Colecistectomía laparoscópica ambulatoria. Dificultades para su implementación y desarrollo: punto de vista del paciente / Outpatient laparoscopic cholecystectomy. Difficulties in its implementation and development: point of view of the patient

Introducción: El objetivo del estudio es saber las preocupaciones y expectativas del paciente en la colecistectomía laparoscópica ambulatoria (CLA) antes de su desarrollo e implementación en nuestro Hospital. Conocer la dificultades que van a presentarse. Diseñar las medidas que deben introducirse para transmitirle seguridad, disminuir su temor y lograr su confianza y aceptación. Material y método: Estudio prospectivo iniciado en abril de 2012 y finalizado en marzo de 2013, observacional y descriptivo de los pacientes intervenidos consecutivamente de colecistectomía laparoscópica electiva con hospitalización. Participaron voluntariamente en una encuesta realizada antes y después de la operación que hacía referencia a su conocimiento y opinión de la CLA y de su predisposición a su aceptación. Resultados: Se examinaron 114 casos. Preoperatoriamente, el 46 % habrían aceptado la CLA. Este porcentaje se incrementó al 60 % en los pacientes que cumplieron criterios de selección preoperatorios de CLA (p < 0,05). Esta opinión favorable estuvo relacionada con el nivel de estudios (primarios, secundarios y universitarios: 41, 42 y 100 %, respectivamente [p < 0,01-]).Tras la intervención, solo el 18 % la hubieran preferido (p < 0,01). El único factor que contribuyó a elegir esta decisión fue el cirujano que practicó la operación que varió entre O y 43 % (p < 0,05). La causa principal del rechazo fue el temor a las posibles complicaciones. Conclusiones: La opinión del paciente es mayoritariamente desfavorable a la CLA. El cirujano deberá realizar un sobreesfuerzo informativo y docente para eliminar los prejuicios previos. Selección adecuada, estudios superiores y el cirujano apropiado pueden facilitar la aceptación de CLA (AU)

Introduction: The aim of our study is to understand the worries and expectations from the patients in ambulatory laparoscopic cholecystectomy (ALC) before the development of ALC in our Hospital. Knowing what difficulties can occur. Designing measures to be introduced to convey safety and reduce fear to the patient and allow achieve his confidence and acceptance. Material and method: Prospective study started in April 2012 and completed in March 2013, observational and descriptive of patients undergoing consecutively elective inpatient laparoscopic cholecystectomy. Voluntarily participated in a survey before and after the operation referring to their knowledge and opinion about the ALC and their predisposition to acceptance. Results: 114 cases were examined. Before the operation, 46 % would have accepted outpatient surgery option. This percentage increased to 60 % in patients who had preoperative selection criteria of ALC (p < 0.05). This favourable opinion was related to the study's level (primary, secondary and university: 41, 42 and 100 %, respectively, [p < 0.01]). Only 18 % would have accepter after the operation (p < 0.01). The only factor that contributed to choosing this decision was the surgeon who performed the operation, ranged from O to 43 % (p < 0.05). The main reason for rejection was the fear of possible complications. Conclusions: The opinion of the patient is mostly unfavourable to the ALC. The surgeon should strive to provide information and teaching to eliminate the previous prejudices of the patient. Proper selection, higher education and the appropriate surgeon may facilitate the acceptance of CLA (AU)

Indicadores de calidad asistencial en cirugía mayor ambulatoria (2010-2012) / Indicators of healthcare quality in day surgery (2010-2012)

