal wall

Introducción. La integridad de la pared intestinal es fundamental en la función de la barrera y depende del balance de proliferación/apoptosis. El intestino Corto (IC) o la Nutrición Parenteral (NP) inducen un alto índice de translocación bacteriana (TB) seguramente por fallo dela barrera intestinal. La administración de probióticos o la nutrición enteral mínima(NEM) han reducido la TB en modelos animales. Objetivos. Determinar en 2 modelos animales de TB (IC o NP)el efecto de la NEM y los probióticos sobre los índices de proliferación(IP) y apoptosis (IA) de la pared intestinal. Metodología. Setenta y una ratas Wistar, divididas en 4 grupos: 1)NP (N=23): Nutrición parenteral; 2) NPNEM (N=16): NP + NEM (2,9g/100 g/día dieta estándar); 3) RES (N=15): Resección intestinal 80%y dieta oral estándar; 4) RESPROB (N=17): RES + probióticos (..) (AU)

Background. The intestinal wall integrity is central to the barrier function and depends on the balance of proliferation/apoptosis. Short bowel (SB) or Parenteral Nutrition (PN) induce high bacterial translocation (BT) probably by the intestinal barrier bug. Probiotics or minimal enteral nutrition (MEN) have reduced BT in animal models. Objective. Determine in two BT animal models (SB or PN) the effect of MEN or probiotics on proliferation and apoptosis rates of the intestinal wall. Methods. Seventy-one Wistar rats, divided into 4 groups: 1) PN(N = 23): parenteral nutrition; 2) PNMEN (N = 16): PN + MEN (2.9g/100 g/day standard diet); 3) RES (N = 15): 80% bowel resection (..) (AU)

[Adaptation in the small intestine: Effect of minimal enteral nutrition and probiotics on proliferation and apoptosis in the intestinal wall]. / Adaptación en el intestino corto: efecto de la nutrición enteral mínima y los probióticos sobre la proliferación y la apoptosis en la pared intestinal.

BACKGROUND: The intestinal wall integrity is central to the barrier function and depends on the balance of proliferation/apoptosis. Short bowel (SB) or Parenteral Nutrition (PN) induce high bacterial translocation (BT) probably by the intestinal barrier bug. Probiotics or minimal enteral nutrition (MEN) have reduced BT in animal models. OBJECTIVE: Determine in two BT animal models (SB or PN) the effect of MEN or probiotics on proliferation and apoptosis rates of the intestinal wall. METHODS: Seventy-one Wistar rats, divided into 4 groups: 1) PN (N = 23): parenteral nutrition; 2) PNMEN (N = 16): PN + MEN (2.9 g/100 g/day standard diet); 3) RES (N = 15): 80% bowel resection and standard oral diet; 4) RESPROB (N = 17): RES + probiotics (7 X 10(9) CFU Bifidobacterium lactis). After 10 days in metabolic cages, mesenteryc lymph nodes, portal blood and peripheral blood were cultured. By immunohistochemistry, proliferation and apoptosis index were calculated as well as the proliferation-apoptosis rate. RESULTS: BT: decreased in PNMEN (45%) and RESPROB groups (35%) versus PN (65%) and RES (67%) groups (p<0.05). Proliferation index: was better in PNMEN (12,07) and RESPROB (13,93) groups than PN (7,45) and RES (5,54) groups. (p

[Detection of bacterial translocation by polymerase chain reaction in an experimental short bowel model]. / Diagnóstico de la translocación bacteriana en el intestino corto experimental mediante reacción en cadena de polimerasa.

