Anal encirclement with a simple prosthetic sling for faecal incontinence.

BACKGROUND: Millions of people suffer from anal incontinence not currently treated due to the complexity and cost of the surgical techniques in use. The purpose of this report is to evaluate the results of anal encirclement with a simple device in a group of patients with faecal incontinence of multiple causes. METHODS: Surgery was performed as a modified Thiersch procedure through minimal perianal incisions, and a flat band of silicone was introduced to encircle the anus. Results were assessed by clinical response and objectively evaluated by comparing pre- and post-operative manometry, Jorge-Wexner and QOL (Rockwood) scores. RESULTS: Over a period of 5 years, this procedure was performed in 20 women and 13 men, mean age 54 years (27-86 years). Causes of incontinence were iatrogenic (5), obstetric (5), idiopathic (5), restorative proctectomy (5), rectal prolapsed (4), congenital (4), neuropathic (3), trauma (1) and mixed (1). Mortality was nil and morbidity was related to early infection (n = 2) and late skin erosion/infection (n = 2). Early or late breaking of the sling occurred in nine patients, due to the inappropriate method of closing the device. There were 13 explants: 3 as definitive and 10 re-implantations. All but one patient improved the clinical status which was objectively assessed by Jorge-Wexner and QOL scores, with significant differences. CONCLUSIONS: This simple, safe and low-cost technique is useful for treating from disturbing soiling to severe incontinence in all those patients with failed sphincteroplasty or not amenable to sphincter repair. However, a proper device needs to be designed.

Pseudomyxoma peritonei secondary to epithelial appendicular neoplasms. Experience in a non-specialised centre.

INTRODUCTION: Pseudomyxoma peritonei is an infrequent entity, defined by collections of gelatinous material in the abdomen and pelvis and mucinous implants on peritoneum, secondary to the rupture of a mucinous lesion, usually of ovarian or appendiceal origin. MATERIALS AND METHODS: We present our experience of 11 cases (6 males and 5 females) diagnosed with pseudomyxoma peritonei secondary to epithelial appendicular neoplasms over 27 years. The mean age of the patients was 68 years. Clinical manifestations were abdominal distension (55%), right lower quadrant pain (45%) suggesting acute appendicitis and constitutional syndrome (36%). An abdominal mass was detected at physical examination in 4 patients. CT scan revealed a tumour in right iliac fossa in 4 patients, peritoneal enlargement in 1 and a liquid collection in 1. Preoperative diagnosis was acute abdomen in 5 patients, peritoneal carcinomatosis in 3 and undetermined abdominal mass in 3. RESULTS: Surgical findings suggested pseudomyxoma peritonei in 8 patients and peritoneal carcinomatosis in 3. Appendicectomy was performed in 9 patients, and in 3 of them bilateral anexectomy was also performed. One patient underwent ileocaecal resection and another a right hemicolectomy. In all the cases, mucinous material was eliminated as much as possible. Pathology revealed mucinous cystoadenoma in 6 cases, mucinous cystoadenocarcinoma in 3 and epithelial hyperplasia in 2 patients. Median survival was 54 months, with a 5- year survival rate of 40%. The last case we treated was sent to a reference centre for the treatment of pseudomyxoma peritonei. CONCLUSIONS: There is no consensus on the best treatment for pseudomyxoma peritonei. We recommend avoiding incomplete surgical resections in non-reference centres and submitting patients to a reference centre to undergo adequate treatment.

