Influence of psychopathological changes on quality of life after laparoscopic fundoplication for the treatment of gastroesophageal reflux.

There are references in medical literature to the influence of psychopathological changes and their negative impact on the results of laparoscopic fundoplication. The objective of this study is to analyze the influence of psychological changes, as assessed by the General Health Questionnaire-28 (GHQ-28), on patients undergoing surgery for gastroesophageal reflux. This is a prospective study in a series of 103 consecutive patients (62 males and 41 females with a mean age of 40 years) undergoing laparoscopic fundoplication. In addition to functional studies, patients completed the SF-36, Gastrointestinal Quality of Life Index, and GHQ-28 before surgery. Functional tests and questionnaires were repeated 6 months after surgery. Patients were also questioned about their degree of satisfaction. Postoperative results of patients with a normal GHQ-28 and patients showing psychopathological changes as defined by the GHQ-28 questionnaire before surgery were compared. Overall, all patients experienced an improvement in their quality of life. Forty-one patients showed a pathological result in the preoperative GHQ-28 questionnaire. No differences were found in functional results and degree of satisfaction with surgery between patients with normal and pathological results in the preoperative GHQ-28 questionnaire. However, patients with a pathological result in the preoperative GHQ-28 had poorer results in all domains of the postoperative Gastrointestinal Quality of Life Index and SF36 quality of life questionnaires as compared to patients with a normal preoperative GHQ-28 questionnaire. Patients with pathological results in the preoperative GHQ-28 had poorer results in terms of postoperative quality of life despite having normal postoperative physiological studies; this decreased quality of life did not have an impact on the degree of satisfaction with surgery performed. The GHQ-28 does not therefore appear to serve as a predictor of postoperative satisfaction.

Results of R0 surgery with D2 lymphadenectomy for the treatment of localised gastric cancer.

INTRODUCTION: Surgical excision is the best therapeutic option for gastric cancer, provided it is performed with curative intent as R0 surgery. And, according to many authors, D2 lymphadenectomy may be performed with acceptable morbidity and mortality rates. MATERIALS AND METHODS: A prospective study was conducted on a series of 126 consecutive cases of gastric cancer treated with gastrectomy and D2 lymphadenectomy. A R0 resection was done in 99 cases (78.6%). RESULTS: Total gastrectomy was performed in 70 patients and subtotal gastrectomy in 29. The mean number of lymph nodes removed was 32.5 per patient. Suture dehiscence occurred in 3 patients (in one of them in the esophago-jejunal anastomosis). Hospital mortality was 2%. Twenty-six recurrences were detected after a median follow-up of 73.6 months. Five-year actuarial survival was 65%. Five-year survival of patients with positive lymph nodes at the N2 level was 26.5%. CONCLUSIONS: Gastrectomy with D2 lymphadenectomy may be performed with low morbidity and mortality. R0 resection allows acceptable survival rates to be achieved. There is even a group of patients with invaded lymph nodes at the N2 level surviving at 5 years. It appears to be very important that this surgery is performed by specialised surgeons.

Results of R0 surgery with D2 lymphadenectomy for the treatment of localised gastric cancer

INTRODUCTION: Surgical excision is the best therapeutic option for gastric cancer, provided it is performed with curative intent as R0 surgery. And, according to many authors, D2 lymphadenectomy may be performed with acceptable morbidity and mortality rates. MATERIALS AND METHODS: A prospective study was conducted on a series of 126 consecutive cases of gastric cancer treated with gastrectomy and D2 lymphadenectomy. A R0 resection was done in 99 cases (78.6%). RESULTS: Total gastrectomy was performed in 70 patients and subtotal gastrectomy in 29. The mean number of lymph nodes removed was 32.5 per patient. Suture dehiscence occurred in 3 patients (in one of them in the esophago-jejunal anastomosis). Hospital mortality was 2%. Twenty-six recurrences were detected after a median follow-up of 73.6 months. Five-year actuarial survival was 65%. Five-year survival of patients with positive lymph nodes at the N2 level was 26.5%. CONCLUSIONS: Gastrectomy with D2 lymphadenectomy may be performed with low morbidity and mortality. R0 resection allows acceptable survival rates to be achieved. There is even a group of patients with invaded lymph nodes at the N2 level surviving at 5 years. It appears to be very important that this surgery is performed by specialised surgeons (AU)

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Intrahepatic mucinous biliary cystadenoma.