BACKGROUND: Bacterial overgrowth occuring after massive bowel resection, facilitates Gram-negative intestinal Bacterial Translocation (TB). Probiotic agents might have beneficial effects on TB. On the other hand, polymerase chain-reaction (PCR) has better sensitivity than conventional methods for bacterial detection and has not been investigated in experimental models of short bowel syndrome and TB. OBJECTIVE: To test the hypothesis that the administration of Bifidobacterium lactis (BL) decreases Escherichia coli Bacterial Translocation (ECTB) in experimental short bowel syndrome and to confirm the better sensitivity of PCR technique to detect ECTB. METHODS: Adult Wistar rats, orally fed with standard rat chow and tap water "ad libitum", were maintained in individual metabolic cages for ten days and divided into three groups: Control (n = 15): non-manipulated animals. RES (n = 15): 80% gut resection. Daily administration 1 ml of sterile water, after orogastric intubation. RES-PRO (n = 18): same resection and daily administration of 7.8 x10(9) Bifidobacterium lactis Colony Forming Units (CFU). At the end of the experiment, mesenteric lymph nodes (MLN), and both peripheral and portal blood samples were recovered and cultured by standard procedures. Also, genomic DNA from E. coli was detected by PCR technique. RESULTS: By conventional cultures ECTB was detected in 0% in the control group, 73% in the RES group and 33% in the RES-PRO group. PCR technique detected ECTB in 47% of the control group, 87% of the RES group and 33% of RES-PRO group, showing higher sensitivity. By both methods, animals receiving BL (RES-PRO group) showed less ECTB. By conventional culture, the relative risk (RR) was 0.45 (95% CI 0,22-0,79) and the number needed to treat (NNT) was 3 (95% CI 0-11). By PCR technique, the RR was 0.38 (95% CI 0.19-0.76), and the NNT 2 (95% CI 0-4). CONCLUSIONS: 1) Administration of Bifidobacterium lactis reduces the incidence of ECTB. 2) PCR technique is a more sensitive method for ECTB detection.

[Laparoscopic appendectomy after the learning curve]. / La apendicectomía laparoscópica más allá de la curva de aprendizaje.

BACKGROUND: Despite its increasing popularity, laparoscopic appendectomy does not put an unanimous end to the answer to the best treatment for appendicitis. Although the postoperative stay is shorter, the wound infection practically does not exist and scars are minimal, some publications question its advantages due to the incidence of intra-abdominal absceses, postoperative analgesia requirements and the recently described "postlaparoscopic appendectomy complication" (PLAC), an intra-abdominal infection, without abscess formation, which develops after laparoscopic appendectomy for non-complicated appendicitis. Some of this series include the "learning curve", wherein they compare results of inexperienced surgeons in laparoscopic techniques with those obtained after with the firmly established open appendectomy (OA) technique. With the aim to clarify this aspects, we reviewed our experience in laparoscopic appendectomy during (LDC) and after (LAC) the "learning curve" and we compared their complications with the open appendectomies' ones. METHODS: We retrospectively reviewed 807 appendectomies: 208 laparoscopic (LA) and 599 open (OA) from January 2001 to December 2007 performed in our hospital. In the laparoscopic group, 83 of them (40%) were done during the learning curve (each surgeon's 35 first interventions, LDC) and 125 (60%) after the learning curve (LAC). We have compared both laparoscopic subgroups to each other and to the open appendectomies group. We analysed the age, sex, length of stay, kind of appendicitis (simple or perforated appendicitis) and five of the most serious complications: intra-abdominal abscess, postoperative intestinal occlusion, intestinal perforation, haemorrhage and PLAC. RESULTS: The mean age (9 years), sex (58% men; 42% women) and the peritonitis rate (30%) were similar among the 3 groups. The mean length of stay was reduced from 5.4 days in OA group to 4.2 days in LA group and 3.6 days in LAC group (p < 0.01). The simple appendicitis cases had the shortest length of stay: 3.41 days in OA group and 2.16 days in LA group (p < 0.0001). There were no differences in stay for the peritonitis group. In the OA group, we detected 56 severe complications (9,3%): 49 abcesses, 2 occlusions, 2 PLAC, 1 haemorrhage, 1 intestinal perforation and 1 liver abscess. Nineteen severe complications were found in LDC group (22,9%): 9 abscesses, 4 occlusions, 4 haemorrhages, 1 intestinal perforation and 1 PLAC (p < 0.01 vs OA group). In the LAC group, we found 13 complications (10,4%): 9 abscesses, 1 occlusion, 1 PLAC and 2 haemorrhages (p = 0.3 vs OA group). CONCLUSIONS: 1. The length of stay was significantly reduced in laparoscopic appendectomies. 2. Severe complications, particularly intestinal occlusions and haemorrhages, increased significantly during the learning curve, with a slight fluctuation for intra-abdominal abscesses and PLAC. 3. After the learning curve, complications' global rate was similar to the OA group's, with an increment of haemorrhages and occlusions, no variation for PLAC and a slight reduction for intra-abdominal abscesses. 4. In our experience, laparoscopic appendectomy after the learning curve is the best therapeutic option for acute appendicitis.

