[Laparoscopic apendicectomy vs open approach for the treatment of acute appendicitis]. / Apendicectomía laparoscópica frente al abordaje abierto para el tratamiento de la apendicitis aguda.

BACKGROUND: There is no international consensus on the approach of choice for performing appendectomy. AIMS: To analyze and compare open and laparoscopic approaches in the surgical treatment of acute appendicitis. MATERIAL AND METHODS: A retrospective study was carried out on patients over 14-years-old operated on for suspected acute appendicitis between January 2007 and December 2009. Variables were: age, sex, body mass index, specialized surgeon or resident in training, progression duration, conversion rate, use of drains, abdominal cavity irrigation, macroscopic appearance of the appendix, onset time of anesthesia, ASA classification, postoperative hospital stay, resumption of intake of liquids, and complications. The patients were divided into two groups: laparoscopic approach (LA) and open approach (OA). RESULTS: A total of 533 patients were enrolled (290 LA and 243 OA). Onset time of anesthesia was 75 min (30-190 min) in LA vs 55 min (20-160 min) in OA (p<0,0001). COMPLICATIONS: intraabdominal abscesses in 17 LA cases vs 13 OA cases (p=0,79); surgical wound alterations in 16 LA cases vs 47 OA cases (p=0,0001); incisional hernias in 2 LA cases (1%) vs 10 OA cases (p=0,008). There were no statistically significant differences in postoperative hospital stay (3 days), resumption of intake of liquids (1 day) or readmission rate (8%). CONCLUSIONS: There are fewer surgical wound alterations and incisional hernias with the laparoscopic approach, but there is higher cost, lengthier surgery duration, and a longer learning curve. Our results cannot provide a clear indication for one approach or the other, and therefore each case must be evaluated on an individual basis.

Hartmann's operation: how often is it reversed and at what cost? A multicentre study.

AIM: The study evaluated the rate of reversal of Hartmann's operation after the initial surgery and its morbidity. METHOD: A multicentre retrospective study was carried out in seven hospitals in the Valencia area of patients who underwent Hartmann's operation from 2004 to 2008. The incidence of reversal was determined. RESULTS: Four hundred and fifty-two patients of mean age 67.5 ± 15.4 years were included, of whom 78.8% had an emergency operation. The most common diagnosis was cancer (58.6%), although diverticulitis predominated in the emergency setting. At a median follow up of 44 months, 159 (35.2%) patients had undergone reversal, including 16.6% after elective surgery and 40.4% after an emergency Hartmann's procedure (P < 0.001). The most frequent reason why reversal was not done was death (74 [25%] patients). Patients undergoing reversal were younger and had a low ASA risk. Trauma was associated with a higher rate of reversal, followed by diverticular disease. Surgery was performed at a median of 10 months. An open approach with stapled anastomosis was used in most cases. The mortality was 3.5%. Complications occurred in 45.2%, with a 6.2% rate of anastomotic leakage. Complications were associated with age, diabetes mellitus, arteriosclerosis, obesity, smoking, chemotherapy and COPD. CONCLUSION: Hartmann's reversal was performed in a small percentage of patients, mostly including those with benign disease. It had a significant morbidity.

Linfangiosarcoma sobre un linfedema crónico postmastectomía: síndrome de Stewart-Treves / No disponible

En 1948, Stewart y Treves comunicaron la aparición de unlinfangiosarcoma en el brazo edematoso de 6 pacientes sometidasa mastectomía radical por cáncer de mama. El síndromede Stewart-Treves describe la presentación de un linfangiosarcomao de un hemangiosarcoma sobre un linfedema crónico.Comunicamos el caso de una mujer de 74 años que fue sometidaa mastectomía radical derecha con radioterapia 23 añosantes y que consultó por la aparición de lesiones cutáneas enforma de placas violáceas en el brazo homolateral que llegarona hacerse nodulares. Tras la biopsia, el análisis histopatológicoconfirmó el diagnóstico de linfangiosarcoma. El estudio de extensiónfue negativo para metástasis. Se decidió la amputaciónde la extremidad. Seis meses más tarde, se diagnosticóuna metástasis cerebral y la paciente falleció poco tiempo después.Las opciones terapéuticas en estos casos (amputación,radioterapia y quimioterapia) son muy agresivas y ofrecen pobresresultados. Sólo un diagnóstico muy precoz, basado en lasospecha clínica, puede mejorar el pronóstico de esta complicaciónde la linfadenectomía axilar. La biopsia es obligatoriaante cualquier lesión sospechosa(AU)

In 1948, Stewart and Treves reported a lymphangiosarcomain 6 patient’s edematous arm after radical mastectomy forbreast cancer. Stewart-Treves syndrome describes a cutaneouslymphangiosarcoma or hemangiosarcoma that develops inlong-standing chronic lymphedema. We report a 74-year-oldwoman who was submitted to a right mastectomy and radiotherapy23 years before. She developed a chronic lymphedemain the same limb and fast-growing purplish lesions on thearm. These lesions became nodular. After the biopsy examinationthey were diagnosed as lymphangiosarcoma. The studyfor metastatic extension was negative. It was decided the amputationof the limb. Six months after the treatment, a brainmetastasis was diagnosed and the patient died. The therapeuticpossibilities (amputation, radiotherapy, chemotherapy) arevery aggresive and offer poor results. The physician mustmaintain a high index of suspicion in diagnosing this complicationof lymphadenectomy. If there is any doubt, biopsy is mandatory(AU)

