A multicentre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery.

AIM: The introduction of multimodal or fast track (FT) rehabilitation and laparoscopy in colorectal surgery has improved patient recovery and shortened hospital stay (HS). This study aimed to determine the influence of laparoscopic or open surgery on the postoperative recovery of colorectal cancer patients having a conventional care (CC) or FT protocol in the postoperative period. METHOD: A multicentre prospective study was controlled with a retrospective group. The prospective group included 300 patients having elective colorectal resection for cancer. The retrospective control group included 201 patients with the same characteristics who were treated before the introduction of the programme. The patients were divided into four groups including laparoscopy + FT, open surgery + FT, laparoscopy + CC, and open surgery + CC. The primary end-points were HS and morbidity. Secondary end-points included mortality and reoperation rates. RESULTS: The overall median HS was 7 days. The median HS for laparoscopy + FT was 5 days, open + FT 6 days, laparoscopy + CC 9 days and open + CC 10 days (P < 0.001). In the regression model the laparoscopy + FT group had the greatest reduction in HS (P < 0.001). A significant reduction in HS was observed in the laparoscopy + FT group compared with laparoscopy + CC (P < 0.001). The overall patient morbidity was 30.6%. The logistic regression model adjusted for propensity score showed no statistically significant differences between the study groups regarding all other end-points. CONCLUSION: Colorectal cancer patients who underwent laparoscopic surgery within a multimodal rehabilitation protocol experienced the shortest HS and the lowest morbidity.

Sistema de telemedicina mediante telefonía móvil para control postoperatorio en cirugía mayor ambulatoria. Estudio piloto / No disponible

Objetivo: Exponer el desarrollo del estudio piloto de un sistema de telemedicina (telecontrol postoperatorio domiciliario), previamente implementado y validado en la Unidad de Cirugía Mayor Ambulatoria del Hospital Clínico San Carlos de Madrid, mediante la utilización de telefonía móvil con sistema GPRS, que permite la toma y envío de imágenes de la zona operatoria en general y del apósito, vendaje y herida quirúrgica, en particular, para mejorar el control postoperatorio domiciliario de los pacientes de dicha unidad y evitar desplazamientos innecesarios al Servicio de Urgencia. Material y métodos: Se han incluido 96 pacientes intervenidos entre el 1 de junio y el 15 de octubre de 2004: 58,3% varones; edad 52,6 ± 14,2 (21-84 años). Se han identificado los procesos de mayor utilidad para la implantación del sistema de telemedicina (hernias inguino-crurales y umbílico-epigástricas; hallux valgus; síndrome del túnel carpiano; varices esenciales extremidades inferiores; varicocele e hidrocele). Se han analizado la capacidad y eficacia diagnósticas para establecer la magnitud de posibles complicaciones locales postoperatorias, mediante el análisis de imágenes realizadas con un total de 30 terminales móviles Nokia 6600 (formato JPEG, resolución 640 x 480), enviadas mediante mensajes MMS y visualizadas en un monitor de 17 pulgadas tipo estándar, de un ordenador personal con microprocesador Intel Pentium 4 de 1,41 GHz. Se ha analizado la opinión, valoración y satisfacción de los pacientes mediante formulario con 9preguntas (8 cerradas –6 dicotómicas puras, ofreciendo sólo dos opciones de respuesta, y 2 de opción múltiple con alternativas mutuamente excluyentes– y 1 pregunta abierta). La calificación del sistema se realiza con una nota en una escala del 1 al 10. Resultados: El 31% ha presentado problemas locales durante el postoperatorio domiciliario. Los más frecuentes han sido: hematomas(67%) (en hernias 88%, hidrocele y varicocele 50% y varices 50%) y el manchado hemorrágico (27%) (en hallux valgus 63% y en varices 50%), siendo sangre oscura, coagulada, en la mayoría de los casos (80 y 100% respectivamente). En el 95% de las 225 fotografías recibidas la calidad de la imagen ha sido buena y en todas se ha identificado la incidencia postoperatoria, permitiendo realizar la evaluación clínica de la situación así como la adopción de una conducta a seguir. El 56,6% ha manifestado que, de no haber dispuesto de este sistema de telemedicina, habría solicitado directamente la valoración presencial hospitalaria de dicha complicación. El 100% considera que se incrementa la sensación de seguridad en el postoperatorio domiciliario. La valoración ha sido calificada con una nota media de 8,9 ± 1 (límites 6 y 10, mediana 9 y moda 10). Conclusiones: Los resultados ponen de manifiesto que este sistema de telemedicina posee una probada capacidad y eficacia diagnóstica que le confiere una considerable utilidad para incrementar la seguridad y la calidad del control postoperatorio domiciliario en CMA, evitando desplazamientos innecesarios al hospital y aumentando claramente la satisfacción de los pacientes (AU)

