Fiber optic bronchoscopy-assisted percutaneous tracheostomy: a decade of experience at a university hospital

Objective

To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation.

Methods

Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates.

Results

The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma.

Conclusion

Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using a standardized procedure.

High-volume hemofiltration and prone ventilation in subarachnoid hemorrhage complicated by severe acute respiratory distress syndrome and refractory septic shock

We report the successful treatment of two patients with aneurismal subarachnoid hemorrhage complicated by severe respiratory failure and refractory septic shock using simultaneous prone position ventilation and high-volume hemofiltration. These rescue therapies allowed the patients to overcome the critical situation without associated complications and with no detrimental effects on the intracranial and cerebral perfusion pressures. Prone position ventilation is now an accepted therapy for severe acute respiratory distress syndrome, and high-volume hemofiltration is a non-conventional hemodynamic support that has several potential mechanisms for improving septic shock. In this manuscript, we briefly review these therapies and the related evidence. When other conventional treatments are insufficient for providing safe limits of oxygenation and perfusion as part of basic neuroprotective care in subarachnoid hemorrhage patients, these rescue therapies should be considered on a case-by-case basis by an experienced critical care team.

Central venous saturation in septic shock: co-oximetry vs gasometry

OBJECTIVES

Central venous oxygen saturation calculated by gasometry (Gaso-Scvo2) is more available than central venous oxygen saturation measured by co-oximetry (Co-oxy-Scvo2) in environments with less resources and underdeveloped countries. Therefore, we aimed to determine the agreement between Co-oxy-Scvo2 and Gaso-Scvo2 and between central venous oxygen tension measured by gasometry (Gaso-Pcvo2) and Co-oxy-Scvo2, respectively.

DESIGN AND SETTINGS

This is a prospective study in a university hospital's intensive care unit.

PATIENTS

Sixteen patients were studied during the first 48 hours after diagnosis of septic shock. All patients were intubated, connected to mechanical ventilation, and resuscitated according to the standards of care.

MEASUREMENTS AND RESULTS

One hundred eleven pairs of central venous blood measurements were analyzed both by conventional gasometry and co-oximetry. Bland and Altman analysis between Co-oxy-Scvo2 and Gaso-Scvo2 showed lack of agreement (1.7 [-10.7, +14.2]). A Gaso-Scvo2 less than 70% had a positive predictive value of 63% in relation to Co-oxy-Scvo2, and its negative predictive value was 90% with 20% false-positives and 5% false-negatives. The area under the receiver operator characteristic curve of Gaso-Pcvo2 to discriminate a Co-oxy-Scvo2 greater than or equal to 70% was 0.87 (confidence interval, 0.80-0.93), and the best cut-off point was a Gaso-Pcvo2 more than 40 mm Hg, (sensitivity, 75%; specificity, 93%).

CONCLUSIONS

The reliability of Gaso-Scvo2 determination during the resuscitation phase of septic shock is not acceptable. There is a good agreement between a Gaso-Pcvo2 more than 40 mm Hg and a Co-oxy-Scvo2 greater than or equal to 70%. Our results suggest that given these limitations, Gaso-Scvo2 results should be interpreted with caution, helped by Gaso-Pcvo2 measurements and in context with other perfusion parameters.

Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome

RATIONALE

Positive end-expiratory pressure (PEEP) and prone positioning may induce lung recruitment and affect alveolar dynamics in acute respiratory distress syndrome (ARDS). Whether there is interdependence between the effects of PEEP and prone positioning on these variables is unknown.

OBJECTIVES

To determine the effects of high PEEP and prone positioning on lung recruitment, cyclic recruitment/derecruitment, and tidal hyperinflation and how these effects are influenced by lung recruitability.

METHODS

Mechanically ventilated patients (Vt 6 ml/kg ideal body weight) underwent whole-lung computed tomography (CT) during breath-holding sessions at airway pressures of 5, 15, and 45 cm H2O and Cine-CTs on a fixed thoracic transverse slice at PEEP 5 and 15 cm H2O. CT images were repeated in supine and prone positioning. A recruitment maneuver at 45 cm H2O was performed before each PEEP change. Lung recruitability was defined as the difference in percentage of nonaerated tissue between 5 and 45 cm H2O. Cyclic recruitment/de-recruitment and tidal hyperinflation were determined as tidal changes in percentage of nonaerated and hyperinflated tissue, respectively.

