[Diaphragmatic hernia of Morgagni-Larrey in adults: analysis of 10 cases]. / Hernia diafragmática de Morgagni-Larrey en el adulto: análisis de 10 casos.

Congenital diaphragmatic hernia of Morgagni-Larrey is a rare entity that usually presents on the right side. These hernias, occurring in the anterior midline through the sternocostal hiatus of the diaphragm, are usually discovered incidentally when the patient has reached adulthood, or when they become symptomatic due to intestinal involvement (occlusive symptoms) or when respiratory dysfunction occurs. We present 10 patients (mean age: 69 years) with symptomatic sternocostal hernia and intestinal occlusion. In 7 patients, the hernia was located on the right (Morgagni's hernia) and in three it was located on the left (Larrey's hernia). Most of the patients presented important associated comorbidity, mainly cardiovascular and neoplastic. Surgical treatment consisted of reduction of the contents of the herniated sac and hernia repair through simple suture with or without mesh for reinforcement, mainly through the abdominal approach. Mortality in this series was nil. The infrequency of this entity and its diagnosis mainly in adults, with a high prevalence of circumstances favoring abdominal hernias, suggest that an embryological defect of the sternocostal foramina of Morgagni or Larrey are an essential element in the physiopathology of these processes.

Gangrena de Fournier / Fournier's gangrene

Introducción. La gangrena de Fournier es una infección necrosante subcutánea de origen urogenital o anorrectal, que afecta a la zona genital, perineo y pared anterior del abdomen en la que están implicados gérmenes aerobios y anaerobios. Es una enfermedad poco frecuente, pero potencialmente letal. Pacientes y métodos. Estudiamos de forma retrospectiva 10 casos de gangrena de Fournier, desde 1994 hasta 1999. En la recogida de datos figuran: filiación, edad y sexo, antecedentes patológicos, factores predisponentes, causas, clínica, analítica, tratamiento médico y quirúrgico, gérmenes, antibioterapia, estancia, ingreso en UCI y resultados. Resultados. Todos los pacientes eran varones, con una edad media de 65 años. Todos tenían importante patología orgánica de base y presentaban factores predisponentes, destacando la diabetes mellitus (6 casos) seguida del consumo crónico de alcohol (5 casos). La etiología fue: absceso perianal (3 casos), instrumentación urológica o rectal (2 casos), enfermedades genitourinarias (2 casos), idiopática (2 casos) y traumatismo (un caso). La clínica fue similar, con una zona de celulitis inicial, con dolor local en el escroto y posterior diseminación perineal, con crepitación y cuadro febril. Todos presentaban leucocitosis franca. En todos los pacientes se instauró antibioterapia y se realizó desbridamiento en una o varias sesiones, así como medidas de soporte metabólico y nutricional. En 3 casos se realizó íleo-colostomía derivativa y en 2 casos cistostomía suprapúbica. El germen más aislado fue E. coli, seguido de Bacteroides. En la antibioterapia destaca el uso de piperacilina/tazobactam. La estancia media fue d 27 días. Cinco pacientes requirieron su ingreso en la UCI. Fallecieron 4 pacientes (40 por ciento), con un denominador común de sepsis; de ellos dos llevaban estoma (colostomía).Conclusiones. La gangrena de Fournier es una enfermedad de alta morbimortalidad, especialmente en pacientes mayores, con factores predisponentes como diabetes y alcoholismo y cuya causa desencadenante es una enfermedad perirrectal o urogenital, que no ha sido tratada correctamente. El pronóstico es incierto, llegando nuestra serie a una mortalidad del 40 por ciento, por lo que el diagnóstico precoz y la terapéutica temprana y agresiva son esenciales (desbridamiento quirúrgico, antibióticos de amplio espectro y cuidados intensivos) (AU)

Hernia de Richter como causa de obstrucción del intestino delgado / Richter's hernia presenting as small bowel obstruction

El objetivo del trabajo es presentar 4 casos de hernia de Richter que ocasionan problemas mecánicos intestinales, concretamente oclusión del intestino delgado. En todos los casos hubo un grave deterioro del estado general y una deshidratación importante, siendo el cuadro clínico lentamente progresivo con una sintomatología en varios casos de distensión abdominal y en otro caso de diarrea persistente. La demora en su diagnóstico ocasiona una cirugía tardía, con un aumento de la morbimortalidad, por lo que creemos que el adecuado conocimiento de esta rara enfermedad quirúrgica es importante (AU)

Thoracic esophageal perforations: surgical management with mechanical bipolar exclusion.

We report 12 cases of thoracic esophageal perforation diagnosed during the last seven years. Management was nonsurgical in 2 patients and the rest were treated surgically. Primary repair and drainage were performed in 2 patients, and 7 patients underwent suture of the perforation and bipolar exclusion using nonresorbable staples. The remaining patient was treated with proximal unipolar exclusion. The approach was always through a posterolateral thoracotomy. The result was optimal in 8 patients; the most important postsurgical complications were 2 esophageal fistulas that required surgery, and only one of the patients died of fulminating sepsis. Bipolar exclusion is a procedure that needs only one operation and provides excellent morbidity-mortality rates compared with other exclusion techniques with later reconstruction. We consider suturing with nonresorbable staples to be a simple and safe procedure, with spontaneous recanalization of the esophageal lumen in 2 weeks.

