Testicular-epididymal hemodynamics and inguinal hernia.

Testicular-epididymal hemodynamics is studied by ultrasonographic color velocity imaging (CVI) in patients with primary, uncomplicated inguinal hernias. This procedure allows more precision than any other known Doppler system in measuring hemodynamic parameters such as peak systolic and diastolic velocity, resistance index and pulsatility index. The results of the exploration of 480 arteries of various testicular vascular territories are compared with those obtained by other authors in young healthy individuals using color Doppler. This procedure shows that the hernia does not cause significant alterations in the arterial circulation of the testicle and epididymis.

Alteraciones del equilibrio hidroelectrolítico y ácido-base en la peritonitis generalizada / Alterations in hydroelectrolytic and acid-base equilibrium in generalized peritonitis

La peritonitis secundaria generalizada es una sepsis grave, que se produce como consecuencia de un desequilibrio entre la reacción proinflamatoria sistémica (SIRS) y la antiinflamatoria compensatoria (CARS), que ocasiona un síndrome de disfunción multiorgánica (MODS).El MODS se caracteriza por dos hechos fisiopatológicos esenciales: aumento de la permeabilidad de todas las barreras del organismo y trastornos de la microcirculación con la subsiguiente hipoperfusión textural. El íleo paralítico constituye un hecho trascendental en la fisiopatología de la peritonitis, pues la falta de reabsorción, unida a la hipersecreción de la mucosa y al aumento de permeabilidad de la pared intestinal, propicia un importante secuestro de líquidos en el llamado tercer espacio. Se produce así, además de un profundo trastorno hidroelectrolítico, una hipovolemia grave. La acidosis metabólica que el íleo paralítico origina se potencia por la aparición precoz de un síndrome de insuficiencia respiratoria (ARDS).El tratamiento para ser eficaz ha de conseguir la erradicación quirúrgica total de los focos infecciosos, pues es la única manera de romper el círculo vicioso de la sepsis peritoneal. La fluidoterapia, encaminada a restituir la volemia y el equilibrio hidroelectrolítico y ácido-base, es fundamental, así como el precoz tratamiento del íleo y del ARDS (AU)

[The behavior of atherogenic indices under the effect of growth hormone in postoperative disease]. / Comportamiento de los índices aterogénicos bajo el efecto de la hormona de crecimiento en la enfermedad postoperatoria.

OBJECTIVE: It has been studied the effect of the growth hormone (GH) in the atherogenic indexes, during the postoperative period in 28 patients, operated for digestive surgery. METHOD: Patients were divided in: I) control group, patients without treatment, and II) treatment group, patients treated with 8 U.I. of GH during five days after the intervention. RESULTS: Results show that, while in the control group the atherogenic values increased to pathologic levels, in the treatment group, these values stabilized in the physiological limits. CONCLUSIONS: Thus, these results let conclude to the beneficial antiatherogenic effect of growth hormone in the postoperative disease.

Comportamiento de los índices aterogénicos bajo el efecto de la hormona de crecimiento en la enfermedad postoperatoria / Behavior of atherogenic indexes under the effects of crowth hormone in the postoperative disease

Objetivo: Se ha llevado a cabo el estudio del efecto de la hormona de crecimiento (GH) sobre los índices aterogénicos, en el periodo postoperatorio de 28 pacientes, intervenidos de cirugía digestiva. Método: Los pacientes fueron divididos en: I) grupo control, pacientes sin tratamiento, y II) grupo tratamiento, pacientes tratados con 8 U.I. de GH durante los cinco primeros días tras la intervención. Resultados: Los resultados muestran que, mientras en el grupo control los valores de los índices aterogénicos se incrementaron a niveles patológicos, en el grupo tratamiento, éstos se mantuvieron dentro de los límites fisiológicos. Conclusiones: Dichos resultados, por tanto, permiten concluir que la hormona de crecimiento tiene un efecto beneficioso antiaterogénico en la enfermedad postoperatoria (AU)

[Growth hormone and its effects on cholesterol and lipoprotein metabolism following surgical intervention (hGH and cholesterol metabolism during surgery)]. / La hormona de crecimiento y sus efectos sobre el metabolismo del colesterol y lipoproteínas postagresión quirúrgica (hGH y metabolismo del colesterol tras la cirugía).