Objective: To describe the development of a pilot study for a telemedicine system in our Ambulatory Surgical Unit (Hospital Clínico San Carlos in Madrid), using mobile phones with a GPRS system. This system allows the taking and sending of pictures of the surgical area, surgical dressing or bandage and the surgical wound, to improve the postoperative control in their home of the patients from our Unit and to avoid unnecessary displacements to the Hospital Emergency Service. Material and methods: The study included 96 patients undergoing ambulatory surgery between June 1st and October 15th, 2004: 58.3% were male, mean age was 52.6 ± 14.2 (21-84 years). We identified the procedures in which the introduction of the telemedicine system would be most useful (inguinal and femoralhernias, umbilical and epigastric hernias; hallux valgus; carpal tunnel syndrome; varicose veins of the lower extremities; varicocele and hydrocele). We analyzed the diagnostic capacity and effectiveness to establish the magnitude of potential postoperative local complications, by analysing images taken with a total of 30 mobilephones Nokia 6600 (JPEG format, 640 x 480 resolution), andsent via MMS messages displayed on a 17-inch standard monitor of a personal computer with Intel Pentium 4 microprocessor (1.41 GHz). We analyzed the opinion, evaluation and satisfaction of patients through a 9 questions survey (8 closed –6 purely dichotomous, offering only two response options, and 2 multiple choicequestions with mutually excluding answers– and 1 open question). The rating system was studied with a note on a scale from 1 to 10. Results: 31% presented local postoperative problems at home. The most frequent problems were: Haematomas (67%: 88% in hernias, 50% in hidrocele and varicocele, and 50% in varices) and blood-stained wounds (27%: 63% in hallux valgus and 50% in varices), the blood stain was dark or coagulated in most of the cases (80 and 100% respectively). In 95% of the 225 received pictures the quality of the image was good and in all of them the postoperative local complication was identified allowing us to make a clinical evaluation of the situation. In 56.6% of cases, had they not had this telemedicine system, patients would have gone directly to the hospital to evaluate this complication. They all (100%) agreed that there was an increased sense of postoperative security at home. This system was marked with a mean value of 8.9 ± 1 out of 10 (limits 6-10, median 9 and mode 10). Conclusions: According to the results obtained, this telemedicine system proves to be diagnostically effective and gives an increased sense of safety and quality of postoperative control in ambulatory surgery, and avoids unnecessary displacements to the hospital, clearly increasing patient satisfaction (AU)

Desarrollo de un sistema de telemedicina, con telefonía móvil, para control postoperatorio en cirugía mayor ambulatoria / No disponible

No disponible

Ambulatorización de la cirugía tiroidea / No disponible

No disponible

[Improving communication between levels of health care: direct referral of patients to a one-stop service for major outpatient surgery]. / Mejora de la comunicación entre niveles asistenciales: derivación directa de pacientes a una consulta de alta resolución de cirugía mayor ambulatoria.

OBJECTIVE: To analyze the results obtained with a "one-stop" specialty service designed as part of a collaborative program involving primary and specialized care in order to improve communication between levels of care and reduce the delay in referral and surgical treatment for patients eligible for outpatient surgery. DESIGN: Prospective, descriptive, longitudinal study. SETTING: Major Outpatient Surgery Unit of the Hospital Clinico San Carlos and health centers serving Health Area 7 in Madrid, central Spain. PARTICIPANTS: Patients more than 14 years of age with a surgical condition involving the abdominal wall, pilonidal sinus, soft-tissue tumor, or proctological disease. INTERVENTION: Direct referral, with completed preoperative work-up, of patients from health centers to the Major Outpatient Surgery Unit of the Hospital Clinico San Carlos according to a protocol developed by consensus. The patient is seen on the same day for surgical work-up and anesthesia work-up, and is given preoperative information. Patients then make only one further visit to the hospital to undergo surgery. MAIN MEASURES: Number of patients with each diagnosis referred, diagnostic concordance between the health center and hospital, delay from referral to surgical treatment, number of trips made for different appointments, and referral rate. RESULTS: A total of 188 patients were referred. More than two thirds (68.7%) had an abdominal wall condition eligible for direct referral. Diagnostic concordance was 96%. The delay from referral until surgery was reduced by 60%, and the number of trips for appointments was reduced by 66.6%. The overall referral rate was 12.6%. CONCLUSIONS: Because of its feasibility, acceptability, and cost-efficiency, the direct referral system has the potential to improve relations between primary and specialized care and enhance the quality of care by shortening the delay to treatment.

