Detection of non-alcoholic steatohepatitis in patients with morbid obesity before bariatric surgery: preliminary evaluation with acoustic radiation force impulse imaging.

OBJECTIVE: To investigate the utility of acoustic radiation force impulse (ARFI) imaging, with the determination of shear wave velocity (SWV), to differentiate non-alcoholic fatty liver disease (NAFLD) from non-alcoholic steatohepatitis (NASH) in patients with morbid obesity before bariatric surgery. METHODS: Thirty-two patients with morbid obesity were evaluated with ARFI and conventional ultrasound before bariatric surgery. The ARFI and ultrasound results were compared with liver biopsy findings, which is the reference standard. The patients were classed according to their histological findings into three groups: group A, simple steatosis; group B, inflammation; and group C, fibrosis. RESULTS: The median SWV was 1.57 ± 0.79 m/s. Hepatic alterations were observed in the histopathological findings for all the patients in the study (100 %), with the results of the laboratory tests proving normal. Differences in SWV were also observed between groups A, B and C: 1.34 ± 0.90 m/s, 1.55 ± 0.79 m/s and 1.86 ± 0.75 m/s (P < 0.001), respectively. The Az for differentiating NAFLD from NASH or fibrosis was 0.899 (optimal cut-off value 1.3 m/s; sensitivity 85 %; specificity 83.3 %). CONCLUSION: The ARFI technique is a useful diagnostic tool for differentiating NAFLD from NASH in asymptomatic patients with morbid obesity. KEY POINTS : • Acoustic radiation force impulse imaging provides ultrasonic shear wave velocity measurements. • SWV measurements were higher in patients with inflammation or fibrosis than NAFLD. • ARFI differentiates NAFLD from NASH in patients with morbid obesity. • Results suggest that ARFI can detect NASH in asymptomatic morbidly obese patients.

COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer.

INTRODUCTION: Laparoscopic resection of rectal cancer has been proven efficacious but morbidity and oncological outcome need to be investigated in a randomized clinical trial. TRIAL DESIGN: Non-inferiority randomized clinical trial. METHODS: The COLOR II trial is an ongoing international randomized clinical trial. Currently 27 hospitals from Europe, South Korea and Canada are including patients. The primary endpoint is loco-regional recurrence rate three years post-operatively. Secondary endpoints cover quality of life, overall and disease free survival, post-operative morbidity and health economy analysis. RESULTS: By July 2008, 27 hospitals from the Netherlands, Belgium, Germany, Sweden, Spain, Denmark, South Korea and Canada had included 739 patients. The intra-operative conversion rate in the laparoscopic group was 17%. Distribution of age, location of the tumor and radiotherapy were equal in both treatment groups. Most tumors are located in the mid-rectum (41%). CONCLUSION: Laparoscopic surgery in the treatment of rectal cancer is feasible. The results and safety of laparoscopic surgery in the treatment of rectal cancer remain unknown, but are subject of interim analysis within the COLOR II trial. Completion of inclusion is expected by the end of 2009. TRIAL REGISTRATION: Clinicaltrials.gov, identifier: NCT00297791 (www.clinicaltrials.gov).

[Portal-splenic-mesenteric venous thrombosis secondary to a mutation of the prothrombin gene]. / Trombosis venosa portoesplenomesaraica secundaria a mutación del gen de la protrombina.

Thrombosis of the portal-mesenteric axis is an infrequent cause of intestinal ischemia or infarction. In addition to the multiple acquired factors that contribute to the development of this entity, hereditary risk factors, especially the factor V Leiden mutation and the G20210A mutation of the prothrombin gene, have been implicated. The G20210A mutation of the prothrombin gene is found in up to 40% of patients with splenic-portal-mesenteric thrombosis. The present case illustrates the unusual and nonspecific presentation of this mutation in the form of diarrhea and images of thrombosis of the superior mesenteric-portal vein and cavernous transformation of the portal vein. Delayed diagnosis is highly frequent since the clinical signs, laboratory investigations and radiological tests do not suggest the diagnosis. The patient received anticoagulant treatment and showed clinical improvement with complete portal-mesenteric recanalization. Currently the diagnostic technique of choice is magnetic resonance angiography or computerized tomography angiography and treatment consists of indefinite anticoagulation. This case illustrates that an unusual or atypical localization of venous thrombosis may be a manifestation of thrombophilia, emphasizing the importance of genetic screening in these cases.