The objective of this work was to determine whether the increase in serum GH, IGF1, glucose and insulin levels caused by the administration of hGH modifies the normal response of cholesterol and lipoproteins to surgical aggression. A prospective, randomized, and double blind study is carried out in 28 patients operated for gallstones and diverticulitis. The control group (n = 15) was not given anything except conventional fluidtherapy in the postoperative period: the patients in the hGH (n = 13) group were also given 8 IU of hGH during the first five days after the intervention. The comparative study of the triglycerides, cholesterol, LDLc, HDL-c, and A-1 B apolipoproteins shows that in the group treated with hGH the normal response of cholesterol and lipoproteins to surgical aggression is attenuated.

Severe head injury combined with orthopedic and vascular trauma of the limbs.

From 1982 to 1992, 2766 brain injury patients were admitted to the University Hospital San Cecilio of Granada, Spain. In 873 cases head injury was concomitant with other injuries but the association of severe head injury and combined orthopedic and vascular trauma of the limbs was observed only in 23 cases (incidence 2%). Thirteen patients were scheduled for revascularization, and of these secondary amputation was mandatory in two cases to keep rising intracranial pressure under control. Except for epidural hematomas which constitute an absolute neurosurgical emergency, combined orthopedic and vascular trauma of the limbs can be treated before head injury. However, we prefer to work with two operating teams simultaneously. Physical examination and judicious arteriography provide means for prompt diagnosis and treatment of the injured limb. The compartment syndrome should be anticipated and fasciotomy should be used routinely. Vascular repairs normally using reverse autogenous vein are the first priority, but we must always bear in mind the deleterious effects of the revascularization syndrome which expose the brain to a second aggression, and amputation, when necessary, should be undertaken to reduce mortality.

Effects of human growth hormone on the catabolic state after surgical trauma.

The aims of our studies were: (1) to determine if the protein catabolic response after a major or moderate surgical trauma can be restrained by the administration of exogenous human growth hormone (hGH); (2) to determine if the administration of hGH can improve systemic host defenses, thus reducing the risk of infection, and (3) given that the postoperative fatigue syndrome (POF) is mediated by the endocrino-metabolic response to surgery we attempt to determine if the administration of hGH can prevent or reduce POF. Therefore, we performed three placebo-controlled randomized double-blind trials on 216 patients. Major gastrointestinal surgery was treated only with total parenteral nutrition (TPN; n = 20) or TPN plus 4 IU hGH (n = 18). Patients with moderate surgical trauma received either hypocaloric parenteral nutrition (HPN; n = 93) or HPN and 8 IU hGH (n = 87). In this study, we also determined the evolution of the systemic host defenses and thereby the risk of infection. In 48 patients who underwent cholecystectomy treated (n = 26) either with HPN or HPN plus 8 IU hGH, we measured the protein catabolic response, postoperative fatigue and anthropometric modifications. The treatment with hGH together with HPN or TPN (1) overcomes the protein catabolic effects of the trauma response induced by major or moderate surgery by increasing protein synthesis, (2) improves humoral and cellular systemic host defenses, thus reducing the risk of infection, (3) preserves or increases lean body mass and reduces adipose tissue and (4) minimizes POF.

Can the use of growth hormone reduce the postoperative fatigue syndrome?

Convalescence after surgery is characterized by a period of fatigue (POF). If we assume that the POF syndrome has a multifactorial etiology, it is clear that the aim of therapeutic measures should be to reduce the response to surgical stress. The purpose of the present study was to determine if administering exogenous human growth hormone (hGH) can prevent the development or reduce the duration of the POF. We carried out a placebo-controlled randomized double-blind trial with 48 patients after elective cholecystectomy (placebo, or control group, n = 26; hGH-treated group, n = 22). Eligibility criteria were strict so as to introduce as few variables as possible. The results obtained in the study show that for moderate surgical injury (cholecystectomy in metabolically healthy subjects) the administering of low doses of hGH (8 IU/day) minimized the POF syndrome (Christensen score). Furthermore, a positive nitrogen balance was achieved in the hGH-treated group during the postoperative period from the first 24 hours onward. This finding correlates with the significant increase in serum levels of hGH (p < 0.05) and insulin-like growth factor 1 (IGF-1) (p < 0.001). On the other hand, anthropometric measurements in the hGH-treated group revealed a slight but continuous decrease in body weight and thickness of the triceps skinfold; however, arm muscle circumference did not significantly change during the postoperative period. These findings are related to the effects of the application of exogenous growth hormone, which preserves or increases lean body mass and reduces adipose tissue mass. The serum transferrin level proved to be a reliable biochemical indicator of POF.