Mejora de la comunicación entre niveles asistenciales: derivación directa de pacientes a una consulta de alta resolución de cirugía mayor ambulatoria / Improving communication between levels of health care: direct referral of patients to a “one-stop” service for major outpatient surgery

Objetivo. Analizar los resultados de una consulta de alta resolución (CAR) diseñada en el entorno de un programa de colaboración entre atención primaria (AP) y especializada (AE) para mejorar la comunicación entre niveles asistenciales y disminuir la demora de derivación y tratamiento quirúrgico de pacientes susceptibles de ser operados sin ingreso. Diseño. Estudio prospectivo, descriptivo y longitudinal. Emplazamiento. Unidad de Cirugía Mayor Ambulatoria (UCMA) del Hospital Clínico San Carlos y centros de salud del Área Sanitaria 7 de Madrid. Participantes. Pacientes > 14 años con enfermedad quirúrgica de la pared abdominal, sinus pilonidal, tumores de partes blandas y proctología. Intervención. Derivación directa de pacientes a la CAR de la UCMA desde los centros de salud según un protocolo consensuado y con el preoperatorio realizado. El paciente realiza la consulta quirúrgica, preanestésica e informativa el mismo día, y acude al hospital sólo una vez más para ser intervenido. Mediciones principales. Cuantificación de los procesos, concordancia diagnóstica entre la AP y la UCMA, duración del circuito, número de desplazamientos e índice de sustitución de los procesos. Resultados. Se ha remitido a 188 pacientes. El 68,7% presentaba enfermedad de la pared abdominal. La concordancia diagnóstica ha sido del 96%. La duración del circuito desde la derivación hasta la intervención se ha reducido en un 60% y los desplazamientos en un 66,6%. El índice de sustitución global ha sido del 12,6% (tabla 4). Conclusiones. Sobre la base de los resultados obtenidos, destacamos las posibilidades del programa en cuanto a factibilidad en su realización, aceptabilidad y rentabilidad, mejorando la relación entre AP y AE y la calidad en la atención al paciente al disminuir el circuito asistencial

Objective. To analyze the results obtained with a "one-stop" specialty service designed as part of a collaborative program involving primary and specialized care in order to improve communication between levels of care and reduce the delay in referral and surgical treatment for patients eligible for outpatient surgery. Design. Prospective, descriptive, longitudinal study. Setting. Major Outpatient Surgery Unit of the Hospital Clínico San Carlos and health centers serving Health Area 7 in Madrid, central Spain. Participants. Patients more than 14 years of age with a surgical condition involving the abdominal wall, pilonidal sinus, soft-tissue tumor, or proctological disease. Intervention. Direct referral, with completed preoperative work-up, of patients from health centers to the Major Outpatient Surgery Unit of the Hospital Clínico San Carlos according to a protocol developed by consensus. The patient is seen on the same day for surgical work-up and anesthesia work-up, and is given preoperative information. Patients then make only one further visit to the hospital to undergo surgery. Main measures. Number of patients with each diagnosis referred, diagnostic concordance between the health center and hospital, delay from referral to surgical treatment, number of trips made for different appointments, and referral rate. Results. A total of 188 patients were referred. More than two thirds (68.7%) had an abdominal wall condition eligible for direct referral. Diagnostic concordance was 96%. The delay from referral until surgery was reduced by 60%, and the number of trips for appointments was reduced by 66.6%. The overall referral rate was 12.6%. Conclusions. Because of its feasibility, acceptability, and cost-efficiency, the direct referral system has the potential to improve relations between primary and specialized care and enhance the quality of care by shortening the delay to treatment

Laboratory evaluation of the effect of prophylaxis for thromboembolism with fractionated heparin in patients undergoing laparoscopic cholecystectomy.