Introducción: La monitorización de indicadores de calidad en las unidades de Cirugía Mayor Ambulatoria es una herramienta fundamental para identificar los problemas, corregirlos y prevenirlos. Dado su gran número, es indispensable la selección de los más válidos. Objetivos: Mejora continuada de la calidad asistencial de la cirugía ambulatoria en nuestro centro mediante el seguimiento de parámetros de calidad selectivos, la información periódica de los resultados y la toma de medidas correctivas. Conseguir un porcentaje de pernoctas no planificadas y cancelaciones dentro de los estándares de calidad. Material y método: Estudio prospectivo, observacional y descriptivo de la cirugía ambulatoria realizada desde enero de 2010 a diciembre de 2012. Se seleccionaron y monitorizaron los ingresos imprevistos y las anulaciones el mismo día de la operación, y sus motivos. Los ingresos se clasificaron en selección inadecuada, complicaciones médico-quirúrgicas y otros. Los resultados se evaluaron anualmente y se analizaron estadísticamente con la prueba de χ2. Resultados: Durante estos 3 años, 8.300 pacientes fueron intervenidos en régimen de cirugía mayor ambulatoria. La cirugía ambulatoria y el índice de ambulatorización se incrementaron un 5,4 y 6,4%, respectivamente (p < 0,01). Los ingresos no previstos disminuyeron progresivamente, a expensas de un menor número de complicaciones (p < 0,01). Descendieron los debidos a tiempo prolongado en la recuperación de la anestesia locorregional (p < 0,01). Las náuseas y vómitos y el dolor mal controlado fueron mejor prevenidos. La proporción de ingresos de tarde se redujo significativamente (p < 0,01). Las anulaciones se incrementaron en el año 2011 (p < 0,01). Conclusiones: La monitorización de parámetros de calidad en cirugía mayor ambulatoria ha sido una herramienta útil en nuestra gestión clínica y de la calidad. Globalmente, los ingresos imprevistos y las anulaciones han estado dentro de los estándares de calidad y han mejorado muchos indicadores analizados (AU)

Introduction: Monitoring quality indicators in Ambulatory Surgery centers is fundamental in order to identify problems, correct them and prevent them. Given their large number, it is essential to select the most valid ones. Objectives: The objectives of the study are the continuous improvement in the quality of healthcare of day-case surgery in our center, by monitoring selective quality parameters, having periodic information on the results and taking corrective measures, as well as achieving a percentage of unplanned transfer and cancellations within quality standards. Material and method: Prospective, observational and descriptive study of the day-case surgery carried out from January 2010 to December 2012. Unplanned hospital admissions and cancellations on the same day of the operation were selected and monitored, along with their reasons. Hospital admissions were classified as: inappropriate selection, medical-surgical complications, and others. The results were evaluated each year and statistically analysed using 2 tests. Results: A total of 8,300 patients underwent day surgery during the 3 years studied. The daycase surgery and outpatient index increased by 5.4 and 6.4%, respectively (P < .01). Unexpected hospital admissions gradually decreased due to the lower number of complications (P < .01). Hospital admissions, due to an extended period of time in locoregional anaesthesia recovery, also decreased (P < .01). There was improved prevention of nausea and vomiting, and of poorly controlled pain. The proportion of afternoon admissions was significantly reduced (P < .01). The cancellations increased in 2011 (P < .01). Conclusions: The monitoring of quality parameters in day-case surgery has been a useful tool in our clinical and quality management. Globally, the unplanned transfer and cancellations have been within the quality standards and many of the indicators analysed have improved

[Indicators of healthcare quality in day surgery (2010-2012)]. / Indicadores de calidad asistencial en cirugía mayor ambulatoria (2010-2012).

INTRODUCTION: Monitoring quality indicators in Ambulatory Surgery centers is fundamental in order to identify problems, correct them and prevent them. Given their large number, it is essential to select the most valid ones. OBJECTIVES: The objectives of the study are the continuous improvement in the quality of healthcare of day-case surgery in our center, by monitoring selective quality parameters, having periodic information on the results and taking corrective measures, as well as achieving a percentage of unplanned transfer and cancellations within quality standards. MATERIAL AND METHOD: Prospective, observational and descriptive study of the day-case surgery carried out from January 2010 to December 2012. Unplanned hospital admissions and cancellations on the same day of the operation were selected and monitored, along with their reasons. Hospital admissions were classified as: inappropriate selection, medical-surgical complications, and others. The results were evaluated each year and statistically analysed using χ(2) tests. RESULTS: A total of 8,300 patients underwent day surgery during the 3 years studied. The day-case surgery and outpatient index increased by 5.4 and 6.4%, respectively (P<.01). Unexpected hospital admissions gradually decreased due to the lower number of complications (P<.01). Hospital admissions, due to an extended period of time in locoregional anaesthesia recovery, also decreased (P<.01). There was improved prevention of nausea and vomiting, and of poorly controlled pain. The proportion of afternoon admissions was significantly reduced (P<.01). The cancellations increased in 2011 (P<.01). CONCLUSIONS: The monitoring of quality parameters in day-case surgery has been a useful tool in our clinical and quality management. Globally, the unplanned transfer and cancellations have been within the quality standards and many of the indicators analysed have improved.