[Physiology and physiopathology of postoperative disease. Therapeutic implications]. / Fisiología y fisiopatología de la enfermedad postoperatoria. Implicaciones terapéuticas.

The organism responds to each and every aggression by means of a neuro-endocrine activation, which is translated into a metabolic change. The action of the surgeon should not be any other than to improve the neuro-endocrine-metabolic response. This review describes the physiological and physiopathological occurrences which develop in every traumatized patient.

Indications and advantages of laparoscopy-assisted colon resection for carcinoma in elderly patients.

The controversy about laparoscopy assisted colectomy for cancer is based on doubt about performing a radical resection and adequate histopathological staging. Therefore, we selected a group of patients who could profit from the accepted benefits of the technique, while avoiding its uncontrolled outcome. We operated on patients with colorectal cancer with distant metastasis and on patients over 70 years old and American Society of Anesthesia (ASA) III-IV with a high operative risk with standard surgery. The results for the first 18 patients demonstrated the following: (a) the size of the surgical specimen and the number of lymph nodes were similar to those in standard surgery; (b) no mortality and very low morbidity occurred despite the patients' advanced age, debilitated condition, and comorbid diseases; (c) minor postoperative complications occurred in five of 18 patients; (d) the hospital stay was 6-7 days for nonmetastatic patients and 9-12 days for metastatic patients; (e) the 1-year survey revealed a relapse in only one patient 9 months after the first operation.

Graves' ophthalmopathy after subtotal thyroidectomy and radioiodine therapy.

Forty-five patients with Graves' ophthalmopathy were studied prospectively. Twenty-one patients (42 orbits; group 1) were treated surgically by subtotal thyroidectomy and 24 (48 orbits; group 2) received radioiodine therapy. All patients underwent tests of thyroid function, ophthalmological examination, and axial and coronal computed tomography before and 12 months after treatment. Patients in group 1 showed significant improvement in the Feldon score (P < 0.001), in proptosis as estimated by Hertel exophthalmometry (P < 0.001) and in proptosis (P < 0.001), maximum diameter of the medial rectus (P < 0.01), lateral rectus (P < 0.05), superior group (P < 0.05) and inferior rectus (P < 0.001) muscles as estimated by computed tomography. Patients in group 2 showed significant improvement only in the Feldon score (P < 0.05). The ophthalmopathy of Graves' disease improves to a greater extent after subtotal thyroidectomy than after radioiodine therapy.

Exogenous growth hormone: effects on the catabolic response to surgically produced acute stress and on postoperative immune function.

The first purpose of the present prospective randomized study was to determine if the protein catabolic response after operation could be restrained by administration of hypocaloric parenteral nutrition (HPN) plus human growth hormone (hGH). Our second aim was to determine if the administration of hGH could improve the systemic host defenses, thereby reducing the risk of infection. We performed a placebo-controlled randomized double-blind trial in 180 patients after elective cholecystectomy with or without choledochoduodenostomy (placebo = control group, n = 93; hGH-treated group, n = 87). The results obtained in this study show that positive nitrogen balance can be achieved during the postoperative period from the first 24 hours onward, with a combination of HPN support (1.0-1.5 g protein/kg/day and 900 kcal/day) together with the administration of small doses (8 IU) of hGH. The potassium balance tended to follow the same positive balance as the nitrogen balance. Our study shows that in the control group, treated only with HPN, a significant decrease in serum levels of some acute-phase proteins (retinol-binding protein, transferrin, prealbumin), albumin, total proteins, and immunoglobulins occurs by the 5th postoperative day. In the GH group the values of all the above-mentioned proteins do not change or tend to rise if compared to preoperative levels. In the GH-treated group liver function appeared to improve at the start of the study. GH and somatomedin C levels were similar in the two groups and had not changed significantly in the control group by the 5th postoperative day.(ABSTRACT TRUNCATED AT 250 WORDS)

[Minimally aggressive surgery in advanced cancer of the colon]. / Cirugía mínimamente agresiva en el cáncer de colon avanzado.