Mucinous biliary cystadenoma (MBC) is a very rare cystic tumour of the liver usually occurring in middleaged women. This condition is difficult to diagnose before surgery; differential diagnosis with hydatid disease of the liver has to be done and is difficult to distinguish from mucinous biliary cystadenocarcinoma. We report two diagnosed and treated cases of intrahepatic MBC.

Intra-abdominal follicular dendritic cell sarcoma

Follicular dendritic cell (FDC) sarcoma is a very rare condition. We report here an intra-abdominal FDC sarcoma occurring as a mass, dependent on the celiac and left gastric lymph chains, that was completely excised. Eighteen months after surgery a recurrence at the liver pedicle was detected by a CT-scan and fully resected; in order to prevent another disease relapse postoperative radiotherapy was given (AU)

Gastroesophageal reflux: prevalence of psychopathological disorders and quality of life implications.

There is evidence in the literature that psychosocial aspects affect the symptoms and results of surgery for gastroesophageal reflux. The purpose of this study was to estimate the prevalence of psychopathological disorders measured using the General Health Questionnaire (GHQ-28) in a sample of patients with gastroesophageal reflux, and to assess the influence of such disorders on their quality of life. A prospective study was conducted in 74 consecutive patients before gastroesophageal reflux surgery; patients answered the GHQ-28, the health questionnaire SF-36, and the Gastrointestinal Quality of Life Index (GIQLI). The convergent validity of the GHQ-28 questionnaire as compared to the other two questionnaires and preoperative quality of life was tested. A pathological result of the GHQ-28 questionnaire was found in 38.3% of patients. A correlation was seen between the results of the GHQ-28 questionnaire and all categories of the SF-36 and GIQLI questionnaires. Patients with pathological results in the GHQ-28 questionnaire had poorer results in all dimensions of the SF-36 and GIQLI quality of life questionnaires as compared to patients with a normal result in the GHQ-28 questionnaire. In conclusion, 38.3% of patients with gastroesophageal reflux showed psychopathological disorders when administered the GHQ-28 questionnaire. These patients also had poorer results in quality of life studies.

Valoración por parte de los pacientes con incontinencia fecal de los resultados del biofeedback / Patient evaluation of the results of biofeedback in fecal incontinence

Objetivo. Valoración subjetiva de los resultados inmediatos y a largo plazo del biofeedback para el tratamiento de la incontinencia fecal, y su correlación con los resultados objetivos logrados. Pacientes y métodos. Se incluyeron en el estudio 20 pacientes (16 mujeres y 4 varones, con una media de edad 62,05 ñ 13,84 años), con incontinencia fecal (idiopática 14, traumatismo de médula espinal 2, poscirugía de fisura anal 2, posresección anterior baja 1, colitis ulcerosa 1). Se han realizado cuatro sesiones con periodicidad quincenal. A todos se les ha valorado su continencia anal previa, al término de las sesiones y a largo plazo (media 23,1 meses; rango 12-41 meses) mediante una escala de cuatro grados: menos de una fuga al mes, más de una fuga al mes y menos de una a la semana, más de una fuga a la semana y menos de una al día, y fugas diarias. La valoración subjetiva se ha hecho con una escala analógica (0-10 puntos), y otra de sensación (empeoramiento, no empeoramiento). Resultados. Inmediatos: 10 (50 por ciento) reducen escapes; menos de una fuga al mes, 5 casos (25 por ciento); más de una fuga al mes y menos de una a la semana, 4 casos (20 por ciento); más de una fuga a la semana y menos de una al día 9 casos (45 por ciento), y fugas diarias 2 casos (10 por ciento); valoración subjetiva 6,35 ñ 2,5; 4 casos (20 por ciento) valoración de 9-10 puntos, 6 casos (30 por ciento) de 7-8 puntos, 6 casos (30 por ciento) de 5-6 puntos, y 4 (20 por ciento) inferior a 5 puntos. La valoración subjetiva se correlaciona con la frecuencia de escapes lograda: menos de un escape/semana (n = 9) 8,0 ñ 1,50, más de un escape/semana (n = 11) 5,0 ñ 2,53 (t -3,13; p < 0,006). Tardíos: 18 (90 por ciento) no han empeorado; menos de una fuga al mes 15 (75 por ciento); más de una fuga a la semana y menos de una al día 1 (5 por ciento), y fugas diarias 4 (20 por ciento); valoración subjetiva 5,05 ñ 2,8 (p < 0,01); en 2 casos (10 por ciento) la valoración fue de 9-10 puntos, en 4 casos (20 por ciento) fue de 7-8 puntos, en 5 casos (25 por ciento) fue de 5-6 puntos, y en 9 (45 por ciento) inferior a 5.La valoración subjetiva también se relaciona con la frecuencia de escapes: menos de uno/semana (n = 5) 5,86 ñ 2,5, más de un escape/semana (n = 15) 2,6 ñ 2,5 (t -2,53; p < 0,02). Diecinueve pacientes (95 por ciento) consideran no haber empeorado; 17 de los 18 que no han aumentado su frecuencia de escapes así lo han valorado. Conclusión. La valoración subjetiva de los resultados del biofeedback para el tratamiento de la incontinencia fecal, tanto inmediata como a largo plazo, coincide con los resultados objetivos logrados aunque sean moderados (AU)