[Short bowel syndrome in the research setting: 15 years' experience]. / El síndrome de intestino corto en el ambito experimental: experiencia de 15 años.

The fight against infection and liver disease associated with parenteral nutrition (PN) are surely two of the most problematic aspects in the management of paediatric patients with short bowel syndrome (SBS). In the Research Unit of Donostia Hospital, we have spent the past 15 years investigating different ways of reducing these complications in an experimental model of short bowel in the Wistar rat (resection of 80% of the small bowel, with and without PN). All the experiments had a duration of 10 days and 323 animals reached the end of the study period. Nine groups were established in which some type of intervention was performed, and there were 8 control groups. The interventions were: 3 dietary (minimal enteral nutrition [MEN] with low or high dose probiotics); 5 pharmacological (administration of growth hormone [GH], epidermal growth factor [EGF], insulin, cholecystokinin [CCK], and selective intestinal decontamination [SID]); and 1 surgical (resection of the ileocaecal valve). Infection due to bacterial translocation (BT) was detected by culture of mesenteric lymph nodes, portal blood and peripheral blood, and liver damage by the levels of proinflammatory cytokines (IL-1 and TNF-alpha). In summary, our results are: Probiotics, MEN and SID reduce BT. Liver damage was milder in the groups with MEN, SID and CCK. The groups receiving GH, EGF or insulin presented a higher incidence of BT. BT was lower after resection of the ileocaecal valve. In conclusion, the probiotics, MEN and CCK could be useful in the management of children with SBS. These data confirm the utility of this experimental model of short bowel for the investigation of different aspects of SBS.

Diagnóstico de la translocación bacteriana en el intestino corto experimental mediante reacción en cadena de polimerasa / Detection of bacterial translocation by polymerase chain reaction in an experimental short bowel model

Introducción. El sobrecrecimento bacteriano que ocurre tras la resección intestinal masiva facilita la translocación de gérmenes gramnegativos intestinales. Los probióticos pueden tener efectos beneficiosos sobre la translocación bacteriana (TB).Por otro lado, la reacción en cadena de polimerasa (PCR) tiene más sensibilidad que los métodos convencionales para la detección bacteriana y no ha sido investigada en modelos experimentales de intestino corto y TB. Objetivo. Poner a prueba la hipótesis de que la administración de un probiótico (Bifidobacterium lactis, BL) disminuye la translocación de Escherichia coli en un modelo de intestino corto experimental bajo probióticos y confirmar la mejor sensibilidad de la técnica de PCR para detectar TB. Material y métodos. Cuarenta y ocho ratas wistar adultas alimentadas por vía oral se mantuvieron en cajas metabólicas individualizadas durante diez días y se dividieron en tres grupos:- Control (n=15): animales no manipulados.- RES (n=15): Resección intestinal del 80% y administración diaria de 1 ml de agua por sondaje orogástrico.- RES-PRO (n=18): la misma resección y administración diaria de7,8x109 unidades formadoras de colonias (UFC) de Bifidobacteriumlactis. Al final del experimento se tomaron muestras para cultivo bacteriológico de sangre portal y periférica y de ganglios linfáticos mesentéricos. Además se detectó ADN genómico de E. coli por PCR. Resultados. Por cultivo convencional no se detectó translocación de E. coli en el grupo control. En el grupo RES fue del 73% y en el grupo RES-PRO, del 33%. Por PCR se detectó translocación en el 47% del grupo control, en el 87% del grupo RES, y en el 33% del grupo RESPRO, mostrando así alta sensibilidad. Por ambos métodos, los animales que recibieron BL mostraron menos translocación. Por cultivo convencional, el riesgo relativo (RR)fue de 0,45 (95% CI 0,22-0,79) y el número necesario a tratar (NNT)fue 3 (95% CI 0-11). Por PCR, el RR fue de 0,38 (95% CI 0.19-0.76),y el NNT 2 (95% CI 0-4).Conclusiones. 1) La administración de Bifidobacterium lactis reduce la incidencia de translocación. 2) La técnica de PCR es más sensible para la detección de la translocación por E. coli (AU)