Trombosis venosa portoesplenomesaraica secundaria a mutación del gen de la protrombina / Portal-Splenic-Mesenteric venous thrombosis secondary to a mutation of the prothrombin gene

La trombosis del eje portomesaraico es una causa infrecuente de isquemia o infarto intestinal. Además de múltiples factores adquiridos que contribuyen al desarrollo de este cuadro, recientemente se han implicado factores de riesgo hereditario, especialmente la mutación del factor V de Leiden y la mutación G20210A del gen de la protrombina. La mutación G20210A del gen de la protrombina se encuentra hasta en el 40% de los pacientes con trombosis portoesplenomesaraica. El presente caso ilustra la presentación inusual e inespecífica de dicha mutación, en forma de diarreas e imágenes de trombosis de la vena mesentérica superior y porta y cavernomatosis portal. Es muy frecuente el retraso en el diagnóstico ya que los signos clínicos, analíticos y la radiología no apuntan el diagnóstico. El paciente recibió tratamiento anticoagulante y mejoró clínicamente, con una repermeabilización completa portomesaraica. En la actualidad la técnica diagnóstica de elección es la angiorresonancia magnética o la angiotomografía computarizada, y el tratamiento, la anticoagulación de manera indefinida. Nuestro caso ilustra que una localización inusual o atípica de trombosis venosa puede ser la manifestación de una trombofilia, lo que recalca la importancia del cribado genético en estos casos

Thrombosis of the portal-mesenteric axis is an infrequent cause of intestinal ischemia or infarction. In addition to the multiple acquired factors that contribute to the development of this entity, hereditary risk factors, especially the factor V Leiden mutation and the G20210A mutation of the prothrombin gene, have been implicated. The G20210A mutation of the prothrombin gene is found in up to 40% of patients with splenic-portal-mesenteric thrombosis. The present case illustrates the unusual and nonspecific presentation of this mutation in the form of diarrhea and images of thrombosis of the superior mesenteric-portal vein and cavernous transformation of the portal vein. Delayed diagnosis is highly frequent since the clinical signs, laboratory investigations and radiological tests do not suggest the diagnosis. The patient received anticoagulant treatment and showed clinical improvement with complete portal-mesenteric recanalization. Currently the diagnostic technique of choice is magnetic resonance angiography or computerized tomography angiography and treatment consists of indefinite anticoagulation. This case illustrates that an unusual or atypical localization of venous thrombosis may be a manifestation of thrombophilia, emphasizing the importance of genetic screening in these cases

Role of appendectomy in training for laparoscopic surgery.

BACKGROUND: This study aimed to evaluate a program of training in laparoscopic surgery based on clinical practice in the emergency room, in which laparoscopic appendectomy is the first technique that residents perform as surgeons. METHODS: A prospective nonrandomized study was conducted involving all the laparoscopies performed in emergencies with a diagnosis of acute abdomen, appendicular in origin, during the period between June 1991 and December 1997. RESULTS: There were no statistically significant differences between residents and assistants in terms of conversion rates (22/242 vs 15/158), mean hospital stay for each type of surgeon (5.2 days for residents and 5.1 days for assistants), and complications (12.8% for residents and 13.7% for assistants). Operating time, was significantly longer (p < 0.05) for residents (52.2 min) than for assistants (48 min). CONCLUSIONS: Apprenticeship in laparoscopic appendectomy can be accomplished with gradual clinical training and without the need for resort to animal experimentation laboratories.