Guía en DVD en la Cirugía Mayor Ambulatoria. Análisis de los resultados iniciales / Ambulatory surgery DVD guide. Analysis of the initial results

Introducción: Con la intención de mejorar la calidad asistencial se ha producido colateralmente una mayor complejidad en los circuitos peroperatorios. Así, en nuestro centro hemos asistido en los últimos años a un incremento de los pasos que deben realizar los pacientes desde que son derivados al cirujano para ser valorado un posible tratamiento quirúrgico hasta la fecha de la operación. Todo ello puede ocasionar confusión y angustia al paciente, a pesar del soporte y de la información oral y escrita que recibe de los diferentes profesionales sanitarios que visita. Objetivos: Para paliar esta situación se realizó un DVD que es entregado al paciente en la primera visita del especialista. Dicho DVD da a conocer una visión general del circuito de la CMA de nuestro centro y detalla cada paso que deberá realizar. De esta forma, el paciente puede verlo en su domicilio todas las veces que considere oportunas. Su observación familiariza al paciente con nuestras instalaciones y el ambiente hospitalario, complementa las explicaciones orales y escritas entregadas para clarificar las dudas que todavía pudieran persistir y creemos ayuda a disminuir la ansiedad del enfermo ante este acontecimiento. Material y método: Voluntariamente, el paciente realiza na encuesta de satisfacción que es remitida varias semanas tras el alta. Los resultados se comparan con los de un grupo de control que han visualizado el DVD. Resultados: Actualmente el estudio no está finalizado. Se han recibido 35 encuestas de las entregadas a los pacientes de cirugía general, de las cuales solo a 13 pacientes se le había entregado el DVD. El 31% de los pacientes a los que se entregó el DVD no tuvieron interés en verlo, los que lo consultaron refieren que la información fue útil en el 100% de los casos. Comparando los que reciben DVD de los que no, referente a sus preferencias de ingreso, el 11% hubieran preferido ingresar en comparación al 14% del grupo a los que no se les entregó. El grado de satisfacción fue elevado en ambos grupos, 8,8 puntos sobre 10. Conclusiones: La información perioperatoria puede ser mejorada con la entrega de material audiovisual complementario. Esta herramienta sintetiza y aclara todas las etapas que debe realizar el paciente. Incrementa el grado de satisfacción y la calidad asistencial percibida del paciente de la CMA realizada en nuestro hospital (AU)

Introduction: Nowadays there is more complexity in the per-operative circuits as a collateral consequence of trying to improve the health care quality. In the last years, we have seen an increase in steps that patients should be at our hospital since they are derived to the surgeon to be valued a possible surgical treatment until the date of the operation. All this can cause confusion and distress to the patient, despite the support and the oral and written information received from different specialists visited. Objective: A DVD was made to remedy this situation that is delivered to the patient in the first surgeon's visit. This DVD gives a general vision of the circuit of the ambulatory surgery of our center and details of each step. In this way the patient can see it at his home every time he deems appropriate. Its observation familiarizes him with our facilities and the hospitable atmosphere, clarifies the doubts that could still persist and we believe helps to decrease his anxiety before this event. Material and method: The patient performs a satisfaction questionnaire and he returns it several weeks after discharge from hospital. The results are compared with those of a control group that not viewed the DVD. Results: Currently the study is not complete. There have been 35 surveys delivered to the general surgery patients, of which only 13 patients had been given the DVD. 31% of patients who gave the DVD had no interest in seeing it, those who report that looked at the information was useful in 100% of cases. Comparing those who received the DVD not concerning their preferences for income, 11% would have preferred to enter compared to 14% of the group to which they were not given. The degree of satisfaction was high in both groups, 8.8 ut of 10. Conclusions: The preoperative information can be improved with the delivery of additional audiovisual material. This tool summarizes and clarifies all the stages that the patient should perform, increases the degree of satisfaction and the perceived quality in the care of ambulatory surgery patient in our hospital (AU)

Epigenetic events in normal colonic mucosa surrounding colorectal cancer lesions.