Background. Bacterial overgrowth occurring after massive bowel resection, facilitates Gram-negative intestinal Bacterial Translocation(TB). Probiotic agents might have beneficial effects on TB. On the other hand, polymerase chain-reaction (PCR) has better sensitivity than conventional methods for bacterial detection and has not been investigated in experimental models of short bowel syndrome and TB. Objective. To test the hypothesis that the administration of Bifidobacteriumlactis (BL) decreases Escherichia coli Bacterial Translocation(ECTB) in experimental short bowel syndrome and to confirm the better sensitivity of PCR technique to detect ECTB. Methods: Adult Wistar rats, orally fed with standard rat chow and tap water “ad libitum”, were maintained in individual metabolic cages for ten days and divided into three groups:- Control (n=15): non-manipulated animals.- RES (n=15): 80% gut resection. Daily administration 1 ml of sterile water, after or gastric intubation.- RES-PRO (n=18): same resection and daily administration of7.8x109 Bifidobacterium lactis Colony Forming Units (CFU).At the end of the experiment, mesenteric lymph nodes (MLN), and both peripheral and portal blood samples were recovered and cultured by standard procedures. Also, genomic DNA from E. coli was detected by PCR technique. Results. By conventional cultures ECTB was detected in 0% in the control group, 73% in the RES group and 33% in the RES-PRO group. PCR technique detected ECTB in 47% of the control group, 87% of the RES group and 33% of RES-PRO group, showing higher sensitivity. By both methods, animals receiving BL (RES-PRO group) showed less ECTB. By conventional culture, the relative risk (RR) was 0.45(95% CI 0,22-0,79) and the number needed to treat (NNT) was 3 (95%CI 0-11). By PCR technique, the RR was 0.38 (95% CI 0.19-0.76), and the NNT 2 (95% CI 0-4). Conclusions: 1) Administration of Bifidobacterium lactis reduces the incidence of ECTB. 2) PCR technique is a more sensitive method for ECTB detection (AU)

La apendicectomía laparoscópica más allá de la curva de aprendizaje / Laparoscopic appendectomy after the learning curve