Pseudomyxoma peritonei secondary to epithelial appendicular neoplasms. Experience in a non-specialised centre

INTRODUCTION: Pseudomyxoma peritonei is an infrequent entity, defined by collections of gelatinous material in the abdomen and pelvis and mucinous implants on peritoneum, secondary to the rupture of a mucinous lesion, usually of ovarian or appendiceal origin. MATERIALS AND METHODS: We present our experience of 11 cases (6 males and 5 females) diagnosed with pseudomyxoma peritonei secondary to epithelial appendicular neoplasms over 27 years. The mean age of the patients was 68 years. Clinical manifestations were abdominal distension (55%), right lower quadrant pain (45%) suggesting acute appendicitis and constitutional syndrome (36%). An abdominal mass was detected at physical examination in 4 patients. CT scan revealed a tumour in right iliac fossa in 4 patients, peritoneal enlargement in 1 and a liquid collection in 1. Preoperative diagnosis was acute abdomen in 5 patients, peritoneal carcinomatosis in 3 and undetermined abdominal mass in 3. RESULTS: Surgical findings suggested pseudomyxoma peritonei in 8 patients and peritoneal carcinomatosis in 3. Appendicectomy was performed in 9 patients, and in 3 of them bilateral anexectomy was also performed. One patient underwent ileocaecal resection and another a right hemicolectomy. In all the cases, mucinous material was eliminated as much as possible. Pathology revealed mucinous cystoadenoma in 6 cases, mucinous cystoadenocarcinoma in 3 and epithelial hyperplasia in 2 patients. Median survival was 54 months, with a 5- year survival rate of 40%. The last case we treated was sent to a reference centre for the treatment of pseudomyxoma peritonei. CONCLUSIONS: There is no consensus on the best treatment for pseudomyxoma peritonei. We recommend avoiding incomplete surgical resections in non-reference centres and submitting patients to a reference centre to undergo adequate treatment (AU)

[Renal cell carcinoma with liver extension: a report of a new case and literature review]. / Tumor renal con invasión hepática: aportación de un nuevo caso y revisión de la literatura.

Locally advanced renal cell carcinoma (RCC) with involvement to adjacent organs is uncommon and the prognosis is poor. Radical surgery remains the only effective treatment. We report the case of a woman with RCC and direct liver extension who was surgically treated. A literature review is made.

Extraosseous retroperitoneal Ewing's sarcoma.

Ewing's sarcoma/primitive neuroectodermal tumour (ES/PNET) belongs to the group of paediatric small round blue-cell tumours. ES/PNET is classically a tumour of the soft tissue or bone in children and young adults. The case of a 21-year-old woman with a retroperitoneal localisation of Ewing's sarcoma is described.

[Diagnosis and treatment of pancreatic insulinoma]. / Manejo diagnóstico y terapéutico del insulinoma pancreático.

INTRODUCTION: insulinoma is the most frequent pancreatic endocrine tumor. Its preoperative diagnosis has been controversial for many years. The aim of this study was to evaluate the experience in the management and treatment of this kind of tumor at Hospital Ramón y Cajal. MATERIAL AND METHODS: between January 1999 and July 2006, 12 patients were operated on in our hospital (9 females and 3 males) who had been diagnosed with insulinoma, with a mean age of 56 years (16-72 years). RESULTS: octreotide scintigraphy allowed a diagnosis in 33.3% of cases, abdominal CT in 83.3%, and echoendoscopy in 100%. Intraoperative ultrasonography confirmed the presence of an insulinoma in 100% of cases. In all cases a complete excision was possible, with 9 enucleations and 3 distal pancreatectomies. Two patients developed a pancreatic fistula, and one a pancreatic pseudocyst that healed spontaneously without surgery. The overall cure rate was 100%. After a mean follow-up of 48 months no recurrences have been reported. CONCLUSION: in our experience, we consider advisable that abdominal CT and echoendoscopy be performed before surgery. However, the initial procedure of choice would be pancreas palpation and intraoperative ultrasonography. Surgery cured 100% of cases, and the procedure selected depends on size, location, distance from the main pancreatic duct, and relation to multiple endocrine neoplasm 1 (MEN-1).