Gene inactivation by promoter hypermethylation has been demonstrated in the colonic mucosa of colorectal cancer (CRC) patients. However, current data do not prove direct involvement of this epigenetic modification in the early stages of CRC. Promoter methylation profiles of E-cadherin, hMLH1, MGMT, p16(INK4a), p15(INK4b) and p14(ARF); mutations of K-ras, B-raf and TP53 and microsatellite instability (MSI) were examined in normal and cancerous colonic mucosal tissue in 82 CRC patients using methylation-specific PCR assays. Methylation of hMLH1 and MGMT in normal mucosa correlated significantly with MSI and K-ras activation in neighbouring cancerous mucosal tissues. Similarly, poorly differentiated tumours were associated with methylated p16(INK4a) and E-cadherin in neighbouring normal colonic tissues (NCTs). Our results indicate that epigenetic changes in mucosa surrounding colorectal neoplastic lesions may describe a 'field cancerisation' phenomenon that may occur previous to genetic alterations in early stages of carcinogenesis.

Preperitoneal repair for recurrent inguinal hernia: laparoscopic and open approach.

BACKGROUND: The aim of this study was to investigate the outcome of preperitoneal repair using laparoscopic (TEP) and open (OPM) approach in recurrent inguinal hernia. METHODS: We performed a prospective controlled nonrandomized clinical study in 188 patients with 207 recurrent inguinal hernias over a period of 5 years. TEP repair was employed for 86 repairs, and OPM was used in 121 procedures. The main outcome measurements were: recurrence rate, operating time, hospital stay, and postoperative complications. RESULTS: There were three recurrences (1.7%). Two in the OPM group (1.8%) and one (1.3%) in the TEP group [ P=NS (not significant)]. The TEP procedure was faster than OPM for unilateral repair (40.8 vs 46.3 min) (P<0.001). Postoperative complications were more frequent in the OPM group (23.9%) than the TEP group (13.9%) ( P=NS). Hospital stay was significantly shorter in the TEP group (1.2 vs 3.9 days) (P<0.001). CONCLUSIONS: Preperitoneal approach (open or laparoscopic) seems to be a good option in recurrent inguinal hernia when these procedures are done by experienced surgeons.

[Camptocormia: an infrequent muscular disease]. / Camptocormia: una enfermedad muscular infrecuente.

The camptocormia is an entity characterized by a kyphosis lumbar reductible in supine decubitus, associated to dysfunctions in computed tomography scans and histologics in the paravertebrals muscles of the lumbar segment. We contribute a new case corresponding to a 70 year-old woman with chronic lumbar pain and kyphosis dorsolumbar reductible, in who the on-line tomography showed compatible images with fatty degeneration and atrophy of the lumbar musculature, discoveries that were confirmed in the histologic study.

Tumor estromal extragastrointestinal. Peculiaridades en su semiología y terapéutica clínica / Extragastrointestinal stromal tumor. Semiology and clinical therapy peculiarities

Los tumores estromales gastrointestinales con localización extragastrointestinal son muy infrecuentes. Suelen diagnosticarse cuando presentan un gran tamaño. Su naturaleza benigna o maligna es difícil de determinar. Los mejores parámetros histológicos para evaluar su pronóstico son: un alto grado de celularidad, la presencia de necrosis tumoral y poseer más de dos mitosis por cincuenta campos. Presentamos el caso de una paciente asintomática que, por un control ecográfico rutinario por hepatopatía crónica por virus C, fue diagnosticada de un tumor mesentérico. La enferma fue tratada quirúrgicamente. El estudio inmunohistológico de la tumoración confirmó un tumor estromal gastrointestinal. El análisis del caso presentado y la bibliografía consultada sugieren unos hallazgos clínicos propios de esta entidad. Se revisa y actualiza la histogénesis de estas neoplasias y se destaca la utilidad de nuevos fármacos para el control de la progresión tumoral (AU)