MEASUREMENTS AND MAIN RESULTS

Twenty-four patients with ARDS were included. Increasing PEEP from 5 to 15 cm H2O decreased nonaerated tissue (501 ± 201 to 322 ± 132 grams; P < 0.001) and increased tidal-hyperinflation (0.41 ± 0.26 to 0.57 ± 0.30%; P = 0.004) in supine. Prone positioning further decreased nonaerated tissue (322 ± 132 to 290 ± 141 grams; P = 0.028) and reduced tidal hyperinflation observed at PEEP 15 in supine patients (0.57 ± 0.30 to 0.41 ± 0.22%). Cyclic recruitment/de-recruitment only decreased when high PEEP and prone positioning were applied together (4.1 ± 1.9 to 2.9 ± 0.9%; P = 0.003), particularly in patients with high lung recruitability.

CONCLUSIONS

Prone positioning enhances lung recruitment and decreases alveolar instability and hyperinflation observed at high PEEP in patients with ARDS.

[Celiac disease: descriptive study at the Anglo American clinic]

BACKGROUND

Celiac disease (CD) is a condition in which gluten intake develops an autoimmune response generating intestinal villous atrophy, causing malabsorption. Prevalence worldwide is approximately 1%, in our country it is not known.

MATERIAL AND METHODS

Retrospective, descriptive, observational study in Anglo American Clinic between September 2004 and February 2012. We reviewed the medical charts, upper GI endoscopy reports and duodenal biopsy reports of all patients with positive anti TTG results, who were older than 18 years of age.

RESULTS

We studied 39 cases, 26 (66.7%) women and 13 (33.3%) men. Mean age was 61.25 years. The symptoms were chronic diarrhea in 32 (82.1%), abdominal pain in 22 (56.4%), abdominal distention in 14 (35.9%), and others in lower frequency. Eight (20.5%) patients had anemia. Just 5 (12.8%) had upper endoscopy findings consistent with CD, and Marsh classification was: 0: 5 (12.7%), I: 1 (2.6%), II: 0 (0%), IIII A: 20 (51.3%), III B: 12 (30.8%) y III C: 1 (2.6%).

CONCLUSIONS

CD should be considered as a differential diagnosis of patients with non-specific long-term gastrointestinal symptoms, extraintestinal symptoms should also be taken into account. Diagnosis should be made with anti TTG as the initial test and posteriorly with a duodenal biopsy for staging.

Systematic approach for severe respiratory failure due to novel A (H1N1) influenza

AIM

In April 2009, a novel influenza A (H1N1) virus appeared in Mexico. It rapidly acquired the characteristics of a pandemic disease. Our objective is to present a case series of mechanically ventilated patients with severe influenza, treated with a systematic approach.

METHODS

Prospective, observational, single-center study in a University Hospital. A (H1N1) virus was confirmed by rRT-PCR. In this report, we only considered patients that required mechanical ventilation (MV). All patients received antibiotics, steroids and oseltamivir from the time of admission. The main strategies incorporated in the systematic approach were a lung-protective strategy, PEEP adjusted for each patient, protocol-guided sedoanalgesia, restrictive fluid management, weaning protocol, and prolonged prone ventilation and extracorporeal membrane oxygenation (ECMO) as rescue therapies.

RESULTS

We studied 19 patients: age 41 ± 13 years old, APACHE II 16 ± 7 and SOFA 8 ± 4. All patients presented PaO2/FiO2 ≤ 200 before connection to MV. Their worst values within the first 24 hours for oxygenation index, PaO2/FiO2, and PaCO2 on MV were 21.8 ± 13, 98 ± 39, and 48 ± 16 mmHg, respectively. Sixteen patients achieved ARDS; three exhibited acute lung injury criteria. Ten required a prone position, and two required ECMO (one patient required both therapies). Time on MV was 16 ± 13 days. Length of stay in the ICU and in hospital was 18 ± 12 and 28 ± 17 days, respectively. Mortality was 21%.

CONCLUSION

Severe hypoxemia and a high rate of rescue therapies were observed among our patients. Nevertheless, mortality was lower than previously reported in comparable populations, which may be related to the management by a critical care team and the use of a systematic approach for ventilatory and non-ventilatory therapeutic strategies.

Organizing pneumonia in patients with severe respiratory failure due to novel A (H1N1) influenza

The authors describe two cases that developed organizing pneumonia (OP) associated with novel influenza A(H1N1) virus. These patients were admitted to intensive care unit (ICU) because of severe respiratory failure. After initial clinical improvement, both patients worsened their condition during their second week of ICU stay, presenting fever, increasing in inflammatory parameters and worsening in oxygen exchange and respiratory mechanics. Chest x-rays and computed tomographies showed an increment on lung infiltrates, given by areas of consolidation and ground glass opacification. Although broad-spectrum antibiotics were administered, patients showed no improvement. All cultures, including bronchoalveolar lavage samples, were negative. In both cases, an open lung biopsy was performed, and histopathological examination of the specimen was compatible with OP. Both patients were successfully treated with high-dose corticoids. The aim of this report is to alert about the possibility of OP associated with novel influenza virus in patients with severe respiratory failure.