OBJECTIVE: We studied the effect of prophylaxis for thromboembolism with low-molecular-weight heparin (LMWH) during hospitalization on the biological hemostasis system in patients who had undergone laparoscopic cholecystectomy. METHODS: This was a prospective paired cohort study without a control group (i.e., a before-after study). The subjects were 20 patients operated on laparoscopically for uncomplicated cholelithiasis. All patients received LMWH 2 h before the operation and 24 h after the first dose. Mean duration of surgery was 70 min. Pneumoperitoneum was accomplished at 14 mmHg, and all patients were operated on in the inverted Trendelenberg position (30 degrees). Patients were mobilized within 24 h, and were discharged within 48 h after surgery. As parameters of hemostasis we studied anti-Xa factor activity (anti-Xa), antithrombin III (AT III), partial active thromboplastin time (PTT) and fibrinogen. Samples were taken for laboratory analyses under basal conditions the day before the operation (first determination), 1 h after the first preoperative dose of LMWH was given (second), at the end of the operation (third), 24 h after surgery (fourth), and on postoperative day 7 (fifth). RESULTS: Mean basal values of all parameters were within the normal range. Mean anti-Xa activity was significantly higher in the second and third determinations than in the first and fifth measurements (p < 0.05). Mean PTT was significantly elevated on the second determination and decreased thereafter; however, none of the results differed significantly from the normal value. Mean AT III was significantly lower in the third determination in comparison with the first and fifth measurements. Fibrinogen was significantly higher in the fourth and fifth determinations than in the second and third measurements. Among all parameters and sampling times, the only values outside the normal range were anti-Xa activity on the second, third and fourth determinations. CONCLUSIONS: Plasma anti-Xa factor activity was increased preoperatively, and remained elevated for 24 h after surgery, returning to basal values on postoperative day 7. Partial thromboplastin time was slightly prolonged after the first dose of LMWH, indicating good antithrombotic action.

Valoración analítica de la profilaxis tromboembólica con heparina fraccionada en la colecistectimía laparoscópica / Laboratory evaluation of the effect of prophylaxis for thromboembolism with fractionated heparin in patiens undergoing laparoscopic cholecystectomy

OBJETIVO: se estudia la repercusión que la pauta de profilaxis tromboembólica con heparina de bajo peso molecular (HBPM) realizada únicamente durante el periodo de hospitalización, tiene sobre el sistema biológico de la hemostasia, en pacientes colecistectomizados por vía laparoscópica. DISEÑO DE TRABAJO: se ha realizado un estudio de cohortes prospectivo apareado sin grupo control ("antesdespués"). PACIENTES Y MÉTODOS: el estudio se ha realizado en 20 pacientes intervenidos de colelitiasis no complicada, mediante cirugía laparoscópica. A todos los pacientes se les administró HBPM, dos horas antes de la intervención y a las 24 horas de la primera dosis. La duración media de la operación fue de 70 minutos. A todos se les realizó neumoperitoneo a 14 mmHg y fueron intervenidos en posición de Trendelenburg invertida (30º). La movilización se realizó antes de las 24 horas, y se les dio de alta a las 48 horas de la intervención. Los parámetros de hemostasia estudiados han sido: la actividad antifactor X activado (anti-Xa) y la Antitrombina III, el Tiempo Parcial de Tromboplastina Activada (TPTA), y el Fibrinógeno. Se recogieron muestras para la valoración de estos parámetros en los siguientes momentos: 1ª) En condiciones basales el día anterior a la intervención. 2ª) Preoperatoriamente, una hora después de administrar la HBPM. 3ª) Al finalizar la intervención. 4ª) A las 24 horas de la misma, y 5ª) En el 7º día del postoperatorio. RESULTADOS: todos los parámetros de hemostasia tenían valores medios en el rango normal, en las determinaciones basales. Los valores medios de la actividad anti-Xa aumentó significativamente en las determinaciones 2ª y 3ª en relación a los valores de la 1ª y 5ª (p < 0,05). El valor medio del TPTA aumentó significativamente en la 2ª determinación para luego descender, sin embargo ninguna de las determinaciones de este parámetro difieren de los valores normales. El valor medio de la ATIII sólo desciende significativamente en la determinación 3ª en relación a la 1ª y a la 5ª. El valor medio del Fibrinógeno aumentó significativamente en las determinaciones 4ª y 51 en relación a la 2ª y 3ª. De todos los parámetros estudiados, sólo estaban fuera del rango normal los valores de la actividad anti-Xa, en las determinaciones correspondientes a la 2ª, 3ª y 4ª extracciones. CONCLUSIONES: se ha producido un aumento de la actividad plasmática anti-factor X activado, preoperatoriamente y que se mantiene hasta las 24 horas del postoperatorio, alcanzando los valores basales en la determinación efectuada al 7º día, con sólo un pequeño alargamiento del TPTA a la hora de administrar la heparina, lo que nos indicaría una buena acción antitrombótica (AU)

Roux-en-Y syndrome after surgical treatment of alkaline reflux gastritis.