Anastomosis coloanal con reservorio: ¿es una solución para el síndrome de la resección anterior? / Coloanal anastomosis with reservoir: a solution to anterior resection syndrome?

Introducción. La anastomosis coloanal con reservorio se ha propuesto como solución para mejorar la función defecatoria tras anastomosis rectales muy bajas. Objetivo. Evaluar los resultados funcionales de una serie consecutiva. Pacientes y métodos. Un total de 55 pacientes a los que se ha realizado una anastomosis coloanal con reservorio en "J". Para la evaluación funcional debe haber transcurrido por lo menos un año del cierre del estoma temporal. Resultados. Complicaciones: cuatro abscesos pélvicos/dehiscencias (7,2 por ciento), un absceso subhepático (1,8 por ciento), tres íleos (5,4 por ciento), dos disfunciones de la ileostomía (3,6 por ciento), 21 fallecimientos por embolismo pulmonar (1,8 por ciento). Funcionales: evaluados 36 pacientes. Frecuencia deposicional de 8 casos de 1,9/día; 20 problemas funcionales de forma global (56 por ciento): ocho tenesmos (22 por ciento), ocho dificultades evacuatorias (22 por ciento), cuatro urgencias (11 por ciento), 13 casos de incontinencia (36 por ciento) (gases en tres, heces en cinco y ensuciamiento en cinco). Conclusión. La anastomosis coloanal con reservorio mejora la frecuencia deposicional, pero no el resto de problemas funcionales. La evaluación de la cirugía conservadora de esfínteres deberá hacer más hincapié sobre la calidad de vida que sobre los resultados funcionales (AU)

Life table analysis of hernia following end colostomy construction.

OBJECTIVE: To study the long-term hernia rate and risk factors after end colostomy construction. PATIENTS AND METHODS: 86 patients with a permanent end colostomy constructed over 5 years were examined and interviewed. There were 35 men and the mean age was 56.5 (28-87) years. Risk factors which were analysed included emergency operation, age over 60 years, obesity, steroids, cancer, infection at the stoma site, smoking and chronic obstructive airways disease. RESULTS: Para-colostomy hernia occurred in 12/86 cases (13.9%). The cumulative recurrence rose with duration of follow up. Overall 10/45 patients (22%) over 60 years developed hernia vs. 2/41 patients (4.8%) less than 60 years (P=0.02). There were no other risk factors that correlated with para-colostomy hernia. CONCLUSIONS: These data indicate that the incidence of colostomy related hernia increases with follow up and is significantly higher in patients over the age of 60. Other risk factors, particularly obesity and coexisting cardiorespiratory disease, have no impact.

¿Debe usarse la graciloplastia dinámica en la reconstrucción anorrectal tras la amputación abdominoperineal? / Should dynamic graciloplasty be employed in anorectal reconstruction following abdominoperineal resection?