[Long term survival of patients operated for early gastric cancer]

BACKGROUND

Early gastric cancer involves mucosa and submucosa, independent of lymph node involvement. Radical gastrectomy is the standard treatment.

AIM

To assess long term survival of patients operated for an early gastric cancer.

MATERIAL AND METHODS

Retrospective review of medical and pathology records of patients subjected to a gastrectomy for an early gastric cancer, between 1975 and 2002. All were treated using a standardized protocol and staged according to 2002 TNM classification of the American Joint Committee of Cancer (AJCC). Demographic and pathologic features, operation performed and long term survival were recorded. Survival was analyzed using Kaplan-Meier method.

RESULTS

The series is comprised by 64 males and 41 females aged 61 +/- 1 years. Tumor was located in the upper third of the stomach on 33 subjects and a total gastrectomy was performed in 53. Pathology showed an intestinal type adenocarcinoma in 82 and a diffuse type in 23. In patients with involvement of mucosa and submucosa, 24 +/- 14 and 22 +/- 14 lymph nodes were excised, respectively. Lymph node involvement was present in 8% and 22% of patients with involvement of mucosa and submucosa, respectively. Five years survival was 94% and 78% in patients without and with lymph node involvement, respectively. Survival among patients in stage IA and IB was 94% and 76%, respectively. Multivariate analysis showed that the lymph node involvement was an independent mortality risk factor.

CONCLUSIONS

Total gastrectomy in patients with early gastric cancer is associated with a good survival. Lymph node involvement is a mortality risk factor.

[Prolonged prone position ventilation for severe respiratory distress syndrome post-pneumonectomy. Report of one case]

Management of patients with severe respiratory failure is mainly supportive, and protective mechanical ventilation is the pivotal treatment. When conventional therapy is insufficient to improve oxygenation without deleterious effects, other strategies should be considered. We report a 53 year-old male who presented a severe respiratory failure refractory to conventional management after pneumonectomy. Prone position ventilation was used for 36 hours. Respiratory variables improved and he did not show hemodynamic instability. He was returned to the supine position without worsening of oxygenation parameters. Extended prone position ventilation could be considered in patients presenting with unresponsive severe respiratory failure after pulmonary resection.

[Gastric adenocarcinoma appearing 32 years after the resection of a gastric lymphoma. Report of one case]

The association of gastric lymphoma and gastric adenocarcinoma in the same patient is uncommon. We report a 76 year-old male with a previous history of massive upper gastrointestinal bleeding who required a subtotal gastrectomy with Billroth II reconstruction in 1974. Pathology demonstrated a gastric lympho-histiocytic non-Hodgkin's lymphoma. The patient received complementary radiotherapy and was followed with annual endoscopies for 23 years. In 2006, he presented with fatigue. An upper gastrointestinal endoscopy showed an ulcerated and proliferative lesion at the gastric stump. Biopsy demonstrated a gastric adenocarcinoma. Gastric stump resection with lymph node dissection was performed. Pathology of the excised specimen showed a moderately differentiated tubular adenocarcinoma of the gastrojejunal anastomoses which infiltrated up to the subserosa. Additionally lymphatic permeations were observed and 10 of the 16 excised lymph nodes were invaded by the tumor.

[Gastric cancer in patients older than 75 years. Surgical treatment and long-term survival]

INTRODUCTION

The characteristics and results of radical gastrectomy for gastric cancer in elderly patients are controversial. Aim. To analyze the clinicopathologic characteristics and the results of gastrectomy for cancer in a group of patients > or = 75 year old.

MATERIAL AND METHOD

A series of 442 patients who underwent surgery for gastric cancer was divided into group A (< 75 years old) and group B (> or = 75 years old). The clinicopathologic characteristics, results of gastrectomy, and long-term survival were compared.

RESULTS

The mean age was 62 +/- 13 years. There were 361 patients in group A and 81 patients in group B. Tumoral location in the upper third of the stomach was more frequent in group A than in group B (36.8% vs 24.7%), while localization in the lower third of the stomach was more frequent in group B than in group A (50.6% vs 29.4%) (p < 0.05). Total gastrectomy was performed in 66% of patients in group A and in 38% of those in group B (p < 0.05); 27.3 +/- 3.5 nodes were resected in group A and 19.5 +/- 0.7 in group B (p < 0.05). No differences were found in the frequency of complications (16%) or in overall operative mortality between the two groups. However, mortality in total gastrectomy was higher in group B (6.4%) than in group A (3.8%) (p < 0.05). No differences in 5-year survival were found between the two groups (44.3% in group A and 44.4% in group B).