Camptocormia: una enfermedad muscular infrecuente / Camptocormia: a infrequent muscular disease

La camptocormia es una entidad caracterizada por una cifosis lumbar reductible en decúbito supino, asociada trastornos tomodensitométricos e histológicos en los músculos paravertebrales del segmento lumbar. Aportamos un nuevo caso correspondiente a una mujer de 70 años con dolor lumbar crónico y cifosis dorsolumbar reductible, en quien la tomografia computarizada mostró imágenes compatibles con degeneración grasa y atrofia de la musculatura lumbar, hallazgos que se confirmaron en el estudio histológico (AU)

The camptocormia is an entity characterized by a kyphosis lumbar reductible in supine decubitus, associated to dysfunctions in computed tomography scans and histologics in the paravertebrals muscles of the lumbar segment. We contribute a new case corresponding to a 70 year-old woman with chronic lumbar pain and kyphosis dorsolumbar reductible, in who the on-line tomography showed compatible images with fatty degeneration and atrophy of the lumbar musculature, discoveries that were confirmed in the histologic study (AU)

Extra-gastrointestinal stromal tumour--semiology and clinical therapy peculiarities.

The gastrointestinal stromal tumor with extragastrointestinal location are very infrequent. We often diagnose them when they show a big size. Their bening or malignant nature is difficult to fix. The best histological parameters to evaluate their prognosis are a high cellularity, the tumor-like necrosis presence and having more than two mitosis per fifty high-power fields. We introduce an asyntomatic patient's case by a routine echographical control for chronic hepatitis by C virus, that has been diagnosed of a mesentery tumor. The patient has been treated surgically. The inmunohistological study of the tumor had confirmed a stromal gastrointestinal tumor. The showed case's analysis and the considered bibliography suggest some clinical discoveries characteristic of this entity. The histogenesis of these neoplasias are examined and made up to date and the usefulness of the new medication to control check the tumor-like progress is emphasized.

Circulating bile is the main factor responsible for atrial natriuretic peptide release in experimental obstructive jaundice.

BACKGROUND: Biliary obstruction in the rabbit causes increased release of atrial natriuretic peptide (ANP). Circulating bile, raised biliary pressure or absence of bile in the duodenum may be implicated in this hepatocardiac syndrome. METHODS: An experimental model was developed to elucidate the mechanism linking obstructive jaundice and increased plasma ANP. Hepatic and renal function, biliary tree pressure and ANP plasma concentrations were investigated in conscious rabbits 4 and 24 h after common bile duct ligation, biliovenous shunting or external drainage via a biliary fistula. RESULTS: Bilirubin concentration increased after bile duct ligation and creation of a biliovenous shunt. Plasma creatinine increased abruptly in rabbits with a biliovenous shunt. At 4 h, the ANP increase in animals with a biliovenous shunt was ninefold that observed after bile duct obstruction while no change was noted after external biliary diversion (mean 350 versus 45 versus 9 fmol/l; P < 0.01). Relief of biliary tree obstruction was associated with a return of ANP levels towards basal normal values. CONCLUSION: Raised plasma ANP in obstructive jaundice is not the result of an increased biliary pressure per se or absence of bile in the proximal duodenum but of the passage of bile components to the circulation.

Inadequate levels of metronidazole in subcutaneous fat after standard prophylaxis.