Introducción. Aunque la apendicectomía laparoscópica (AL) va ganando en popularidad no termina de ser considerada como la mejor opción para el tratamiento de la apendicitis. Si bien es cierto que la estancia hospitalaria es más corta, que la infección de la herida prácticamente no existe y que las cicatrices son mejores, algunos trabajos cuestionan sus ventajas en aspectos tales como el dolor postoperatorio, la frecuencia de abscesos intraabdominales y la recientemente descrita “complicación post-apendicectomía laparoscópica“ (CPAL), una infección intraabdominal, sin formación de absceso, tras una apendicectomía laparoscópica no complicada. Algunos de esos estudios incluyen la “curva de aprendizaje”, y comparan los resultados obtenidos por cirujanos sin mucha experiencia laparoscópica con los de la bien establecida técnica de la apendicectomía abierta (AA). Con el objetivo de aclarar alguno de estos aspectos hemos revisado las complicaciones graves de las AL durante la curva de aprendizaje (LDC) y tras la curva de aprendizaje (LTC) y las hemos comparado con las de las apendicectomías abiertas (AA). Material y Método. Entre 2001 y 2007 se han realizado 208 AL, 83 de ellas durante la curva de aprendizaje (35 primeras intervenciones por cirujano, LDC) y 125 tras la curva de aprendizaje (LTC). En el mismo período se practicaron 599 AA por el mismo equipo. Hemos comparado los dos grupos laparoscópicos entre ellos y con las AA. Hemos analizado la edad, sexo, estancia, tipo de apendicitis (simple o peritonitis) y cinco complicaciones graves: absceso intraabdominal, oclusión postoperatoria, hemorragia, perforación intestinal y CPAL. Resultados. La edad media (9 a.), el sexo (58% niños, 42% niñas) y el porcentaje de peritonitis (30%) fueron similares en los tres grupos. La estancia media se redujo de 5,4 días en el grupo AA a 4,2 d. en el grupo LDC y a 3,6 d. en el grupo LTC (p<0,01). En las apendicitis simples la diferencia fue mayor: 3,41 d. en las abiertas y 2,16 d. en el grupo LTC (p<0,0001). En las peritonitis no hubo diferencias en la estancia. En el grupo AA se detectaron 56 complicaciones graves (9,3%): 49 abscesos, 2 oclusiones, 1 hemorragia, 2 CPAL, 1 perforación intestinal y 1 absceso intrahepático. En el grupo LDC hubo 19 complicaciones graves (22,9%): 9 abscesos,4 hemorragias, 4 oclusiones, 1 perforación intestinal y 1 CPAL ( p< 0,01 vs AA) En el grupo LTC se detectaron 13 complicaciones (10,4%): 9 abscesos, 1 oclusión, 1 CPAL y 2 hemorragias ( p= 0,3, n.s. vs AA). Conclusiones:1. La estancia media se redujo de manera significativa en las apendicectomías laparoscópicas. 2. Durante la curva de aprendizaje las complicaciones graves aumentaron significativamente, sobre todo las hemorragias y las oclusiones, sin variación en los abscesos intraabdominales y en la CPAL. 3. Tras la curva de aprendizaje el porcentaje global de complicaciones fue similar al de las apendicectomías abiertas, con aumento leve de hemorragias, oclusiones, igual incidencia de CPAL y descenso leve de los abscesos intraabdominales.4. En nuestra experiencia, la apendicectomía laparoscópica más allá de la curva de aprendizaje es la mejor opción para el tratamiento de las apendicitis agudas (AU)