CONCLUSIONS

In patients aged more than 75 years old, tumors were more frequently located in the distal third of the stomach. Age above 75 years does not seem to be a prognostic factor and long-term results depend more on disease stage.

Intra-abdominal hypertension: incidence and association with organ dysfunction during early septic shock

PURPOSE

The objective of this article is to study the cumulative incidence of intra-abdominal hypertension (IAH) in septic shock (SS) patients during the first 72 hours of intensive care unit (ICU) admission and to determine if the presence and severity of IAH are associated with sepsis morbidity and mortality.

MATERIALS AND METHODS

Eighty-one consecutive SS patients admitted to a surgical-medical ICU of an academic university hospital (January 2005 to January 2006) were included. Intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) were measured every 6 h (intermittently) for 72 h. Intra-abdominal pressure was registered as minimal, mean, and maximal values per day, during shock and throughout the study period. Intra-abdominal hypertension was diagnosed if IAP remained 12 mm Hg or higher on 2 consecutive measurements and stratified according to the most recent consensus definition (www.wsacs.org).

RESULTS

According to maximal and mean IAP values, 67 (82.7%) and 62 (76.5%) of the patients developed IAH during the study period, respectively. Mean IAP values remained stable throughout the study period. Surgical patients had a higher incidence of IAH than medical patients (93% vs 73%, P < .009). Maximal IAPs were normally distributed, with nonsurvivors exhibiting significantly higher IAP levels during shock (survivors, 17.2 +/- 5.3; nonsurvivors, 19.9 +/- 5.6 mm Hg; P < .04). Patients with IAH exhibited significantly lower values of APP and diuresis, higher values of lactate and creatinine, and higher maximal norepinephrine doses, and were more frequently mechanically ventilated (P < .05 for all). Increasing degrees of IAH and the development of the abdominal compartment syndrome were associated with lower APP and higher maximal serum creatinine levels (P < .03 for both).

CONCLUSIONS

Septic shock patients have a very high incidence of IAH, which seems to be associated with the severity of shock and could be related to the development of organ dysfunctions, particularly renal dysfunction. Intra-abdominal pressure should be routinely monitored during the course of SS.

[Intraductal papillary mucinous neoplasm of the pancreas]

Intraductal papillary mucinous neoplasm of the pancreas is characterized by a dilatation of the main pancreatic duct and/or secondary ducts, mucin production and the absence of ovarian-like struma. The symptoms are non-specific and often the diagnosis is incidental. The treatment of choice is surgery, since these tumors may become malignant. The prognosis depends on the type of lesion, whether the excision is complete and lymph node involvement. The aim of this review is to analyze the clinical, diagnostic, therapeutic and pathological characteristics of this disease.

[Bouveret syndrome: report of four cases]

Bouveret syndrome is a duodenal obstruction caused by a biliary stone.

AIM

To report patients with Bouveret syndrome.

MATERIAL AND METHODS

Retrospective review of medical records of patients with Bouveret syndrome treated between 1976 and 2006.

RESULTS

We report three women and one man with a mean age of 62.5 years. None had a previous diagnosis of cholelithiasis. AH presented with colicky pain in the right upper quadrant and vomiting, suggesting gastric retention. The diagnosis was suspected after a barium meal in two patients and with a CT scan on the other two. The endoscopical extraction or fragmentation of stones was attempted in three patients but was successful only in one. Three patients were operated and a stone impacted in the first portion of the duodenum was identified, along with a cholecystoduodenal fistula. A duodenostomy and stone extraction was performed. One patient was subjected to a cholecystectomy fistula repair and gastrojejunoanastomosis. No patient died and all were discharged within 8 to 12 days after surgery.

CONCLUSIONS

Bouveret syndrome is an uncommon complication of cholelithiasis. Endoscopy can be diagnostic and therapeutic. Surgery is the other therapeutic option.

[Splenic abscesses. Report of seven cases]

BACKGROUND

Splenic abscesses are uncommon, appear in subjects with predisposing factors such as systemic infections and have high mortality rates.

AIM

To report seven patients with splenic abscesses.

MATERIAL AND METHODS

Retrospective review of medical records of patients with a splenic abscess treated between 1987 and 2005.

RESULTS

The records of four women and three males aged 20 to 74 years, were reviewed. The most common presenting symptoms were fever and abdominal pain and all had predisposing factors. Six patients had a leukocyte count of 19,500 x mm(3). Mean erythrocyte sedimentation rate and C reactive protein values were 75 mm/h and 13.5 mg/dl. Diagnosis was made with ultrasound in two patients and CT scan in five. Six patients had an unique abscess and one patient had multiple lesions. A splenectomy was done in three patients as the first choice treatment and in one, due to medical treatment failure. In two patients, a CT guided percutaneous drainage was performed and one patient was subjected to medical treatment only. Abscess cultures were positive in 50% of patients subjected to percutaneous drainage and in 50% of splenectomized patients. No patient died and no complications were observed in the early or late postoperative period.