The efficacy of antibiotic prophylaxis depends on appropriate tissue levels of the drug being present at the time of potential wound contamination. Metronidazole concentrations in serum, muscle and subcutaneous fat were measured after a single intravenous dose given at two different intervals before operation. Twenty-six patients undergoing abdominal wall procedures were divided into two groups. Patients in group 1 received metronidazole 500 mg intravenously 2 h before surgery, and those in group 2 were given the drug during induction of anaesthesia. Mean plasma levels of metronidazole at the beginning of the procedure were significantly lower (P = 0.01) in group 1 (7.3 (95 per cent confidence interval 5.7-8.9)) micrograms/ml than in group 2 (12.3 (8.9-15.7)) micrograms/ml although in both cases were above the minimum inhibitory concentration for 90 per cent of Bacteroides fragilis. Similar therapeutic concentrations of metronidazole were achieved in plasma and muscle in both groups at the end of the operation. However, patients in both groups had non-therapeutic concentrations of metronidazole in subcutaneous fat: group 1 0.9 (0.6-1.2) micrograms/mg, group 2 1.2 (0.7-1.7) micrograms/mg at the beginning of operation, and 1.2 (0.8-1.6) and 1.5 (0.9-2.1) micrograms/mg respectively at the end of the procedure. It is concluded that infusion of metronidazole 2 h before surgery or during induction of anaesthesia achieved adequate plasma and muscle levels but failed to achieve therapeutic levels in subcutaneous fat.

[A randomized prospective study of antibiotic prophylaxis compared to lavage of the surgical wound in nonperforating appendicitis]. / Estudio prospectivo aleatorizado de la profilaxis antibiótica comparada con el lavado de la herida quirúrgica en apendicitis no perforada.

BACKGROUND: There are many doubts as to the efficacy of systemic antibiotic prophylaxis versus the methods of local treatment in the prevention of infection of the contaminated surgical wound. A controlled prospective study was designed to compare the effectiveness of a combination of parenteral antibiotics with lavage with physiologic serum of the surgical wound to prevent infection of the postappendectomy wound. METHODS: The patients in group A (antibiotic, n = 70) received a sole preoperative dose of methronidazol and gentamicin while in those in group I (irrigation, n = 71) the wounds were irrigated with physiologic serum prior to and following closure of aponeurosis. The patients were controlled at one week and one month after the intervention. RESULTS: The global rate of infection was 9.3%. Six patients of group A and five of group I developed wound infection (p = 0.06), The age and length of the intervention were significantly higher in the infected patients (41 vs 23 years, p = 0.0001 and 53 vs 41 minutes, p = 0.03, respectively). Intraperitoneal culture was positive in 70% of the patients who posteriorly developed wound infection, being positive in only 9.4% of the uninfected patients (p = 0.0001). Eight of the infections (73%) were detected following discharge from hospital. The cost of prophylaxis in group A was seven-fold higher than that of group I. CONCLUSIONS: Lavage of the surgical wound with physiologic serum may be an effective, safe and inexpensive method to prevent infection of the wound following appendicectomy for unperforated appendicitis.

Increased cardiac endocrine activity after common bile duct ligation in the rabbit. Atrial endocrine cells in obstructive jaundice.

OBJECTIVE: This study investigated the pathogenesis of water and sodium metabolism derangements in obstructive jaundice. SUMMARY BACKGROUND DATA: Obstructive jaundice is associated with hypodipsia, depletion of extracellular water, alterations of the water and sodium regulating hormones, and an increased incidence of renal failure. Plasma atrial natriuretic factor (ANF) increases after common bile duct ligation in the rabbit. The present study was designed to investigate ANF-secreting cardiac atrial cells in this animal model. METHODS: Plasma ANF and the percentage of atrial cells staining for ANF were determined in jaundiced and sham-operated rabbits at 24 (group OJ-24, n = 11; group SO-24, n = 5) and 72 hours (group OJ-72, n = 11; group SO-72, n = 5) after surgery. The atrial ANF content was also determined. RESULTS: Plasma ANF was higher in jaundiced animals than in controls both at 24 (63 +/- 44 fmol/mL vs. 17 +/- 10 fmol/mL, p < 0.02) and at 72 hours (73 +/- 49 fmol/mL vs. 12 +/- 11 fmol/mL). In the two OJ groups, the percentage of positive ANF cells per 200-power field in the right atrial appendage was higher than in the SO groups both at 24 (62 +/- 11% vs. 31 +/- 12%, p < 0.003) and at 72 hours (56 +/- 18% vs. 31 +/- 12%, p < 0.01). Similar results were obtained in the right auricular wall. The percentage of positive ANF cells was significantly higher in the left atrium in which significant differences between the OJ and SO groups were also noted. The right atrial ANF content was higher in the OJ than in SO groups (437 +/- 323 pmol/mg of protein vs. 83 +/- 44 pmol/mg of protein). CONCLUSIONS: Cardiac endocrine activity is increased in experimental obstructive jaundice. ANF may be involved in the pathogenesis of the renal and water and sodium metabolic disturbances present in this disease.