Extraosseous retroperitoneal Ewing's sarcoma

Ewing's sarcoma/primitive neuroectodermal tumour (ES/PNET) belongs to the group of paediatric small round blue-cell tumours. ES/PNET is classically a tumour of the soft tissue or bone in children and young adults. The case of a 21-year-old woman with a retroperitoneal localisation of Ewing's sarcoma is described (AU)

Tumor renal con invasión hepática: aportación de un nuevo caso y revisión de la literatura / Renal cell carcinoma with liver extension: a report of a new case and literature review

El carcinoma de células renales (CCR) con invasión directa de órganos adyacentes es un hallazgo infrecuente y de mal pronóstico en el que el único tratamiento potencialmente efectivo es la cirugía radical. Se presenta el caso de una mujer con gran masa renal y afectación hepática y diafragmática sometida a tratamiento quirúrgico, y se realiza revisión de la literatura

Locally advanced renal cell carcinoma (RCC) with involvement to adjacent organs is uncommon and the prognosis is poor. Radical surgery remains the only effective treatment. We report the case of a woman with RCC and direct liver extension who was surgically treated. A literature review is made

Manejo diagnóstico y terapéutico del insulinoma pancreático / Diagnosis and treatment of pancreatic insulinoma

Introducción: el insulinoma es el tumor endocrino pancreático más frecuente. Su diagnóstico preoperatorio ha sido motivo de controversia durante muchos años. El objetivo del trabajo es evaluar la experiencia del Hospital Ramón y Cajal en el manejo diagnóstico y terapéutico de este tipo de tumores. Material y métodos: en el periodo comprendido entre enero de 1999 y julio de 2006 fueron intervenidos en nuestro hospital 12 pacientes (9 mujeres y 3 varones) con el diagnóstico de insulinoma, con una edad media de 56 años (16-72 años). Resultados: la gammagrafía con octreótido nos permitió realizar el diagnóstico en el 33,3% de los casos, el TAC abdominal en el 83,3% y la ecoendoscopia en el 100%. El 100% de los insulinomas fue diagnosticado durante la cirugía gracias al uso de la ecografía intraoperatoria. En todos los casos se realizó la excisión completa del tumor, mediante 9 enucleaciones y 3 pancreatectomías distales. Dos pacientes presentaron una fístula pancreática y otro un pseudoquiste pancreático que se resolvieron de forma conservadora. La tasa de curación fue del 100%. El seguimiento fue de 48 meses, no encontrándose ningún caso de recidiva. Conclusión: en nuestra experiencia, creemos aconsejable la realización de TAC abdominal y ecoendoscopia como pruebas previas a la cirugía. Sin embargo, la técnica de elección sería la palpación del páncreas y la realización de una ecografía intraoperatoria. La cirugía es curativa en el 100% de los casos, y la técnica efectuada dependerá del tamaño, localización y distancia del tumor al conducto pancreático, así como su relación con el síndrome MEN-1

Introduction: insulinoma is the most frequent pancreatic endocrine tumor. Its preoperative diagnosis has been controversial for many years. The aim of this study was to evaluate the experience in the management and treatment of this kind of tumor at Hospital Ramón y Cajal. Material and methods: between January 1999 and July 2006, 12 patients were operated on in our hospital (9 females and 3 males) who had been diagnosed with insulinoma, with a mean age of 56 years (16-72 years). Results: octreotide scintigraphy allowed a diagnosis in 33.3% of cases, abdominal CT in 83.3%, and echoendoscopy in 100%. Intraoperative ultrasonography confirmed the presence of an insulinoma in 100% of cases. In all cases a complete excision was possible, with 9 enucleations and 3 distal pancreatectomies. Two patients developed a pancreatic fistula, and one a pancreatic pseudocyst that healed spontaneously without surgery. The overall cure rate was 100%. After a mean follow-up of 48 months no recurrences have been reported. Conclusion: in our experience, we consider advisable that abdominal CT and echoendoscopy be performed before surgery. However, the initial procedure of choice would be pancreas palpation and intraoperative ultrasonography. Surgery cured 100% of cases, and the procedure selected depends on size, location, distance from the main pancreatic duct, and relation to multiple endocrine neoplasm 1 (MEN-1)

Mucocele of the appendix.