OBJECTIVE: to evaluate the possible existence of the so-called <> in a group of 21 patients who underwent surgery to correct postoperative alkaline reflux gastritis. METHODS: the study group consisted of 15 men and 6 women (mean age 39.2 years). All had undergone Billroth II subtotal gastrectomy (20 for ulcer and 1 for gastric cancer). Alkaline diversion was done with the Roux-en-Y technique 50-60 cm away from the gastrojejunal anastomosis. In all patients bilateral truncal vagotomy at the hiatus was also done. No mechanical alterations in the gastrojejunal anastomosis were found during surgery. Mean follow-up period was 8.2 years (range 6.5-10.7 years), during which clinical, radiological and endoscopic studies were obtained. Gammagraphic study of gastric remnant emptying was done on postoperative day 30. RESULTS: none of the patients had clinical, radiological or endoscopic manifestations that indicated the presence of Roux-en-Y syndrome. Gammagraphic studies of gastric remnant emptying did not demonstrate significant differences between preoperative (T1/2: 7.3 min) and postoperative values (T1/2: 10.1 min). CONCLUSIONS: we found no evidence of disturbances in gastric remnant emptying after Roux-en-Y gastrojejunostomy to treat postoperative alkaline gastric reflux.

Incisional hernias after laparoscopic vs open cholecystectomy.

BACKGROUND: The aim of this study was retrospectively to compare the incidence of incisional hernia formation at trocar sites in laparoscopic cholecystectomy with that after conventional open cholecystectomy. METHODS: In all, 271 patients with cholelithiasis underwent either laparoscopic cholecystectomy (LC group, n = 142) or open cholecystectomy (OC group, n = 129). In the OC group, the surgical approach was to use a right subcostal incision in 20.2%, right transrectal laparotomy in 73.6%, and midlaparotomy in 6.2%. Laparotomy closure was performed by continuous absorbable suture for the peritoneum and discontinuous absorbable stitches for muscle and fascia. Laparoscopic access was achieved by use of four trocars (two 10 mm and two 5 mm). Umbilical port closure was performed by suture of fascia using discontinuous stitches. Closure of the remaining ports was performed by suture of the skin. RESULTS: Both patient groups were statistically similar with respect to general risk factors. Follow-up was performed in 84 (65.1%) OC and 123 (86.6%) LC patients and ranged from 2 to 10 years (mean, 8 years) and 1 to 5 years (mean, 3 years) respectively. Five (5.9%) OC and two (1.6%) LC patients developed incisional hernias, although the difference between groups was not significant. All hernias in OC patients appeared after transrectal laparotomy. The LC hernias appeared at the umbilical port, and one of the patients developed an additional xiphoides port-associated hernia. CONCLUSIONS: The laparoscopic technique showed a lower (although not significantly) incidence of incisional hernias than the open procedure.

Changes in hemostasis after laparoscopic cholecystectomy.