Objetivo. Presentamos nuestra experiencia con la graciloplastia dinámica en la reconstrucción anorrectal después de la amputación abdominoperineal por cáncer de recto. Pacientes y métodos. En 1997 se llevó a cabo el procedimiento en cuatro pacientes, tres de ellos eran varones, con edades comprendidas entre los 42 y 65 años. Todos los pacientes incluidos en el estudio presentaban un adenocarcinoma situado entre 1 y 3 cm del margen anal, de estadio ecográfico T2N0 y ausencia de metástasis o neoplasias sincrónicas, tanto en el estudio preoperatorio como durante la intervención. La técnica se llevó a cabo en tres intervenciones quirúrgicas. En la primera operación se realizó la amputación abdominoperineal y se crearon dos colostomías, una perineal y otra en la fosa ilíaca izquierda. La primera se rodeó con el músculo gracilis de ambas extremidades. Los pacientes realizaron irrigaciones de la colostomía ilíaca. La segunda intervención consistió en la implantación de los electrodos y el neuroestimulador. La tercera intervención, consistente en el cierre de la colostomía, se llevó a cabo al término del proceso de transformación de las fibras musculares. Resultados. El procedimiento se intentó en 4 pacientes. Dos desarrollaron una estenosis tardía del estoma perineal antes del cierre de la colostomía, atribuida a la presión que ejercía el músculo gracilis. A uno de ellos se le realizó la reconstrucción del estoma perineal y ulteriormente rechazó el cierre de la colostomía. El otro paciente rehusó otra intervención quirúrgica. Por tanto, de los 4 pacientes sólo dos completaron el procedimiento. Ambos refirieron ensuciamiento continuo y dificultad para la evacuación por lo que su calidad de vida era mejor con las irrigaciones de la colostomía. A uno de ellos se le realizó una nueva colostomía 8 meses después de completar el procedimiento. Ninguno de los pacientes presentó una recidiva tumoral. Conclusiones. A pesar de la ausencia de complicaciones quirúrgicas inmediatas y de haber conseguido unos valores presivos adecuados, la reconstrucción anorrectal total con una doble graciloplastia tiene en nuestras manos resultados peores que una colostomía en la fosa ilíaca izquierda irrigada (AU)

El esfínter anal artificial. Nuestra experiencia / The artifical bowel sphincter. Our experience

Introducción. Una alternativa para el tratamiento de la incontinencia fecal severa es el esfínter anal artificial. Presentamos los resultados obtenidos en nuestra unidad tras la implantación de seis de estos dispositivos. Pacientes y métodos. Desde septiembre de 1997 hasta febrero de 1999 se han implantado 6 esfínteres anales artificiales a 4 mujeres y 2 varones diagnosticados de incontinencia fecal. Todos ellos fueron refractarios al tratamiento médico-dietético y al biofeedback. A todos se les realizaron en el preoperatorio estudios funcionales y radiológicos. La valoración de la continencia se efectuó con la escala de Miller. Los pacientes fueron intervenidos por el mismo cirujano. Resultados. Durante el postoperatorio no se presentó ninguna complicación inmediata que obligara al explante del dispositivo. Cuatro pacientes presentaron una dehiscencia de la herida perineal y uno un hematoma escrotal. En un caso fue necesario realizar un estoma de derivación por una diarrea refractaria al tratamiento médico. La tasa de infección ha sido nula. En 3 pacientes ha aparecido un cuadro de obstrucción a la defecación. Se ha retirado el dispositivo a una paciente 10 meses después de la intervención debido al dolor que presentaba en todas las zonas donde estaba situado el mismo. En cuanto a la continencia, hemos obtenido una mejoría, pasando los pacientes de un grado III a un grado l (puntuación de 17,6 a 4,6). Conclusiones. El esfínter anal artificial es una alternativa para el tratamiento de la incontinencia anal severa, ya que sus resultados en cuanto a morbilidad y a restauración de la continencia son alentadores (AU)

Albendazole plus praziquantel versus albendazole alone as a pre-operative treatment in intra-abdominal hydatisosis caused by Echinococcus granulosus.