CONCLUSION

Splenic abscesses are associated to predisposing conditions. The first choice is surgical treatment, but percutaneous drainage is also a therapeutic option.

[Laparoscopic Heller myotomy for esophageal achalasia]

BACKGROUND

Achalasia is characterized by an incomplete relaxation of the lower esophageal sphincter. The best treatment is surgical and the laparoscopic approach may have good results.

AIM

To assess the results of laparoscopic Heller myotomy among patients with achalasia.

MATERIAL AND METHODS

Prospective study of patients subjected to a laparoscopic Heller myotomy between 1995 and 2004. Clinical features, early and late operative results were assessed.

RESULTS

Twenty seven patients aged 12 to 74 years (12 females) were operated. All had disphagia lasting for a mean of 32 months. Mean lower esophageal sphincter pressure ranged from 18 to 85 mmHg. Eight patients received other treatments prior to surgery but symptoms persisted or reappeared. The preoperative clinical score was 7. No patient died and no procedure had to be converted to open surgery. In a follow up of 21 to 131 months, all patients are satisfied with the surgical results and the postoperative clinical score is 1. Only one patient with a mega esophagus maintained a clinical score of six.

CONCLUSIONS

In this series of patients, laparoscopic Heller myotomy was an effective and safe treatment for esophageal achalasia.

Survival of Young Patients after Gastrectomy for Gastric Cancer

It has been suggested that gastric cancer has a worse prognosis in young patients, but the data are controversial. The aim of this study was to compare the 5-year survivals after gastrectomy for gastric cancer in two groups of patients (those < or = 45 years of age and those (> 45 years) and to determine some of the prognostic factors. The 5-year survival was significantly better for patients < or = 45 years of age. Survival was also better for young patients with a curative resection and also for those with lymph node metastases. However, survival was not significantly different for the two groups when the resection was not curative and when the lymph nodes were not involved. Survival was no different for the two groups when compared at each stage, although a multivariate analysis showed that age > 45 years, moderate or poor degree of differentiation of the tumor, advanced tumors, the presence of lymph node involvement, and a noncurative resection were independent negative prognostic factors. Long-term survival after gastrectomy for gastric cancer depends on the stage of the disease; the age of the patient is not a decisive factor.

[Ischemic colitis induced by cocaine. Clinical case]

We report a 29 years old male, with a history of cocaine abuse and excessive alcohol intake, who was admitted to the hospital with an acute peritonitis. The patient was operated and multiple perforations of the cecum were found. A right hemicolectomy was performed and the pathological study of the surgical piece showed an ischemic colitis. A literature review reveals 22 reported cases of ischemic colitis associated to cocaine abuse.

Results of surgical treatment of gastric cancer

BACKGROUND/AIM

The extent of gastric resection and the role of lymphadenectomy in the treatment of gastric cancer are controversial.

METHODS

This study evaluates the results of radical gastric resection (D2 lymphadenectomy) in 375 patients with a gastric carcinoma operated according to a prospective protocol.

RESULTS

Total gastrectomy was performed in 196 and a subtotal gastrectomy in 179 patients, with an operative mortality of 3.5 and 2.8%. The presence of lymph node metastasis was related to the depth of the tumor in the gastric wall. The cumulative 5-year survival was dependent on the depth of tumoral invasion in the gastric wall and also on the presence of lymphatic metastasis. Curative resection had a significantly better 5-year survival (72%) than noncurative resection (26%).

CONCLUSION

Although it is difficult to prove the benefits of extended lymphadenectomy in the surgical treatment of gastric carcinoma, the results of these series seem to support its usefulness.

[Non Hodgkin lymphoma of the stomach: evaluation of surgical treatment in 24 patients]

This is a retrospective review of 24 patients with Non Hodgkin Lymphoma of the stomach operated between 1959 and 1991. The diagnosis was reached with a radiological study in 12 of 15 (80%) patients and with endoscopy in 11 of 16 (69%) of patients. Eleven of 14 (78%) preoperative biopsies available at the moment of the revision were positive for non Hodgkin Lymphoma. Clinical staging was performed using Ann Arbor Classification and the histological type was defined according to the Working Formulation. Diffuse large cell lymphoma (intermediate grade) was the most frequent histological subtype. Eleven patients were in clinical stage I, 10 patients in stage II and 3 in stage IV. Eight total gastrectomies and 16 subtotal gastrectomies were performed. Twenty one percent of patients had a postoperative complication and operative mortality was 12%. Stage I patients were treated exclusively with surgery and no recurrences were observed. Stage II patients received adjuvant chemotherapy, the tumor recurred in three and two died due to disease progression. Five years disease free survival was 64%. It is concluded that surgical treatment achieves a good disease control in stage I patients but must be complemented with chemotherapy in stage II tumors.