[Cytomegalovirus enteritis and colitis in nonimmunodepressed patients, a primary disease or superinfection?]. / Enteritis y colitis por citomegalovirus en pacientes no inmunodeprimidos, afectación primaria o sobreinfección?

Cytomegalovirus disease is an opportunistic infection that is seen in patients with inmunodeficiencies. The group most commonly affected are AIDS and transplanted patients. Only a few cases of cytomegalovirus disease in non-immunocompromised patients have been reported. In localized disease, the gastrointestinal tract is the most frequently affected. We report two cases of acute abdomen caused by cytomegalovirus enteritis and colitis (histopathological diagnosis) without any underlying immune disorder. The role that the cytomegalovirus infection might play in the development of the clinical manifestations in these two cases is discussed. Without an established immunodeficiency we must be careful to attribute to cytomegalovirus infection the direct responsibility of the lesions. In the reported cases, the existence of intestinal ischemia is more than just a clinical hypothesis and pathological examination is inconclusive. The absence of an immunocompromised state, the presentation as an acute abdomen and the clinical course forwards intestinal occlusion in the first case are not characteristic of cytomegalovirus enteritis and colitis. We conclude that the two reported cases are in fact an ischemic enteritis upon which cytomegalovirus enteritis and colitis was superimposed, an association that has not been reported before.

[Retroperitoneal hematoma secondary to anticoagulation treatment as a cause of abdominal pain]. / Hematoma retroperitoneal secundario a tratamiento anticoagulante como causa de dolor abdominal.

Retroperitoneal haematoma during anticoagulant therapy is a rare cause of abdominal pain. Over the past five years, five cases of retroperitoneal haemorrhage, two of them due to heparin and three to oral anticoagulant, were diagnosed in our hospital. All patients presented with abdominal pain and a mass. The authors conclude that a high degree of suspicion is mandatory when patients on anticoagulant therapy present with abdominal pain.

[Usefulness of transrectal echography in the study of rectal cancer]. / Utilidad de la ecografía transrectal en el estudio del cáncer de recto.

This paper presents the initial results of a study designed to measure the ability of transrectal ultrasonography (TU) in determining the degree of local invasion of rectal cancer, comparing the preoperative radiographic diagnosis with the histological one. The series consists of 30 patients. In 24 cases preoperative TU was performed--following confirmation of the histological diagnosis--and in six cases UT was used after surgery to study the anastomosis. The postoperative group consists of eight males and 16 females, with a mean age of 70; in 14 cases the tumors were located in the lower third of the rectum, and in 10 cases in the middle third. In 12 of these 24 cases, pelvic CAT was also performed. TU showed the correct stage in 17 of the 24 (70.8%), with two false positives and five false negatives. CAT showed the correct diagnosis in 10 out of 12 (83%), with one false positive and one false negative. In the follow-up of the surgical patients, TU was normal in five cases and local recurrence was diagnosed. On the basis of our results, we consider that TU is a method with a high degree of diagnostic reliability in preoperative staging of rectal cancer; it can be associated with CAT; furthermore, it is an important screening method for early diagnosis of local recurrence at the suture line. Its main drawbacks are in studying high and stenosing lesions.

[Appendicular diverticulitis: a review of 5 cases]. / Diverticulitis apendicular: revisión de cinco casos.

Of a total of 3,669 appendectomies, five corresponded to appendicular diverticulosis (0.13%), all of which had an inflammatory pathology. Four patients underwent emergency surgery with a diagnosis of acute appendicitis, and in only one was a correct preoperative diagnosis made. There were three cases of acute primary diverticulitis and one appendicitis with secondary diverticular affectacion. Another patient was operated electively for a history of long evolution; during the surgical act an appendicular inflammatory mass was found that the pathological report described as diverticulitis with subacute periappendicitis. Certain aspects of this entity are remarked and the bibliography is reviewed.

[A protocol for the treatment of cancers of the tongue]. / Protocole de traitement des cancers de la langue.

The protocole of multidisciplinary therapy of the tongue and base of the tongue tumors in the "Hospital de la Sta. Creu i Sant Pau" is presented. The exposition of the management trends by surgery, radiotherapy and chemotherapy, in our protocole, is followed by the review of the therapeutic indications with special enphasis in the topographic ones in order to plan the surgical treatment. The non advanced tumors will be as well treated by intersticial radiotherapy as by surgery. In the treatment of the advanced tumors the multidisciplinary managament results essential. Depending on the degree of invasion, the topography of the tumor and the outline of therapeutic trials, the therapy will be chosen.