Rapid increase in plasma levels of atrial natriuretic peptide after common bile duct ligation in the rabbit.

Previous studies have shown that common bile duct ligation in the rabbit is followed by a reduction of the extracellular water compartment. To further elucidate the mechanisms leading to volume depletion in this model, water and sodium balances and changes in plasma concentrations of atrial natriuretic peptide (ANP), vasopressin (ADH), plasma renin activity (PRA) and aldosterone (Ald) were investigated during the first 4 days after common bile duct ligation (group OJ,) or sham operation (group SO). Water and chow intakes were lower in group OJ (148 +/- 30 versus 226 +/- 40 mL/4 days; p = 0.004 and 12 +/- 9 versus 171 +/- 40 g/4 days; p = 0.0001). There were no differences in urine output. Sodium urinary losses were marginally higher in group OJ (12.4 +/- 7 versus 6.7 +/- 5 mEq/4 days; p = 0.06). Water balance was lower in group OJ (-50 +/- 56 versus 101 +/- 71 mL/4 days; p = 0.0001). At 24 hours, plasma ANP (41 +/- 7 versus 10.7 +/- 1 fmol/mL, p = 0.0001), ADH (21.8 +/- 7 versus 12.3 +/- 6 pg/mL, p = 0.008) and Ald (14.5 +/- 5 versus 3.7 +/- 3 ng/dL, p = 0.001) were higher in group OJ. These alterations persisted 72 hours after bile duct ligation, when a concomitant increase in PRA (10.7 +/- 5 versus 3 +/- 1.6 ng/dL, p = 0.006) was also observed. A group of pair-fed pair-watered sham-operated controls (group SO2, n = 13) showed a metabolic profile similar to group OJ but a low ANP concentration. Multiple venous sampling in five rabbits 24 hours after bile duct ligation showed the highest plasma levels of ANP in the aorta and infrarenal vena cava. These results suggest that common bile duct ligation in the rabbit is followed by marked hypodipsia and hypophagia, possibly mediated by ANP, leading to isotonic volume depletion and secondary activation of the water and sodium retaining hormones.

Body water compartments in patients with obstructive jaundice.

To elucidate the pathogenesis of renal dysfunction associated with obstructive jaundice, body water compartments were measured using a multi-isotope dilution technique in ten patients with biliary tract obstruction and in ten control subjects matched for age, sex, weight, height and body surface area. Expressed as a fraction of body-weight, total body water was reduced in jaundiced patients (41.8 versus 46.2 per cent, P less than 0.02). Extracellular water volume was also reduced in patients with jaundice (20.3 versus 24.3 per cent, P less than 0.003) owing to a reduction of the interstitial space (16.1 versus 19.5 per cent, P less than 0.004) and, to a lesser degree, of the plasma volume (4.2 versus 4.8 per cent, P = 0.1). There was a close correlation in jaundiced patients between plasma volume and the creatinine clearance rate (r2 = 0.56, P less than 0.02) and between plasma volume and extracellular volume (r2 = 0.77, P less than 0.0001). Extracellular volume in such patients also correlated with the percentage weight loss (r2 = 0.42, P = 0.04). Obstructive jaundice is associated with a contracted extracellular water compartment, although extracellular water, as a percentage of body-weight, increased in proportion to the body-weight lost. Reduction of the interstitial volume and a marginally reduced plasma volume may be determinant factors in the pathogenesis of the renal and haemodynamic disturbances observed in patients with biliary tract obstruction.