[Pyogenic liver abscess. Experience with 50 cases]

During the last years the diagnosis and treatment of pyogenic liver abscess has changed substantially. The aim of this work is to report a retrospective analysis of 50 patients aged 24 to 87 years old, that presented with a pyogenic liver abscess and were treated in the last 13 years. The sensitivity for diagnosis of ultrasound examination, CAT scan and angiography was 68, 89 and 75% respectively. The origin of the abscess was detected at the biliary tree in 46% and remained unknown in 38%. Thirty one patients were operated, 13 were subjected to percutaneous drainage and 5 were treated only with antimicrobials. Forty percent of patients had a septic complication and 4 (8%) died. Mean hospital stay was 31 days for operated patients and 21 for the rest. The abscess recurred in seven patients and two of these had a gallbladder carcinoma. It is concluded that percutaneous drainage is an alternative to surgical treatment that must be accompanied by a careful diagnostic workup.

[Choledochocele. Report of a case and review of the literature]

We report a 29 years old man with a choledochocele or type III choledochal cyst, an extremely rare condition. This was found during a cholecystectomy using a transcystic intra operative cholangiogram. A transduodenal sphincteroplasty was performed. The cyst diameter was 1.5 cm approximately and two 1-2 mm stones were extracted from its lumen. The chemical composition of these was different from those located in the gallbladder. The postoperative period was uneventful and the patient remains asymptomatic.

[Gastrointestinal bleeding of unknown origin. Experience in 31 cases]

Thirty one patients with GI bleeding of obscure origin, defined as those with normal upper endoscopy and colonoscopy, were studied to know the yield of different diagnostic procedures. Seventeen patients consulted for hematochezia and bleeding less than 10 days of evolution in 71%. Small bowel X ray examination was performed in 14 cases with a diagnostic effectiveness (number of diagnosis/number or examination) of 14%, angiography was performed in 12 cases with an effectiveness 33%, radiolabeled erythrocyte scanning in 12 cases with an effectiveness of 75%, scintigraphy with pertechnetate in 6 cases with an effectiveness of 17% and intraoperatory endoscopy in 2 cases with an effectiveness of 50%. A definitive diagnosis was reached in 8 patients during the first admission and in 6 during the second admission. The principal etiologies were small bowel tumors in 3 cases, cecal ulcers in 2 and ileal diverticula in 2. Ten subjects were subjected to surgical and 2 to endoscopic treatment. Five patients with recurrent bleeding remain without diagnosis. It is concluded that radiolabeled erythrocyte scanning and angiography are effective examinations that should follow upper and lower endoscopies in the diagnosis of a concealed GI bleeding. When a diagnosis is not reached in the first admission, patients should be following with repeated diagnostic procedures.

[Colorectal cancer. Study of survival and surgical results]

The aim of this study was to assess the progress in the surgical treatment of colorectal carcinoma in a 15 years period at the Catholic University Clinical Hospital. The medical records of 397 patients were retrospectively analyzed. Two hundred eighty four patients (164 male) aged 24 to 90 years old, subjected to elective and curative interventions, were selected for the study and separated in two groups: 132 subjects operated between 1975 and 1984 (group A) and 152 operated between 1985 and 1989 (group B). Group B patients were older (66.7 vs 61.3 years old), had a higher proportion of Dukes A tumors (11 vs 18%) and a lower proportion of lesions localized in the rectum (37 vs 49%). Rectal operations had higher morbidity than colonic interventions (35 vs 17.5%). Operative mortality was 0.7% in group A and 0.6% in group B. Ninety one percent of patients had a mean follow up of 38 months. Five years actuarial survival was 52% in group A and 69% in group B and 58, 74 and 46% for tumors Dukes A, B and C respectively.

Metaplasia and precursor lesions of gallbladder carcinoma. Frequency, distribution, and probability of detection in routine histologic samples

BACKGROUND

Gallbladder diseases, especially cholelithiasis, are extremely frequent in Chile, and an increasing frequency of gallbladder carcinoma has been observed during the last decades. Hyperplastic and atypical epithelial lesions of gallbladder epithelium have been considered potential precursors of invasive carcinoma. The current study was designed to study the frequency, distribution, extension, and probability of routine detection of potentially preneoplastic changes of gallbladder epithelium.

METHODS

Epithelial changes were histologically studied by mapping gallbladders obtained at elective cholecystectomy for lithiasis in 162 Chilean patients.