BACKGROUND: Mucocele of the appendix is an infrequent event, representing 0.3%-0.7% of appendiceal pathology and 8% of appendiceal tumors. It is characterized by a located or diffuse distension of the appendix with a mucus-filled lumen. MATERIALS AND METHODS: We describe 35 cases of mucocele of the appendix diagnosed at Ramón y Cajal Hospital between January 1985 and January 2006. RESULTS: A total of 21 males and 14 females with a mean age of 52.7 years are described. Most cases manifested as abdominal pain located in right iliac fossa, but 2 cases were incidental findings at CT-scan and 1 at ultrasonography, performed for other reasons. In 4 cases, mucocele coexisted with colorectal cancer and was an incidental finding during laparotomy performed for tumor resection. Ultrasonography and computed tomography (CT) scan helped to achieve a correct diagnosis. Preoperative diagnosis of mucocele was achieved in 29% of the cases; 88% of patients underwent appendectomy, 2 had ileocecal resection, and 2 others underwent right hemicolectomy. Pathology revealed mucous hyperplasia in 34% of the cases, simple mucocele in 29%, cystadenoma in 31%, and cystadenocarcinoma in 2 patients. Two other patients developed adenocarcinoma of the cecum 12 and 33 months after surgery, and one patient developed pseudomyxoma peritonei after 62 months, causing his death. CONCLUSIONS: The pathologist is forced to do an exhaustive study, looking for inadvertent perforations that can change the good prognosis of mucocele. We recommend follow-up of all patients with mucoceles, because sometimes they are associated with colorectal neoplasms and recurrence as pseudomyxoma peritonei.

A survey of beta-lactamases from 618 isolates of Klebsiella spp.

beta-Lactamases from 618 isolates of Klebsiella spp. (487 Klebsiella pneumoniae and 131 Klebsiella oxytoca) were identified by analytical isoelectric focusing. The strains were consecutive isolates from 618 different patients in five hospital centres between 1980 and 1984. Most of the chromosomal beta-lactamases from the K. pneumoniae isolates had a pI of 7.1, and most of the K. oxytoca isolates had chromosomal beta-lactamases of pIs 7.8, 5.3 and 5.5. Plasmid-mediated beta-lactamases were produced by 91.8% of K. pneumoniae isolates and 9.9% of K. oxytoca isolates. The beta-lactamase types identified most frequently were SHV-1 in the former species, and TEM-1 in the latter species. Of the K. pneumoniae isolates, 101 produced both of these plasmid-mediated beta-lactamases, while one strain produced an extended-spectrum SHV-like beta-lactamase. Of the 131 K. oxytoca isolates, 20 were hyper-producers of chromosomal beta-lactamase. The susceptibility of this genus to beta-lactam antibiotics is controlled almost exclusively by beta-lactamases, the production of which may differ from one strain to another; thus the empirical therapeutic use of beta-lactam antibiotics is not recommended for this genus.

Activity of amoxycillin/clavulanate against beta-lactamase-producing Escherichia coli and Klebsiella spp.

We studied the susceptibility to the amoxycillin/clavulanate combination (2:1), and the characteristics of the beta-lactamases, of 1410 amoxycillin-resistant strains of Enterobacteriaceae (785 of Escherichia coli and 625 of Klebsiella spp.). Of the E. coli strains, 97.07% were susceptible to the combination and 98.85% produced plasmid-mediated beta-lactamases. Of the Klebsiella spp. strains, 87.84% were susceptible to the combination and 75.36% produced plasmid-mediated beta-lactamases. In both cases, the differences in MIC values, according to the characteristics of the beta-lactamases of the strains, were statistically significant. Of the 99 strains of E. coli and Klebsiella spp. that were not inhibited by amoxycillin 16 mg/l with clavulanate 8 mg/l, 19 hyperproduced chromosomal beta-lactamase; five produced a plasmid-type beta-lactamase as well. Fifty-seven strains produced two plasmid-type beta-lactamases.