Reduced water and sodium intakes associated with high levels of natriuretic factor following common bile duct ligation in the rabbit.

Renal failure complicating obstructive jaundice (OJ) is probably linked to reduction of the extracellular water compartment. To elucidate the mechanism by which OJ leads to isotonic water depletion we studied a group of rabbits with OJ after common bile duct ligation (n = 17) and another group of sham operated rabbits (n = 14) for 10 days. Water intake and balance for two study periods (1-4 and 7-10 days after operation) were calculated. Renal function, sodium balance and plasma atrial natriuretic factor were determined on the fourth and tenth days after operation. Water intake and balance were lower in the OJ group both in the first study period (230 versus 519 ml/days 1-4, P less than 0.001; and -2.4 versus 219 ml/days 1-4, P less than 0.0001 respectively) and in the second study period (260 versus 865 ml/days 7-10, P less than 0.0001; and 11 versus 379 ml/days 7-10, P less than 0.0001 respectively). Sodium intake was negligible in the OJ group both on day four (0.73 versus 7.15 mM/24 h, P less than 0.0001) and on day 10 (0.78 versus 15.78 mM/24 h, P less than 0.0001). As a result plasma osmolality did not change. Day 10 urine osmolality and osmolar clearance were reduced in the OJ group (653 versus 1103 mOsm/kg, P less than 0.0001 and 0.09 versus 0.25 ml/min, P less than 0.0001 respectively) together with a decreased creatinine clearance (3 versus 11 ml/min, P less than 0.0001). Atrial natriuretic factor was increased in jaundiced rabbits (day 4, 22.7 versus 7.5 fmol/ml, P less than 0.0001; and day 10, 26.5 versus 11.2 fmol/ml, P less than 0.02). These findings suggest that OJ leads to an isotonic volume depletion resulting from abnormalities of the extracellular volume regulating mechanisms. These appear to be secondary to an inappropriate elevation of the atrial natriuretic factor plasma concentration.

[Upper digestive hemorrhage as a complication of postoperative reflux gastritis]. / Hemorragia digestiva alta como complicación de la gastritis postoperatoria por reflujo.

Seven cases of upper gastrointestinal hemorrhage after gastroduodenal surgery are presented; in all the cases the pyloric region had been resected or excluded. The gastritis was documented by endoscopy and/or surgery; it was located in the area proximal to the anastomosis. There were no other causes of bleeding. In five cases the hemorrhage was controlled with medical treatment. In one case it was necessary to operate on urgently. Another case was that of a recurrent hemorrhage after surgery for bleeding peptic ulcer located in the anastomosis. We emphasize the possibility of acute gross hemorrhage as a complication of reflux gastritis; the common clinical finding of previous treatment with antiinflammatory drugs; and the rarity of this lesion as the cause of gastrointestinal hemorrhage and as a complication of postoperative reflux gastritis.

Treatment of 27 postoperative enterocutaneous fistulas with the long half-life somatostatin analogue SMS 201-995.

Twenty-seven patients with postoperative enterocutaneous fistulas were treated with parenteral nutrition and SMS 201-995 (100 micrograms/8 hours, subcutaneously), a long half-life somatostatin analogue. At the time SMS 201-995 was started, 11 patients had low output fistulas (less than 1000 ml/48 hours), 11 patients had high output fistulas (above 1000 ml/48 hours), and 5 patients had fistulas sitting in large abdominal wall defects. Within 24 hours of treatment, a mean reduction of 55% of the fistula output was observed. Fistula site or output before treatment had no influence on the magnitude of output reduction. Spontaneous closure was achieved in 77% of the patients after a mean of 5.8 +/- 2.7 days of treatment with this drug. Two patients died (7.4%). Pain at the injection site was referred by 15% of the patients but no other side effects were observed. Glucose intolerance was not observed. SMS 201-995 has been shown to be very useful in the conservative treatment of enterocutaneous fistulas because of its ability to rapidly reduce fistula output and accelerate spontaneous closure.