Background. Despite its increasing popularity, laparoscopic appendectomy does not put an unanimous end to the answer to the best treatment for appendicitis. Although the postoperative stay is shorter, the wound infection practically does not exist and scars are minimal, some publications question its advantages due to the incidence of intra-abdominal abscesses, postoperative analgesia requirements and the recently described “postlaparoscopic appendectomy complication” (PLAC), an intra-abdominal infection, without abscess formation, which develops after laparoscopic appendectomy for non-complicated appendicitis. Some of this series include the “learning curve”, wherein they compare results of inexperienced surgeons in laparoscopic techniques with those obtained after with the firmly established open appendectomy (OA) technique. With the aim to clarify this aspects, we reviewed our experience in laparoscopic appendectomy during (LDC) and after (LAC) the “learning curve” and we compared their complications with the open appendectomies’ ones. Methods. We retrospectively reviewed 807 appendectomies: 208 laparoscopic (LA) and 599 open (OA) from January 2001 to December 2007 performed in our hospital. In the laparoscopic group, 83 of them (40%) were done during the learning curve (each surgeon’s 35 first interventions, LDC) and 125 (60%) after the learning curve (LAC).We have compared both laparoscopic subgroups to each other and to the open appendectomies group. We analysed the age, sex, length of stay, kind of appendicitis (simple or perforated appendicitis) and five of the most serious complications: intra-abdominal abscess, postoperative intestinal occlusion, intestinal perforation, haemorrhage and PLAC Results. The mean age (9 years), sex (58% men; 42% women) and the peritonitis rate (30%) were similar among the 3 groups. The mean length of stay was reduced from 5.4 days in OA group to 4.2 days in LA group and 3.6 days in LAC group (p<0.01). The simple appendicitis cases had the shortest length of stay: 3.41 days in OA group and 2.16 days in LA group (p<0.0001). There were no differences in stay for the peritonitis group. In the OA group, we detected 56 severe complications (9,3%): 49 abscesses, 2 occlusions, 2 PLAC, 1 haemorrhage, 1 intestinal perforation and 1 liver abscess. Nineteen severe complications were found in LDC group (22,9%): 9 abscesses, 4 occlusions, 4 haemorrhages, 1 intestinal perforation and 1 PLAC (p<0.01 vs OA group).In the LAC group, we found 13 complications (10,4%): 9 abscesses, 1 occlusion, 1 PLAC and 2 haemorrhages (p=0.3 vs OA group). Conclusions: 1. The length of stay was significantly reduced in laparoscopic appendectomies.2. Severe complications, particularly intestinal occlusions and haemorrhages, increased significantly during the learning curve, with a slight fluctuation for intra-abdominal abscesses and PLAC. 3. After the learning curve, complications’ global rate was similar to the OA group’s, with an increment of haemorrhages and occlusions, no variation for PLAC and a slight reduction for intra-abdominal abscesses. 4. In our experience, laparoscopic appendectomy after the learning curve is the best therapeutic option for acute appendicitis (AU)

[Currarino syndrome]. / Sindrome de Currarino.

The Currarino syndrome is a form of caudal regression syndrome characterized by the classic triad of presacral mass, sacral bone defect and anorectal malformation in which an autosomal dominant inheritance has been described. In case of clinical suspicion it is necessary to search for the classic alterations and to detect other possible associated malformations in order to avoid complications. The management is multidisciplinary and depends on the type of alterations that the patient has. We report a 17-month-old female baby that initially passed unnoticed and was detected during a rectoplasty for reconstruction of a rectal stenosis. The baby presented complications derived from ignorance of the existence of a presacral mass. Early diagnose and adequate treatment is very important.

El síndrome de intestino corto en el ámbito experimental: experiencia de 15 años / Short bowel syndrome in the research setting: 15 year´experience

En el manejo de pacientes pediátricos con síndrome de intestino corto (SIC), la lucha contra la infección y la hepatopatía asociada a la nutrición parenteral (NP), son seguramente algunos de los aspectos más problemáticos. En la Unidad Experimental del Hospital Donostia llevamos investigando durante los últimos 15 años diferentes formas de reducir estas complicaciones en un modelo de intestino corto experimental en la rata Wistar (resección del 80% del intestino delgado con o sin NP). Todos los experimentos duraron 10 días y 323 animales llegaron al final del periodo de estudio. Se diseñaron 9 grupos que recibieron algún tipo de intervención y 8 grupos control. Las intervenciones fueron tres dietéticas (nutrición enteral mínima [NEM] y probióticos a dosis baja y alta), cinco farmacológicas (administración de hormona de crecimiento [GH], factor de crecimiento epidérmico [EGF],insulina, colecistoquinina [CCQ] y descontaminación intestinal selectiva[DIS]) y una quirúrgica (resección de la válvula ileocecal).La infección en forma de translocación bacteriana (TB) se detectó cultivando los ganglios linfáticos mesentéricos, sangre portal y sangre periférica, y el daño hepático, por los niveles de citoquinas proinflamatorias (..) (AU)