Reparación de la iatrogenia biliar poscirugía laparoscópica en centros con experiencia en cirugía hepatobiliar / Repair of iatrogenic lesions of the biliary tract after laparoscopic surgery in centers with experience in hepatobiliary surgery

Introducción. La colecistectomía realizada por vía laparoscópica se acompaña de una incidencia de lesiones iatrogénicas de la vía biliar principal mayor que cuando se realiza por vía abierta. Estas lesiones son más graves, al ser más altas en su localización, afectando a la vía biliar intrahepática y con frecuente desaparición de tramos completos de la misma, lo que dificulta su diagnóstico y tratamiento quirúrgico. Pacientes y método. Se presentan 10 casos de lesiones iatrogénicas de la vía biliar principal tras colecistectomía laparoscópica intervenidos en nuestro servicio, tres de ellos con afectación de la vía biliar intrahepática. En los 7 casos de localización extrahepática se practicó una hepaticoyeyunostomía en "Y" de Roux en 4 casos, una coledococoledocostomía terminoterminal sobre tubo en "T" de Kehr en otros 2 casos (en ambos hubo que realizar posteriormente una hepaticoyeyunostomía en "Y" de Roux) y, en el restante, un cierre de una sección parcial del colédoco sobre un tubo en "T" de Kehr. En los 3 casos de lesión intrahepática fracasó una primera reconstrucción en "Y" de Roux, precisando un abordaje intrahepático con tutores múltiples y nueva hepaticoyeyunostomía en "Y" de Roux. Resultados. Todos los enfermos se encuentran asintomáticos y con unas analíticas normales tras un seguimiento medio de 39,2 meses. Conclusión. Las lesiones iatrogénicas de la vía biliar principal tras colecistectomía laparoscópica pueden requerir cirugía compleja para su tratamiento, por lo que deben ser referidas a centros con experiencia en cirugía hepatobiliar, sobre todo si son de localización intrahepática (AU)

Evolución de la categoría del cirujano que realiza la apendicectomía laparoscópica en nuestro servicio / Changes in category of surgeons performing laparoscopic appendectomy in our service

Introducción. Desde que se introdujo la laparoscopia en nuestro hospital ha ido variando la categoría del cirujano que realiza la apendicectomía laparoscópica. El objetivo de nuestro trabajo es analizar la evolución de la categoría del cirujano que efectúa esta técnica. Pacientes y método. Hemos estudiado las 400 apendicecto mías laparoscópicas realizadas entre junio de 1991 y diciembre de 1997, dividiéndolas en 4 grupos de 100. Analizamos los hallazgos operatorios, el tiempo quirúrgico, la tasa de conversiones, las complicaciones, la estancia hospitalaria y la categoría del cirujano en cada grupo. Resultados. Inicialmente, los adjuntos realizaban casi la totalidad de intervenciones, siendo actualmente los residentes los que llevan a cabo más del 85 por ciento de las apendicectomías laparoscópicas. No existen diferencias en el tiempo quirúrgico, complicaciones y estancia hospitalaria en los 4 grupos. Ha aumentado de forma significativa la tasa de conversiones y ha disminuido el número de apendicitis perforadas conforme avanza la serie. Conclusiones. La apendicectomía laparoscópica es una técnica ampliamente asimilada por los residentes de nuestro servicio, que realizan en estos momentos la mayoría de intervenciones (AU)

El cirujano como factor pronóstico en la apendicectomía laparoscópica / The surgeon as a prognostic factor in laparoscopic appendectomy