[Detection of hyperproduction of chromosomal beta-lactamase in strains of Escherichia coli, Enterobacter cloacae and Pseudomonas aeruginosa]. / Detección de la hiperproducción de betalactamasa cromosómica en cepas de Escherichia coli, Enterobacter cloacae y Pseudomonas aeruginosa.

In order to show up the hyperproduction of chromosomic beta-lactamases in strains of Enterobacteriaceae and Pseudomonas aeruginosa we have tested a variant of a technique proposed by Medeiros et al. It is a qualitative technique and, the modification introduced allows errors of interpretation to be avoided, when the strain is a producer of plasmidic beta-lactamase. It is based on evaluating the amount of beta-lactamase in a culture, measured in time taken for the hydrolysis of nitrocefin, with or without the addition of clavulanic acid. We present the results obtained in 526 selected strains: 271 E. coli, 116 E. cloacae and 139 P. aeruginosa. One hundred and twenty for strains hydrolyzed the nitrocefin in the absence of clavulanic acid within 60 seconds. Only 52 (41.94%) of these strains did it when clavulanic acid was present; all of them have been qualified as hyperproducers according to susceptibility to beta-lactam antibiotics and the study and identification of the beta-lactamases by analytic isoelectrofocusing. The hydrolysis was evident before the 15 seconds in the 80% of hyperproducer strains. No false positive results were observed.

[Efficiency of tazobactam as inhibitor of beta-lactamases, combined with piperacillin, against resistant strains to this penicillin]. / Eficacia del tazobactam como inhibidor de betalactamasas, asociado a la piperacilina, frente a cepas resistentes a esta penicilina.

We studied the efficacy of tazobactam (YTR 830), a new beta-lactamase inhibitor in combination with piperacillin (P) against 198 Enterobacteriaceae strains. A comparative study of susceptibility (MIC determined on Mueller Hinton agar; inoculum 10(4) cfu) was made with the combination amoxicillin (A) + clavulanic acid (CA). Of 181 strains resistant to P, 79.56% were susceptible to it in the presence of tazobactam (TZ). The characteristics of the beta-lactamases of 37 strains resistant to P + TZ (MIC greater than 40 micrograms/ml) were studied; 11 were hyperproducers of chromosomic beta-lactamase and 7 produced two types of plasmidic beta-lactamase. The MICs of TZ alone were uniform and high (64-128 micrograms/ml), independently of the characteristics of the strains beta-lactamase. Of 17 strains susceptible to P, the efficacy of P + TZ was significant among carriers of plasmidic beta-lactamase; there was practically no change in the P susceptibility among the non carriers. The efficacy of P + TZ was similar to that of A + AC against E. coli strains; it was higher against strains of Enterobacter, Citrobacter and Serratia.

Activity of ciprofloxacin (BAYo 9867) against Pseudomonas aeruginosa and ampicillin-resistant Enterobacteriaceae.

We studied the in vitro activity of ciprofloxacin against 570 strains of ampicillin-resistant Enterobacteriaceae and 286 Pseudomonas aeruginosa strains. 95.26% of the Enterobacteriaceae and 53.45% of the P. aeruginosa were inhibited by 0.1 mg/l of ciprofloxacin. 2 mg/l of ciprofloxacin inhibited all of the Enterobacteriaceae strains and 4 mg/l all of the P. aeruginosa. We compared the activity of ciprofloxacin with that of temocillin in the Enterobacteriaceae strains. In the P. aeruginosa strains, classified according to their susceptibility to carbenicillin and gentamicin, we compared the activity of ciprofloxacin with that of ceftazidime. In the strains studied, the in vitro activity of ciprofloxacin is superior to that of temocillin against the Enterobacteriaceae and to that of ceftazidime against the P. aeruginosa strains.