We evaluated minimally aggressive surgery in the treatment of metastasic cancer of the colon in 6 patients: 2 females and 4 males, with an average age of 71.8. Preoperative studies showed cancer of the colon (right colon = 4; sigmoid colon = 2) with multiple hepatic metastasis. In all cases laparoscopic mobilization and extracorporeal resection with end-to-end anastomosis was performed employing a biofragmentable anastomotic ring. In two patients laparoscopy discovered peritoneal carcinomatosis. One patient was operated using conventional surgery. Intestinal segments with an average length of 21.3 cm were removed, with a mean of 13.5 lymph-nodes per patient, 70.3% of which had metastasis. Eleven of the 12 resection lines were tumor-free (91.6%). Hospital stay averaged 7.8 days, and mean survival has been 4.5 months. Only two patients, those with peritoneal carcinomatosis, had post-operative complications. If an appropriate patient selection is followed: cancer of the colon with hepatic metastasis and no peritoneal spread, laparoscopic surgery is a reliable and effective treatment for advaned cancer of the colon.

[Xanthogranulomatous cholecystitis]. / Colecistitis xantogranulomatosa.

Ten cases of xanthogranulomatous cholecystitis are presented, 5 women and 5 men, from a total of 439 cholecystectomies (2.2%). In 50% of cases the clinical course was consistent with acute cholecystitis; in 30%, gallbladder cancer was suspected preoperatively; and in 70% of cases cancer was suspected during surgery but intraoperative biopsies showed no malignancy. Definitive pathological findings included early carcinoma of the gallbladder in two patients, and a cholecystocolic fistula in one patient. A perforated gallbladder was found in one patient. The incidence of postoperative septic complications was 18.1%, a figure that doubles that of elective biliary surgery in our hospital.

Effects of growth hormone in patients receiving total parenteral nutrition following major gastrointestinal surgery.

The purpose of the present study was to determine whether the administration of a biosynthetic human growth hormone was capable of enhancing the efficacy of total parenteral nutrition. Patients (n = 38) who had undergone major gastrointestinal surgery were randomly divided into two groups. Group I (n = 20) treated only with PN, and Group II (n = 18) treated as in Group I plus human growth hormone (4 IU daily). Our study shows that the administration of human growth hormone produces a statistically significant increase in serum levels of growth hormone, somatomedin-C, transferrin, albumin and total proteins. It also causes a positive nitrogen balance from the first 24 hours onward. These findings suggest that the administration of human growth hormone produces an increase in protein synthesis, perhaps through somatomedin-C as mediator.

[Effect of growth hormone and parenteral nutrition on the catabolic phase following major digestive surgery]. / Efecto de la hormona del crecimiento y la nutrición parenteral sobre la fase catabólica tras cirugía digestiva mayor.

The purpose of the present study was to determine if the administration of a biosynthetic human growth hormone (bGH) was able to enhance the efficacy of total parenteral nutrition (PN). Patients (n = 38) who had undergone major gastrointestinal surgery were randomly divided in two groups. Group I (n = 20) treated only with PN and Group II (n = 18) treated as in Group I plus bGH (4 UI/daily). Our study shows that the administration of bGH produces a significant increase in serum levels of growth hormone and Somatomedin-C. It also caused a positive nitrogen balance from the first 24 hours on (p less than 0.01). In Group II on day 12 after operation a statistically significant increase in transferrin (p less than 0.05), albumin (p less than 0.01) and total proteins (p less than 0.02) was observed. Our study suggest that the administration of bGH produces, perhaps through Somatomedin-C as mediator, an increase in protein synthesis.

Intrathoracic meningocele presenting as a mediastinal mass lesion. Case report.

A routine chest X-ray in a 52-year-old man revealed a widening of the posterosuperior mediastinum and the patient was hospitalized on the suspicion of having a mediastinal mass lesion. Further investigations revealed an anterior cervicothoracic meningocele (intrathoracic meningocele), the dural herniation passing through two large midline congenital openings of the C7-T3 vertebral bodies which appeared partially fused and associated with other regional skeletal malformations.

[Thovara inguinal hernia operation. Results of follow-up in adults]. / Leistenbruchoperationen nach Thovara. Nachuntersuchungsergebnisse bei Erwachsenen.

A new procedure for inguinal hernia operations is described: the Thovara method, which is really a modified version of the plastic technique by Bassini-Kirschner-Lichtenstein. From 1985-1986 167 patients were operated on for inguinal hernia in our University Hospital, using this hernia plastic technique with a tension-free mesh. Though the rate of early complications is good, we should mention that there were 19 cases of testicle swelling. The number of early and late recurrences were very low: 2 cases (1.2%). Hospitalization averaged from 2 to 4 days. The procedure is easy to perform and almost painless.