Bidirectional endoscopy in patients with fecal occult blood.

BACKGROUND: Current screening protocols for colorectal cancer depend primarily on fecal occult blood testing (FOBT). However, positive test results do not always indicate the presence of a colonic neoplasm. METHODS: We reviewed the results of 100 consecutive bidirectional (upper and lower) endoscopic procedures performed to evaluate positive FOBT results. Patients were excluded if they presented with gross bleeding, a history of bowel lesions, or previous intestinal operations. There were 31 women and 69 men whose mean age was 51 years. RESULTS: Major abnormalities were found on esophagogastroduodenoscopy (n = 24), colonoscopy (n = 13), or both studies (n = 2). Active bleeding was manifested in two patients, (Barrett's ulcer, duodenal arteriovenous malformation). Two other patients had malignancy: One had a cecal adenocarcinoma and the other a gastric adenocarcinoma. Various benign lesions also were identified in the stomach including esophagitis (n = 8), ulcers/erosions (n = 8) varices (n = 5), and arteriovenous malformations (n = 2). Colonic pathology included polyps (n = 8), arteriovenous malformations (n = 3), and rectal varices (n = 1). Diverticulosis and hemorrhoidal disease were present in 29 and 16 patients, respectively, but were not considered to be likely sources of a positive FOBT. CONCLUSION: Positive FOBT results may indicate the presence of either upper or lower intestinal pathology, and bidirectional endoscopy is an efficient and accurate technique for the comprehensive evaluation of occult bleeding.

Comparación del estado ácido-base en sangre del cordón en pacientes postcesárea y su relación con la técnica anestésica / The acid base values of umbilical cord arterial blood of post cesarean newborns

Objetivo: Se ha cuestionado si las técnicas conductivas, específicamente la espinal se asocia o no a mayor acidosis. Se pretende comparar en una población obstétrica normal, los valores ácido- base en sangre arterial del cordón de los recién nacidos postcesarea, con las diferentes técnicas anestésicas y determinar la frecuencia y el tipo de acidosis. Metodología: Se efectúo un estudio cuasiexperimental no aleatorio. 274 pacientes fueron incluidas: 109 asignadas al grupo de anestesia peridural, 109 al grupo de anestesia espinal y 56 al grupo de anestesia general. La muestra se calculo con un poder de 85 por ciento, confiabilidad 95 por ciento y RR de 2. Se determinó electrónicamente las mediciones hemodinámicas en la madre. En sangre arterial placentaria: PH, PCO2, PO2, bicarbonato y base déficit y en el recién nacido el Apgar y las complicaciones neonatales. Resultados: Se hizo análisis multivariado con regresión logística, análisis de varianza y Chi2. No se encontró asociación al evaluar los diferentes tipos de acidosis y las variables independientes, así como tampoco se encontró mayor frecuencia de acidosis con ninguna de las tres técnicas anestésicas utilizadas. Es reconocido hoy que los limites de normalidad son más bajos (PH = 7.00), lo que explicaría las diferencias con otros estudios. Conclusiones: Los resultados sugieren que ningún método anestésico es necesariamente más peligroso o seguro que otro, ni se asocia a mayor acidosis

Metástasis en los sitios de puertos en cirugía laparoscópica del cáncer de colon / Port-site metastases in laparoscopic surgery for cancer of the colon

El primer reporte de una metastasis en el sitio del puerto laparoscopico aparecio en 1978; con la extension de la tecnica laparoscopica para procedimientos que involucran casi cualquier organo de la cavidad abdominal, el numero de informes se ha incrementado notablemente. Se hace una revision de la literatura acerca de las metastasis en sitios de puertos en la cirugia laparoscopica del colon por carcinoma y con enfasis sobre los posibles mecanismos que han sido implicados en el desarrollo de estas siembras. Anotamos algunas maniobras que pudieran contribuir a disminuir la incidencia de las mismas. Si bien los beneficios de la cirugia laparoscopica se basan en la disminucion de la morbilidad quirurgica a corto plazo al evitar las complicaciones asociadas con la herida quirurgica, lo cual contribuye a una recuperacion más rápida y a una pronta incorporacion a las actividades usuales, todos estos beneficios serian irrelevantes si con esta tecnica estuvieramos aumentando las posibilidades de recurrencia tumoral y, por lo tanto, disminuyendo la supervivencia.

Jejunoileal causes of overt gastrointestinal bleeding: diagnosis, management, and outcome.