Introducción. La apendicectomía laparoscópica se introdujo en nuestro servicio de manos de cirujanos con experiencia previa en colecistectomía laparoscópica. Progresivamente, los residentes se iniciaron en la técnica, realizando hoy día la mayor parte de estas intervenciones. El objetivo del estudio es analizar si el grado de experiencia del cirujano influye en el pronóstico del paciente con apendicitis aguda intervenido por laparoscopia. Pacientes y método. Se estudian 400 pacientes con sospecha de apendicitis aguda intervenidos por laparoscopia. Analizamos los hallazgos, el tiempo quirúrgico, las conversiones, las complicaciones y la estancia hospitalaria según el cirujano (adjunto o residente, y año de formación). Resultados. No existen diferencias en cuanto al tiempo quirúrgico, tasa de conversión, complicaciones y estancia hospitalaria entre los pacientes intervenidos por adjuntos o residentes. No obstante, los adjuntos han operado un mayor porcentaje de apendicitis complicadas que los residentes. Conclusión. Los residentes de cirugía deben iniciarse en laparoscopia a través de la apendicectomía laparoscópica, aunque las formas complicadas deben ser operadas por cirujanos con experiencia (AU)

Laparoscopic surgery in the management of traumatic hemoperitoneum in stable patients.

Unnecessary laparotomies in patients with abdominal traumatism (AT) who present hemoperitoneum with stable hemodynamics may be avoided if a diagnostic/therapeutic laparoscopy is performed. Between July 1992 and December 1994, 24 patients with AT and hemoperitoneum underwent this exploration: 5 were found to have a large retroperitoneal hematoma; 2, a tear in the intestinal mesenterium; 4, hepatic injuries; and 13, splenic lesions. Of the 24 patients, 9 needed conversion to open exploration: 8 during the laparoscopy and 1 shortly after operation. Mean hospital stay was 7 days (5-9). There was no morbidity or mortality in the series. Diagnostic/therapeutic laparoscopy is a method that is efficient and economical and can easily be undertaken by surgeons with experience in laparoscopy; it may be a valid alternative to conservative treatment or laparotomy in AT and hemoperitoneum patients who are hemodynamically stable.

Intestinal obstruction and bezoars.

BACKGROUND: Bezoars are large conglomerates of vegetable fibers, hairs, or concretions of various substances located in the stomach or small intestine of humans and certain animals, mainly ruminants. Gastrointestinal bezoars have constituted a relatively common clinical reality ever since the introduction of truncal vagotomy associated with drainage or gastric resection in the treatment of gastroduodenal peptic ulcer. STUDY DESIGN: This study presents a series of 87 cases of intestinal bezoar treated in our department of general surgery. Analysis was made of data obtained retrospectively from clinical histories, together with a clinical and endoscopic review of the patients. RESULTS: Most of the patients had had previous operative treatment (76.3 percent), the most commonly used technique being bilateral truncal vagotomy plus pyloroplasty (75.8 percent). An excessive intake of vegetable fiber was revealed in 39.5 percent of the cases, and alterations in dentition and mastication in 24 percent. Operative treatment was used in all patients. We attempted to fragment the bezoar and milk it to the cecum. Enterotomy and bezoar extraction were reserved for cases where fragmentation was impossible, as enterotomy was associated with more complications (p < 0.05). CONCLUSIONS: Bilateral truncal vagotomy plus pyloroplasty and a excessive ingestion of vegetable fiber are the main factors predisposing to bezoar formation. Clinically, intestinal bezoars manifest themselves in most cases as complete intestinal obstruction. Simple roentgenography of the abdomen is the fundamental technique for diagnosing the occlusive syndrome. Treatment must be operative, during which the bezoar is fragmented and milked to the cecum. The stomach must be explored for associated bezoars.

Quantification of duodenogastric reflux in patients with choledochoduodenostomy.