The fight against infection and liver disease associated with parenteral nutrition (PN) are surely two of the most problematic aspects in the management of paediatric patients with short bowel syndrome (SBS).In the Research Unit of Donostia Hospital, we have spent the past 15years investigating different ways of reducing these complications in an experimental model of short bowel in the Wistar rat (resection of80% of the small bowel, with and without PN). All the experiments had a duration of 10 days and 323 animals reached the end of the study period. Nine groups were established in which some type of intervention was performed, and there were 8 control groups. The interventions were:3 dietary (minimal enteral nutrition [MEN] with low or high dose probiotics);5 pharmacological (administration of growth hormone [GH],epidermal growth factor (..) (AU)

[Effect of the administration of cholecystokinin on the cholestasis associated with total parenteral nutrition in experimental short bowel]. / Efecto de la administración de colescistoquinina sobre la colestasis asociada a la nutrición parenteral total en el intestino corto experimental.

INTRODUCTION: Total parenteral nutrition (TPN) is not free of complications. One of the most serious is cholestasis; the cause of this complication is unclear but it may be due to a lack of an enteral stimulus for cholecystokinin (CCK) production. CCK is essential for contraction of the gallbladder and also stimulates intrahepatic bile flow. Its absence may contribute to cholestasis. After any hepatic aggression, the Kupffer cells respond and release proinflammatory cytokines, such as interleukin-1 (IL-1) and tumour necrosis factor alpha (TNF-alpha), which increase the hepatic damage. The objective of this experimental study has been to observe the effect that the exogenous administration of CCK could have on hepatic damage in experimental short bowel with and without TPN, determined using the serum levels of IL-1 and TNF-alpha. MATERIAL AND METHODS: A resection of 80% of the small bowel was performed on 53 Wistar rats and a continuous infusion of saline or TPN was initiated. The rats were divided into the following groups: SHAM (N = 14): normal saline infusion and free access to food and water. TPN (N = 15): Standard TPN. SHAM-CCK (N = 14): same as the SHAM group but with a daily dose of CCK. TPN-CCK (N = 10): same as the TPN group but with a daily dose of CCK. At the end of the experiment, the animals were sacrificed and blood samples were obtained to determine the IL-1 and TNF-alpha values by ELISA. RESULTS: The IL-1 and TNF-alpha levels were higher in the TPN group (7.537 and 5.899 pg/mL, respectively) than in the SHAM group (6.509 and 4.989 pg/mL, respectively) (p > 0.05). The TNF-alpha values were higher in the SHAM group (4.989 pg/mL) than in the SHAM-CCK group (4.583 pg/mL) (p < 0.001). The IL-1 and TNF-alpha levels were higher in the TPN group than in the TPN-CCK group (6.709 and 4.794 pg/mL, respectively) (p < 0.001 for TNF-alpha). CONCLUSIONS: 1. There is a rise in the serum levels of the pro-inflammatory cytokines IL-1 and TNF-alpha in animals with short bowel on TPN or enteral nutrition. 2. The administration of CCK causes a fall in the IL-1 and TNF-alpha levels, and could be used such as a further measure to prevent TPN-associated cholestasis.

Efecto de la administración de colescistoquinina sobre la colestasis asociada a la nutrición parenteral total en el intestino corto experimental / Effect of the administration of cholecystokinin on the cholestasis associated with total parenteral nutrition in experimental short bowel