RESULTS

Antral-type metaplasia was found in 95.1% of the cases, intestinal metaplasia in 58.1%, hyperplasia in 46.9%, dysplasia in 16%, and carcinoma in situ in 2.5%. A significant association of intestinal metaplasia with hyperplasia, intestinal metaplasia with dysplasia, and hyperplasia with dysplasia was found. Hyperplasia and dysplasia were also present in four cases with carcinoma in situ. Mean extension of the lesions (percentages of the sections in which the change was observed) was antral-type metaplasia (62.7%), intestinal metaplasia (25.3%), hyperplasia (24.1%), dysplasia (15.5%), and carcinoma in situ (9.7%). Antral-type and intestinal metaplasia were more extensive and more severe in patients older than 50 years of age. Hyperplasia was more extensive in cases in which it was associated with dysplasia and carcinoma in situ.

CONCLUSIONS

The extension of metaplasia seems to depend in part on the age of the patients. The association of intestinal metaplasia with hyperplasia and dysplasia agrees with the findings of other authors that relate metaplasia to gallbladder cancer. The epithelial lesions are focal or partially confluent, thus a single random histologic section will detect less than one third of the hyperplasias, dysplasias, and carcinomas in situ.

[Pregnancy and portal hypertension]

The course of pregnancy in three patients with portal hypertension is described. The cause of portal hypertension was cirrhosis in one and portal vein obstruction in two (one of these had previous shunt surgery). The patient with cirrhosis had an episode of encephalopathy at week 27, the rest of the patients had an uneventful pregnancy. All three had preterm vaginal deliveries at week 33, 31 and 37 of pregnancy. The clinical features of pregnancy in women with portal hypertension was reviewed in the literature. There is agreement that the risk of preterm delivery increases and pregnancy does not influence maternal prognosis. Vaginal delivery can be anticipated in most women and cesarean section is reserved for obstetric indications. Pregnancy in these women should be managed in tertiary care centers with close collaboration between perinatologists, internists and surgeons.

[Vascular compression syndrome of the duodenum. Report of 2 cases]

Two young female patients with the syndrome of vascular compression of the duodenum are reported. Both patients presented with a history of vomiting and weight loss. Barium examination of the gastrointestinal tract showed in both cases, marked stomach distention and obstruction of the third portion of the duodenum. In one patient, abdominal CT scan discarded other causes of extrinsic compression. Both patients were operated. The simpler and safer surgical procedure is the section of the Treitz ligament and duodenal liberation, which can be used in the majority of patients.

[Budd-Chiari syndrome. Report of 2 surgical cases]

Two female patients with Budd-Chiari syndrome and suffering of Polycythemia Vera are reported. Both patients were operated performing a central spleno renal shunt with preservation of the spleen and ligation of the splenic artery. The patients are well 6 and 24 months after the operation respectively. The principal features and therapeutic alternatives of this condition are reviewed briefly.

Axonal sprouting induced in the sciatic nerve by the amyloid precursor protein (APP) and other antiproteases

Protease inhibition is the mechanism by which some trophic factors promote the extension of neurites. In the rat sciatic nerve, we assessed the ability to induce sprouts of the APP isoform that embodies the Kunitz antiprotease domain and other antiproteases. With the electron microscope, axonal sprouts were found when antiproteases were supplied but not after administration of inactive substances. We conclude that axons have a drive to sprout which can be released by the unbalance of an extracellular protease-antiprotease system. We propose that this system is involved in the pathogenesis of Alzheimer's disease.

[Treatment of non-variceal upper digestive hemorrhage with endoscopic thermocoagulation]

Over a year period, 60 of 172 patients presenting with upper gastrointestinal bleeding were treated by endoscopic thermocoagulation. Entry criteria included active bleeding (pulsatile or oozing), a visible vessel, sentinel clot or the presence of a pigmented protuberance at the ulcer crater. Hemostatic therapy was performed using the heat probe. The physical status and risk of the patients was estimated according to the ASA classification. Hemostasis was obtained in 17 of 21 patients with pulsatile bleeding (81%), 30 of 30 patients with oozing (100%) and 18 of 18 patients with a visible vessel or a pigmented protuberance in the lesion (100%). Three patients, older than 70 years of age, died. All had pulsatile bleeding from a deep ulcer located at the posterior-inferior wall of the duodenal bulb. They were classified as ASA III (n = 1) or IV (n = 2) with significant concomitant illness. These results suggest that endoscopic thermocoagulation is an effective treatment of active upper gastrointestinal bleeding, especially useful in a group of high risk patients.