BACKGROUND: Frequently, patients present with symptoms after cholecystectomy (pain or discomfort in the upper part of the abdomen, postprandial fullness, bile vomiting, among others). Duodenogastric reflux has been associated with these symptoms in some patients. Therefore, this study was done to investigate this relationship. STUDY DESIGN: We evaluated duodenogastric reflux (DGR) in ten healthy patients, in ten patients who had asymptomatic simple cholecystectomy, in ten patients who had asymptomatic cholecystectomy with supraduodenal choledochoduodenostomy (CD), and in ten patients who had cholecystectomy plus CD followed by discomfort in the upper abdomen, postprandial fullness and bile vomiting, but no colicky pain or acute cholangitis. Duodenogastric reflux was quantified using continuous intravenous infusion of technetium-99m labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequently determining its concentration in gastric juice. RESULTS: All of the patients who underwent operation, whatever the technique used, had higher reflux rates than those in the control group (p < 0.001). Moreover, reflux rates were comparable in the patients who underwent simple cholecystectomy compared with patients in the asymptomatic cholecystectomy plus CD group. Conversely, when patients with cholecystectomy plus CD presented with discomfort in the upper part of the abdomen as well as bile vomiting, they had higher reflux rates than patients who underwent simple cholecystectomy (p < 0.001) and asymptomatic patients with associated CD (p < 0.001). CONCLUSIONS: Our results suggest that DGR must be involved in the genesis of these dyspeptic symptoms.

Laparoscopic versus open appendicectomy: a prospective assessment.

A prospective study of 200 consecutive patients with suspected acute appendicitis was performed to compare open and laparoscopic appendicectomy. Formal randomization was precluded by instrument availability. Some 100 patients underwent laparoscopic appendicectomy (conversion to laparotomy was carried out in five) and 100 had conventional surgery. The groups were similar in sex ratio, age, degree of appendiceal inflammation and antibiotic treatment. The mean duration of open appendicectomy was 46 min and of the laparoscopic procedure 51 min (P not significant). Postoperative complications in patients who underwent laparoscopic appendicectomy included: intra-abdominal abscess (two patients), wound infection (one), early bowel obstruction (four; all resolved with medical treatment) and umbilical haematoma (two). There were no reoperations in the immediate or late postoperative period. Complications after open operation were: wound infection (seven patients) (P < 0.05), early bowel obstruction (five; three resolved with medical treatment, two required surgery) and haematoma of the surgical wound (one). The mean hospital stay was 4.8 days for laparoscopic appendicectomy and 6.0 days for the open operation (P < 0.05). There were no deaths.

Role of Helicobacter pylori infection and duodenogastric reflux in the pathogenesis of alkaline reflux gastritis after gastric operations.

In patients undergoing gastric operations, we studied the relationship between data suggesting alkaline reflux gastritis (symptoms, endoscopic alterations and histologic lesions) and two factors that produce chronic gastritis (helicobacter pylori and duodenogastric reflux). Of 225 patients who underwent operations for gastroduodenal gastric ulcer at our General Surgery Unit between 1980 and 1982, 63 agreed to undergo endoscopy and biopsies. Of these 63 patients, 38 agreed to a test to quantify duodenogastric reflux (24 hour gastric pH monitoring associated with the determination of bile acids in gastric juice). According to the clinical questionnaire, patients were classified as symptomatic and asymptomatic. Endoscopy was considered either normal with mucosal lesions or mucosal lesions plus bile. In the histologic study, we considered normal mucosa, superficial chronic gastritis and atrophic chronic gastritis. Furthermore, the presence of atrophy, metaplasia, foveolar hyperplasia and helicobacter pylori was studied. Symptoms, endoscopic alterations and histologic lesions were not significantly related to helicobacter pylori, but were significantly related to the quantity of duodenogastric reflux. The symptomatic patients presented with a greater quantity of reflux than the asymptomatic patients (p < 0.05). The patients with mucosal lesions plus bile who had endoscopy showed a greater quantity of reflux than those with normal endoscopy (p < 0.001) and those with mucosal lesions without bile (p < 0.02 for pH values and p < 0.001 for bile acids). The patients with atrophic chronic gastritis presented with a greater quantity of reflux than those with normal mucosa and superficial chronic gastritis (p < 0.05, respectively), and the patients with atrophy and metaplasia and foveolar hyperplasia had more reflux than those without (p < 0.001, respectively). The patients who were helicobacter positive and negative presented with similar quantities of reflux.

Duodenogastric reflux in patients with biliary lithiasis before and after cholecystectomy.