Aneurisma de la arteria poplítea como complicación del síndrome de atrapamiento de la arteria poplítea / Aneurysm of the popliteal artery as a complication of popliteal artery entrapment syndrome

Introducción. El síndrome de atrapamiento de la arteria poplítea es una entidad poco frecuente; afecta sobre todo a varones jóvenes y deportistas, con una incidencia de 0,3-3,5 por ciento según diferentes series, provocado por las inserciones condíleas del músculo gastrocnemio interno. Caso clínico. Paciente de 54 años que ingresa por isquemia aguda de miembro inferior derecho. Tras valoración física y hemodinámica, se procedió a realizar arteriografía y se observó oclusión de la segunda porción de la arteria poplítea. Se decide como tratamiento inicial realizar fibrinólisis, que pone de manifiesto la existencia de un aneurisma poplíteo. Tras superar la fase aguda, se intervino quirúrgicamente. Conclusión. La dilatación postestenótica (aneurisma) como complicación de dicho síndrome es poco frecuente y de aparición en etapas de la vida más tardías; pueden llevar a la confusión con los aneurismas poplíteos arterioscleróticos y es difícil el diagnóstico prequirúrgico. Como tratamiento inicial, la fibrinólisis en la fase aguda es una opción a tener en cuenta, siempre que la situación clínica de la extremidad y del paciente lo permita, y el tratamiento definitivo el quirúrgico, basado en la sección de bandas musculofibróticas responsables; en el caso que presentamos, aneurismectomía y by-pass poplíteo-poplíteo con vena safena interna (AU)

Laparoscopically treated duodenal hamartoma of Brunner's glands.

Hamartomas of Brunner's glands are extremely rare lesions, with only about 100 cases reported to date in the world literature; of these, fewer than 25 correspond to growths >2 cm in diameter. We report the case of a patient with a large (6-cm diameter) duodenal hamartoma of Brunner's glands treated by laparoscopic surgery. A review of the literature revealed no other cases via this approach.

The effects of selective stellate ganglion manipulation on ventricular refractoriness and excitability.

The effects of selective stellate ganglion stimulation or stellectomy on ventricular excitability were studied in 30 open chest mongrel dogs anesthetized with alpha-chloralose. The effective refractory period (ERP) and strength interval curves (stimulus intensity [S2] = twice the diastolic threshold [ERP], and 2, 3, 5, 7, and 14 mA) were determined using bipolar epicardial electrodes placed in the mid-anterior wall of the right ventricle (RV) and the mid-posterolateral wall of the left ventricle (LV) during left stellate ganglion stimulation (LSGSt, n = 8) or right stellate ganglion stimulation (RSGSt, n = 8), or after left stellectomy (LSGEx, n = 7) or right stellectomy (RSGEx, n = 7). LSGEx prolonged ERP-LV (172 +/- 9 vs 167 +/- 8 msec, P < 0.05) and ERP-RV (163 +/- 10 vs 158 +/- 14 msec, P < 0.05). RSGEx prolonged ERP-LV (168 +/- 17 vs 162 +/- 15 msec, P < 0.01) and ERP-RV (166 +/- 14 vs 160 +/- 13 msec, P < 0.01), and the times of the strength interval curves obtained for each S2 intensity in both ventricles. LSGSt decreased ERP-LV (157 +/- 11 vs 163 +/- 12 msec, P < 0.01) and ERP-RV (147 +/- 18 vs 157 +/- 17 msec, P < 0.05), and the times of the strength interval curves obtained for each S2 intensity in both ventricles. RSGSt did not significantly decreased ERP-LV (152 +/- 11 vs 156 +/- 9 msec); however, it significantly shortened the times of the strength interval curves obtained for S2 intensities of 2 and 7 mA in the LV, and shortened ERP-RV (139 +/- 10 vs 145 +/- 7 msec, P < 0.01) and the times of the strength interval curve for S2 intensities of 2, 3, and 5 mA in the RV. A significant interaction (MANOVA test) was observed between the ventricle studied and the ganglion stimulated for S2 intensities of 2 and 3 mA, and between the effect of stimulation and the ganglion stimulated for S2 intensities of 3 and 14 mA. To conclude, selective stellectomy prolonged epicardial ventricular refractoriness in both the mid-anterior wall of the RV and the mid-posterolateral wall of the LV; the magnitude of the epicardial excitability variations in both areas was different during selective stellate ganglion stimulation.

[Porto-cholecysto-duodenal fistula as an infrequent cause of upper gastrointestinal hemorrhage]. / Fístula porto-colecisto-duodenal como causa poco frecuente de hemorragia digestiva alta.

A case of porto-cholecysto-duodenal fistula which caused a severe upper gastrointestinal haemorrhage is presented. The difficulties involved in diagnosis and surgical treatment are discussed.