OBJECTIVE: To compare the effects of a combined medication of albendazole (10 mg/kg/day) plus praziquantel (25 mg/kg/day) to those of albendazole alone at different doses (10 and 20 mg/kg/day). METHOD: The protoscoleces' viability was studied in a consecutive series of patients affected by intra-abdominal hydatidosis caused by Echinococcus granulosus. In all cases the drugs were given during the month prior to surgery. RESULTS: A significant increase of patients with nonviable protoscoleces was observed in the group treated with the scolicides combination compared to those treated with albendazole alone, both at a dose of 10 mg/kg/day (P = 0.004) and at a dose of 20 mg/kg/day (P = 0.03). Albendazole sulphoxide levels in serum and in cyst fluid were higher in patients given the combined therapy than in those who received only albendazole (10 mg/kg/day: P = 0.016; 20 mg/kg/day: P = 0.034). Levels in the cysts were not significantly different probably due to the sample size; nevertheless a lineal relation between the values obtained in serum and inside the cysts could be discerned in the patients treated with the combined medication. CONCLUSION: Albendazole plus praziquantel is more effective than monotherapy with albendazole in the preoperative treatment of intra-abdominal hydatidosis.

Is early postoperative feeding feasible in elective colon and rectal surgery?

UNLABELLED: In reports on earlier non-prospectively randomized trials the authors have claimed that early oral postoperative feeding is a unique benefit of laparoscopic surgery. On the other hand, some authors have suggested that early feeding could be tolerated by the majority of patients after elective open surgery. AIM: This prospective randomized study was undertaken to assess the feasibility and safety of immediate oral feeding in patients subjected to elective open colorectal surgery. METHODS: This trial included 190 patients who underwent an elective colon or rectal operation. Patients were randomized after the operative procedure into one of two groups. Group I (n = 95): On the first evening after the operation, patients were allowed ab libitum intake of clear liquids; this continued until the first postoperative day at which time they progressed to a regular diet as desired. Group II (n = 95): In this group the nasogastric tube was removed when the surgeon considered that postoperative ileus had been resolved. RESULTS: Early oral intake was tolerated by 79.6% of the patients in the first 4 days in group I; there were no differences between the two groups from the 4th day on. The incidence of vomiting and nasogastric tube insertion (21.5%) was higher in patients in group I than in those in group II. The time until the first bowel movement was 4.3 days in group I and 4.7 days in group II. Complications appeared in 17.3% of the patients in group I and in 19.3% in group II. CONCLUSION: This study has objectively demonstrated that early oral feeding is feasible and safe in patients who have elective colorectal surgery.

Early postoperative feeding after elective colorectal surgery is not a benefit unique to laparoscopy-assisted procedures.

UNLABELLED: Previous analyses of non-prospectively randomized trials have suggested that early oral postoperative feeding might be a benefit unique to laparoscopic surgery. However, some authors have indicated that early feeding can be tolerated by the majority of patients after elective open surgery. AIM: This prospective randomized study was undertaken to assess whether the time prior to oral intake of food after laparoscopy-assisted surgery is shorter than that after standard laparotomy. METHODS: This trial included 40 patients who were divided randomly into two groups before operation. Group I included 20 patients (mean age, 52 years; range, 15-77 years) who underwent a laparoscopy-assisted colon or rectal procedure (LAP). Group II consisted of 20 patients (mean age, 56 years, range, 41-74 years) who underwent surgery with a standard midline incision (SMI). On the evening after surgery, patients were allowed clear liquids ab libitum. This regimen was continued until the first postoperative day at which time they could elect to start eating a regular diet. If a patient had two episodes of vomiting, a nasogastric tube was inserted. RESULTS: Five laparoscopic procedures were converted to SMI because of adhesions (25%) and an equal number of patients was excluded from the group that was treated in the traditional manner. Therefore, only 30 patients were included in the analysis. There were no deaths in this trial. Complications appeared in four of the patients in the LAP group and in two of the patients in the SMI group (no significant difference). There were no statistically significant differences between the two groups in terms of the ability to tolerate the early oral intake of food, in the frequency of vomiting or in the incidence of insertion of a nasogastric tube. The time to the first bowel movement was 5.4 days in LAP and 5.5 days in SMI, and the difference was not significant. CONCLUSION: This study invalidates the claim by laparoscopic surgeons that earlier oral intake of food is tolerated by their patients than by patients who undergo standard procedures.