Duodenogastric reflux is quantified in ten patients with biliary lithiasis and a functioning gallbladder, before and six months after performing cholecystectomy. The results are compared with those of a control group (n = 10) with similar age and gender, without gastric or hepatobiliary pathologic factors. To evaluate reflux, we used six hour continuous intravenous infusion and subsequent determination in gastric juice of 99mTc-diethyliminodiacetic acid. Our results showed that patients with cholelithiasis have higher reflux rates than those in the control group (p < 0.001). When comparing patients before and after cholecystectomy, we confirmed that removal of the gallbladder produces a significant increase (p < 0.001) in reflux rates compared with preoperative values.

Gastric surgery and bezoars.

We present a series of 56 patients with gastrointestinal bezoar following previous gastric surgery for gastroduodenal peptic ulcer. The following parameters were studied: factors predisposing to bezoar formation (type of previous surgery, alimentation, and mastication), form of clinical presentation, diagnostic tests, and treatment. A bilateral truncal vagotomy plus pyloroplasty had been performed previously on 84% of patients, 44% revealed excessive intake of vegetable fiber, and 30% presented with bad dentition. The most frequent clinical presentation was intestinal obstruction (80%). This was diagnosed mainly by clinical data and simple abdominal radiology. The main exploratory technique for diagnosing cases of gastric bezoar was endoscopy. Surgery is necessary for treating the intestinal forms, and one should always attempt to fragment the bezoar and milk it to the cecum, reserving enterotomy and extraction for cases where this is not possible. The small intestine and stomach should always be explored for retained bezoars. Gastric bezoars should always receive conservative treatment, endoscopic extraction, and/or enzymatic dissolution; gastrotomy and extraction should be performed when this fails.

Management of the perineal wound following abdominoperineal resection: prospective study of three methods.

A prospective study was made of three procedures for treating the perineal wound and presacral cavity in 102 patients undergoing abdominoperineal excision for cancer of the rectum: (1) packing of the presacral space after suture of the pelvic peritoneum; (2) suture of the pelvic peritoneum and perineal wound, leaving two drains through the perineum; and (3) no suture of the pelvic peritoneum, and primary closure of the perineal wound, leaving drains through the abdomen for physiological saline irrigation. The parameters analysed were incidence of infection, primary healing of the perineum, extraperineal complications and mean hospital stay. Primary healing of the perineum was best with method 3, and overall incidence of infection highest with method 2. There were no differences between the methods with regard to extraperineal complications. Hospital stay was shortest with method 3.

[Quantification of duodenogastric reflux in symptomatic patients with choledochoduodenostomy using intravenous continuous perfusion of 99mTc-HIDA as duodenal marker]. / Cuantificación del reflujo duodenogástrico en pacientes con coledocoduodenostomía sintomáticos utilizando la perfusión continua intravenosa de 99mTc-HIDA como marcador duodenal.

The purpose of the present study was to determine whether the measurement of intravenously administered 99mTc-HIDA in samples of gastric juice can be used as a reliable marker of duodenogastric reflux. Ten normal volunteers and 10 patients with a laterolateral choledocho-duodenostomy complaining of dyspepsia but no biliary pain, were given a continuous i.v. infusión of 99mTc-HIDA. The isotope concentration was then measured in samples of gastric juice. We found that duodeno-gastric reflux was significantly higher (p less than 0.001) in patients with choledochoduodenostomy and dyspepsia than in normal volunteers.

[Subcutaneous emphysema as the initial manifestation of perforation of a hollow abdominal viscus]. / Enfisema subcutáneo como manifestación inicial de perforación de víscera hueca abdominal.

The authors reports a case of cervical and abdominal subcutaneous emphysema, associated to pneumoretroperitoneum and pneumomediastinum, with no free air in the abdominal cavity, secondary to perforated diverticulitis of the sigmoid colon. We comment the rarity of this clinical presentation, the physiopathologic mechanisms of subcutaneous air presence in cases of non instrumental perforation of abdominal viscera and the ominous significance of the subcutaneous emphysema in such perforations.