Introducción. La nutrición parenteral total (NPT) no está libre de complicaciones. Una de las más serias es la colestasis, cuyo origen no es muy claro y puede deberse a la falta de estimulo enteral para la producción de colescistoquinina (CCQ). La CCQ es fundamental para la contracción de la vesícula biliar y como estimulante del flujo biliar intrahepático. Su falta puede contribuir a la colestasis. Ante toda agresión hepática, las células de Kupffer responden y liberan citoquinas proinflamatorias, como la interleukina-1 (IL-1) y el factor de necrosis tumoral alfa (TNF-α), que aumentan el daño hepático. El objetivo de este estudio experimental ha sido observar el efecto que la administración exógena de CCQ pudiera tener sobre el daño hepático en el intestino corto experimental con y sin NPT, medido por los niveles séricos de IL-1 y TNF-α. Material y métodos. Cincuenta y tres ratas Wistar fueron sometidas a una resección del 80% del intestino delgado y a una infusión continua de suero o NPT y se asignaron a los siguientes grupos: • SHAM (N=14): infusión de suero fisiológico y acceso libre a comida y agua. • NPT (N=15): NPT estándar. • SHAM-CCQ (N=14): como el grupo SHAM y una administración diaria de CCQ. NPT-CCQ (N=10): como el NPT y una administración diaria de CCQ. Al final del experimento, los animales fueron sacrificados y se obtuvieron muestra de sangre para determinar los valores IL-1 y TNF-α por ELISA. Resultados. Los niveles de IL-1 y TNF-α fueron mayores en el grupo NPT (7,537 y 5,899 pg/mL, respectivamente) que en el grupo SHAM (6,509 y 4,989 pg/mL, respectivamente) (p > 0,05). Los valores de TNF-α fueron mayores en el grupo SHAM (4,989 pg/mL) que en el grupo SHAM-CCQ (4,583 pg/mL), (p < 0,001). Los niveles de IL-1 y TNF-α fueron mayores en el grupo NPT que en el grupo NPT-CCQ (6,709 y 4,794 pg/mL, respectivamente) (p< 0,001 para TNF-α). Conclusiones. 1. En los animales con intestino corto bajo NPT o con nutrición enteral, se elevan los niveles séricos de las citoquinas proinflamatorias IL-1 y TNF-α. 2. La administración de CCQ, disminuye los niveles de IL-1 y TNF- α, pudiendo ser utilizada como una medida más para combatir la colestasis asociada a la NPT

Introduction. Total parenteral nutrition (TPN) is not free of complications. One of the most serious is cholestasis; the cause of this complication is unclear but it may be due to a lack of an enteral stimulus for cholecystokinin (CCK) production. CCK is essential for contraction of the gallbladder and also stimulates intrahepatic bile flow. Its absence may contribute to cholestasis. After any hepatic aggression, the Kupffer cells respond and release proinflammatory cytokines, such as interleukin-1 (IL-1) and tumour necrosis factor alpha (TNF-α), which increase the hepatic damage. The objective of this experimental study has been to observe the effect that the exogenous administration of CCK could have on hepatic damage in experimental short bowel with and without TPN, determined using the serum levels of IL-1 and TNF-α. Material and methods. A resection of 80% of the small bowel was performed on 53 Wistar rats and a continuous infusion of saline or TPN was initiated. The rats were divided into the following groups: • SHAM (N=14): normal saline infusion and free access to food and water. • TPN (N=15): Standard TPN. • SHAM-CCK (N=14): same as the SHAM group but with a daily dose of CCK. • TPN-CCK (N=10): same as the TPN group but with a daily dose of CCK. At the end of the experiment, the animals were sacrificed and blood samples were obtained to determine the IL-1 and TNF-α values by ELISA. Results. The IL-1 and TNF-α levels were higher in the TPN group (7.537 and 5.899 pg/mL, respectively) than in the SHAM group (6.509 and 4.989 pg/mL, respectively) (p>0.05). The TNF-α values were higher in the SHAM group (4.989 pg/mL) than in the SHAM-CCK group (4.583 pg/mL) (p<0.001). The IL-1 and TNF-α levels were higher in the TPN group than in the TPNCCK group (6.709 and 4.794 pg/mL, respectively) (p< 0.001 for TNF-α). Conclusions. 1. There is a rise in the serum levels of the pro-inflammatory cytokines IL- 1 and TNF-α in animals with short bowel on TPN or enteral nutrition. 2. The administration of CCK causes a fall in the IL-1 and TNF-α levels, and could be used such as a further measure to prevent TPN-associated cholestasis