BACKGROUND: The aim of this work was to study hemostasis in laparoscopic cholecystectomy in order to determine if there are any changes that indicate a greater risk of thrombosis. METHODS: The study was carried out in 20 patients who underwent laparoscopic surgery for noncomplicated cholelithiasis. The average age was 59.4 years (range, 34-77). A total of 75% were female. Mean operation time was 70 min (ranges 35-120). Pneumoperitoneum at 14 mmHg was performed on all patients, who were positioned in the 30 degrees reverse Trendelenburg position. Postoperative mobilization was acheived in 24 hs and patients were discharged 48 hs after the operation. The control group was composed of 12 patients, who were evenly distributed by age, sex, and length of surgery. These patients underwent Bassini herniorraphy for inguinal hernia without any complications or relapse. The following hemostatic parameters were studied: prothrombin activity (PA), activated partial thromboplastin time (APTT), fibrinogen (Fg), anti-thrombin III (ATIII), plasma fibrinolytic activity (PFA), euglobulin fibrinolytic activity (EFA), and D-dimer (D-D). Samples were obtained at the following times: (a) under basal conditions the day before surgery, (b) preoperatively, (c) at the end of the operation, (d) 24 hs after the operation, and (e) On the 7th day following the operation. RESULTS: No patient showed any clinical manifestations of thromboembolic disease immediately after surgery or during a medium follow-up period of 16 months (range, 15-18 months). All hemostatic parameters values were within normal range in the basal samples of both groups. In both groups, the mean value of PA showed a significant decrease (p < 0.05) in the second, third, and fourth basal samples, returning to normal levels by the fifth determination. The mean value of fibrinogen decreased slightly in the second and third samples, increasing significantly with respect to the fourth and fifth determinations in both groups (p < 0.05). The mean value of APTT in both groups was slightly enhanced in the second and third determinations in relation to the first and fifth. The global activity of fibrinolysis (PFA and EFA) increased significantly in the third sample with respect to the other determinations in the group who had laparoscopic surgery (p < 0.005). Only EFA increased in the control group (p < 0.05). D-D decreased in the preoperative second determination followed by a significant enhancement immediate postoperatively (third), and 24 hs (fourth) (p < 0.05); it returned to normal basal values on the seventh day. No significant differences were found between the two groups. CONCLUSIONS: These results indicate that laparoscopic cholecystectomy leads to no greater activation of plasma coagulation than low-risk surgery. On the contrary, the increase of fibrinolytic activity in plasma would extend a certain degree of hypocoagulability during surgery, maintaining it for 24 hs and thus possibly reducing thromboembolic risk in patients undergoing this type of surgery.

Fibrinolytic activity in laparoscopic cholecystectomy.

The aim of this study was to examine the fibrinolytic activity in laparoscopic cholecystectomy (LC) to determine whether changes occur that might indicate a greater risk of thrombosis. The study was carried out in 20 patients who had undergone laparoscopic surgery for cholelithiasis without complications. The average age was 59.4 years (34-77 years). Seventy-five percent were women. The mean operating time was 70 minutes (35-120 minutes). Pneumoperitoneum at 14 mm Hg was maintained in all patients, and they were in 30 degrees reverse Trendelenburg position. Postoperative mobilization was obtained before 24 hours, and patients were discharged 48 hours after surgery. The control group was composed of 12 patients, evenly distributed by age, sex, and length of surgery, who had undergone Bassini herniorrhaphy without complications or relapses. The following hemostatic parameters were studied: plasma fibrinolytic activity (PFA), euglobulin fibrinolytic activity (EFA), tissue-type plasminogen activator (t-PA), fast-acting plasminogen activator inhibitor-1 (PAI-1), and D-dimer (D-D). Samples were obtained at the following times: (1) under basal conditions the day before surgery, (2) preoperatively, (3) at the end of surgery, (4) 24 hours after surgery, and (5) on the seventh day following surgery. No patient had clinical manifestations of thromboembolic disease immediately after surgery or during an average follow-up period of 16 months (range 15-18 months). Analysis of the results of global fibrinolysis showed that fibrinolytic activity was enhanced only in the postoperative period (third sample) of the LC patients. The fraction of euglobulins enhances fibrinolytic activity in both groups in the third sample with regard to the other determinations; the LC patients showed a higher degree of significance (p<0.005). A significant increase of postoperative t-PA in both groups was found, being more significant in the LC group (p<0.005). In the PAI-1 values, no significant differences existed between either determinations or groups. A significant increase in D-dimer (p<0.05) occurred in the immediate postoperative period (third sample) and 24 hours later (fourth sample), returning to normal basal values on the seventh day. No significant differences were found between the two groups. These results seem to indicate that LC produces an increase in the fibrinolytic activity in plasma as a result of the liberation of tissue plasminogen activator from the venous endothelium, which could indicate hypocoagulability during the immediate postoperative period and, therefore, signify less thrombotic risk for patients undergoing this procedure.

[Anatomopathologic changes in the distal esophagus following proximal gastric vagotomy. Experimental study]. / Cambios anatomo-patológicos en el esófago distal tras la vagotomía gástrica proximal. Estudio experimental.