Major bleeding from the small intestine is uncommon and difficult to localize. We examined its etiologies and assessed available diagnostic and therapeutic approaches. The records of all adults undergoing operation for small intestinal hemorrhage over a 10-year period (1/89-12/98) were reviewed. There were eight men and four women with a mean age of 54 years. Six patients presented with arteriovenous malformations. Preoperative diagnosis was by endoscopy (three of six), scintigraphy (two of two), and/or angiography (two of six). Intraoperative panendoscopy was used for localization in 5 cases. Three other patients had tumors (leiomyoma, leiomyosarcoma, and adenocarcinoma) by CT scan (two) and/or scintigraphy (two). All were resected but one patient died of recurrence. Two patients underwent resection of a Meckel's diverticulum, one after angiographic diagnosis. Another patient with Crohn's disease had a positive angiogram and colonoscopy before resection. There were no operative deaths but major morbidity occurred in five patients (42%) and hospitalization averaged 17 days. We conclude that jejunoileal lesions are a rare cause of intestinal bleeding but can be associated with substantial morbidity. Arteriovenous malformations and tumors remain the most common causes. An accurate diagnosis and definitive management depend on selective preoperative imaging and judicious operative exploration.

Outcome analysis of external coloanal anastomosis.

BACKGROUND: To evaluate the safety and efficacy of treating low-lying rectal lesions with resection and primary repair using a pull-through technique with rectal stump eversion and external coloanal anastomosis with immediate reintroduction into the pelvis. METHODS: All coloanal anastomoses with the above technique on the Gastrointestinal Surgery Service at the University of Pittsburgh from March 1990 to September 1995 were evaluated. RESULTS: Fifty-two patients underwent coloanal anastomoses with the above technique, and follow-up was available for 96% (50 of 52) of patients. Rectal lesions in the 50 patients included cancer (n = 34), rectal adenomas (n = 13), and other lesions (n = 3). Mean follow-up period was 29.6 +/- 21.8 months (28.5 months for patients with carcinoma). Fecal continence was normal or good in 88% (44 of 50) of patients. Moderate or complete incontinence was present in 12% (6 of 50) of patients. The local recurrence rate of rectal cancer was 0%. Morbidity occurred in 22% (11 of 50) of patients. Survival was 90% (45 of 50 patients). CONCLUSIONS: Coloanal anastomosis with this technique provides effective treatment for low-lying malignant or benign rectal lesions and has an acceptable complication rate.

Tratamiento del paciente con sospecha de coledocolitiasis: contribución de la colangioscopia flexible / Management of the patient with suspected choledocholithiasis: value of flexible cholangioscopy

Se realizo un estudio observacional, descriptivo y prospectivo en el "Hospital General de Medellin ", desde octubre de 1993 hasta septiembre de 1995. Se practico exploracion de la via biliar y colocacion de tubo en T a 113 pacientes en quienes se sospechaba Coledocolitiasis. A todos se les hizo seguimiento clinico y colangiografia postoperatoria de conrol. La incidencia global de litiasis residual fue 8.8 por ciento (n=0). Los pacientes se dividieron en tres grupos de acuerdo con la ayuda diagnostica utilizada durante la cirugia, asi: 17 con colangioscopia flexible; 49 con colangiografia, y 26 ayuda diagnostica. El grupo con colangioscopia demostró tener la menor incidencia (n= 1:2.6 por ciento) de coledocolitiasis residual (p= 0.0745). La colangioscopia demostro ser de fácil manejo y sirvio, además, para la extraccion de calculos retenidos, a traves del trayecto del tubo en T. El ilangioscopio flexible parece ser un avance importante para el tratamiento y postoperatorio de la coledocolitiasis.

Early enteral nutrition in gastrointestinal surgery: a pilot study.

There is still some concern about the safety of early enteral nutrition (EN) to patients with recent anastomoses. A pilot trial was carried out on a prospective basis to evaluate the tolerance and clinical outcome of 56 patients who received early EN following gastrointestinal (GI) surgery. A continuous infusion of an elemental, peptide-based diet was administered using a nasointestinal feeding tube placed beyond the pylorus by the operating surgeon. Tube feeds were started at 6.07 +/- 4.99 h after surgery and advanced as tolerated to a rate of 60 mL/h on the third postoperative day. Patients received the diet either proximal or distal (in the case of gastrectomies) to their recent anastomosis. Forty-six patients met the inclusion criteria and were included in the analysis. EN was well tolerated with a low incidence of side effects (19.5%), nausea and vomiting being the most frequent. Oral feeding was started 2.89 +/- 1.28 d after surgery. There was one case of small bowel suture leakage, but no relationship to the tube feeding was established. Early EN appears to be a useful and safe therapeutic alternative for the postoperative management of patients undergoing GI surgery. It may contribute to faster recovery of bowel function and lead to a shorter hospital stay. Careful selection of patients is necessary in order to obtain the greatest benefit of early enteral feeding in this patient population.