In order to determine the causes of postvagotomy dysphagia, we examined microscopic changes in the lower esophagus after a proximal gastric vagotomy. Forty dogs were divided into 4 groups (n = 10). Group I was used as control. In group II, the effect of denervation was studied by means of transthoracic vagotomy. In group III, the effect of mechanical traction of the lower esophagus was studied, without denervation or surgical manoeuvres. In group IV, the effect of denervation, esophageal traction and the surgical manoeuvres, of proximal gastric vagotomy was examined. No periesophageal hematomas or fibrosis was found. Degenerative nerve phenomena were found with no significant differences in the three groups. In groups III and IV, lesions of the esophageal muscular layer were observed, without significant differences. Chronic inflammatory changes and fibrosis were also encountered being more intense and significantly more frequent in group IV. We conclude that the surgical manoeuvers necessary to obtain denervation of the cardioesophageal function during proximal gastric vagotomy, could be responsible for the appearance of post-vagotomy dysphagia.

[Risk factors of peptic ulcer hemorrhage]. / Estudio de factores de riesgo de la hemorragia por úlcera péptica.

A retrospective analysis is made of the risk factors in 229 patients admitted to hospital with hemorrhage from peptic ulcer. The factors that have been studied are: 1) age. 2) type of ulcer lesion. 3) associated disease. 4) antiinflammatory intake. 5) prior ulcer symptoms. 6) intensity and outcome of the bleeding episode. 7) endoscopic findings. 8) treatment modality. 9) mortality. The analysis of these factors tries to establish, by means of the square chi test with Yates correction, the possible relations between the factors, to determine which ones will have a pronostic value. From the results obtained we conclude that the factors with the highest pronostic importance are: 1) With respect to the severity of the bleeding episode, antiinflammatory intake and duodenal location of the ulcer lesion. 2) With respect to the need for urgent surgical treatment, antiinflammatory intake and prior ulcer symptoms. 3) With respect to mortality, severity, persistence and recurrence of bleeding, and the need for urgent surgical treatment. Finally, it is important to mention the absence of pronostic value, with respect to mortality, of advanced age and the endoscopic findings of active and/or recent bleeding.

[Blood gastrin changes in the late postoperative period after proximal gastric vagotomy]. / Alteraciones de la gastrinemia en el postoperatorio tardío tras vagotomía gástrica proximal.

Changes in serum gastrin levels in the late postoperative period have been studied in 24 patients with non-stenotic duodenal ulcer who underwent proximal gastric vagotomy. Twenty healthy volunteers were used as a control group. Serum gastrin levels were determined under basal conditions and after a high protein meal stimulation. Both measurements were done in the preoperative, early postoperative (12th day) and late postoperative periods (X = 5.5 yrs.). Regarding basal serum gastrin levels, the results show mean values of 46.2 pg/ml in the preoperative, 61.6 pg/ml in the early postoperative, 73.9 pg/ml in the late postoperative and 51 pg/ml in the control group. Early and late postoperative period values show statistical significant differences when compared with preoperative values (p < 0.05), but not with the control group ones. Stimulated gastrin levels show mean values of 75.7 pg/ml in the preoperative, 99.1 pg/ml in the early postoperative, 134.1 pg/ml in the late postoperative and 73.4 pg/ml in the control group. Late postoperative values show statistical significant differences when compared with preoperative and early postoperative values (p < 0.05), and also when compared with the control group (p < 0.05). Possible causes and the physiopathological effects of these variations are discussed.

[Carcinoma in a long-standing Zenker's diverticulum]. / Carcinoma en divertículo de Zenker de larga evolución.

The authors report a case of carcinoma arising in a longstanding Zenker's diverticulum, in a 66 years old man that refused surgical treatment for 25 years. Three months prior to his admission to our hospital, an exacerbation of his dysphagia, which became severe, was observed; and so was regurgitation, with passage to the airway during swallowing or when asleep. The esophagram showed the diverticulum without images suggestive of neoplasm, and with spilling of barium into the tracheobronchial tree. Esophagoscopy was refused by the patient. After surgical diverticulectomy, a thickened area in the inferior portion of the diverticular body was observed, which was histologically reported as a squamous cell carcinoma with pearl formation, involving only the diverticular wall. Complementary radiotherapy with TCT was administered over the esophagus, mediastinum and supraclavicular lymphatic areas, with a total dose of 5000 Cgy. Concomitant chemotherapy with Mitomycin and 5-Fluorouracil was administered. After a 2 year follow-up, the patient is completely asymptomatic. We discuss etiopathogenic factors, clinical manifestations, diagnostic procedures, and therapeutic possibilities.