[Acute severe pancreatitis. Analysis of mortality and morbidity]

Sixty-three patients with severe acute pancreatitis have been studied. Pancreatitis was associated with biliary tract disease in 23 patients (36.5%) and with alcoholism in 21 (33.3%). It occurred post-operatively in 9, and was associated with other conditions in 10. We evaluated the Ranson prognostic signs (RPS) with the appearance of complications. 36 patients (57.2%) had 3-4 RPS, 9 (30.2%) had 5-6 RPS and 8 (12.6%) had 7 or more RPS. Diagnostic laparotomy was performed in 11 patients (17.5%). 55 patients were operated one or more times due to failure of medical treatment and/or local and septic complications. The most frequent complications were pancreatic abscess (60.3%), sepsis (58.7%) and pulmonary insufficiency (52.4%). Renal failure occurred in 26 patients and 9 required dialysis. Of the patients with renal failure, 84.6% (22/26) had 4 or more RPS; 78.4% (29/37) of those with sepsis and 71.6% (27/38) of those with pancreatic abscess also had 4 or more RPS. The mean duration of hospitalization of survivors was 58 +/- 30 days. Overall mortality was 28.6%. We conclude that RPS are helpful to predict complications in patients with severe pancreatitis.

[Regeneration of gastric mucosa after endoscopic biopsy]

Eleven gastric mucosal defects produced by endoscopic biopsy in non-tumoral areas were histologically studied in gastrectomy specimens. The biopsies had been performed from one up to seven days before the operation. The base of each defect was formed by submucosa infiltrated by erythrocytes, fibrin and neutrophils, which were later replaced by small blood vessels, fibroblasts and collagen fibrils. The mucosa of the margins bowed down towards the base of the defect. This marginal mucosa showed dedifferentiation of the glandular epithelial cells, increased mitotic index and some cystic glandular structures lined by basophilic cells. The defect was progressively covered by a layer of flattened or cuboidal cells in which no mitoses were observed; their cytoplasm contained mucosubstances similar to those of the superficial epithelium of the remaining mucosa, either foveolar- or intestinal metaplastic-type. From this layer, simple gland-like invaginations to the underlying connective tissue were observed. The findings are consistent with the regenerative events described in experimental gastric ulcers in animals. The method employed may be useful to study specific aspects on the regeneration of the human gastric mucosa.

[The medical treatment of intestinal obstruction due to adhesions and adherences]

Adhesions are the most common cause of intestinal obstruction. Medical treatment for those patients with no signs of vascular involvement has been successful in many cases. We reviewed the clinical records of 87 patients with intestinal obstruction due to adhesions, having a total of 122 episodes. Satisfactory follow up was obtained in 76% of patients for a mean of 29.6 months. 47% of episodes resolved without need for surgical intervention. Volume entrapment during the first hours was correlated with need for surgical treatment (p < 0.01). Recurrences were not different between medical and surgical patients (p = 0.28). Thus, medical treatment of this type of intestinal obstruction may be attempted in most patients, not only those who are poor surgical risks.

[Duodenal obstruction caused by cholelithiasis (Bouverets' syndrome): a clinical case]

A 55 year old man presented with vomiting, abdominal pain, diarrhea, jaundice and choluria. An obstruction of the gastric outlet by a large gallstone located at the duodenum was demonstrated by radiologic, ultrasonographic and endoscopic examinations. The stone could not be removed through endoscopy and the patient was successfully operated on. A review of published reports is included.

[Gastric cancer: surgical results and survival]

From 1975 to 1984, 292 patients with gastric cancer were treated according to a prospective and standardized surgical protocol. This series included 195 men and 97 women, with an average age of 62.5 +/- 11 years (SD). In 20 patients (6.8%) surgery was not performed and 99 were considered unresectable at laparotomy. Gastric resection was performed in 173 (63.3%) (distal subtotal gastrectomy in 94 and total gastrectomy in 79). Operative mortality for subtotal gastrectomy was 3.1% and 6.3% for total gastrectomy. Early gastric cancer was found in 21 patients (none presented lymph node metastases). The cancer invaded the muscular layer in 18 (31% with lymph node metastases) and reached beyond the muscular layer in 134 patients (60.8% with lymph node metastases). The five year actuarial survival was 0% in patients who did not undergo gastric resection, 35.5% for those patients with tumor invading the serosal layer or beyond who were resected, 56.5% for those with invasion up to the muscular layer and 91.8% for patients with early gastric cancer. For those patients who underwent a curative resection, actuarial five year survival was 81%.

[Splenic abscess]

Splenic abscess is an uncommon condition associated with a high mortality. In most cases an hematogenous focus can be identified. Early diagnosis is essential for recovery. CT scan and ultrasound tomography are the best diagnostic tools. The latter was used to establish the diagnosis in 2 patients who were successfully treated by surgery.

[Value of preoperative colonoscopy in colon-rectal neoplasms]

The surgical approach to treat colo-rectal carcinoma is usually based on the findings of barium enema. In 102 patients we reviewed the yield of pre-operative colonoscopy. Barium enema revealed the cancer in 76 of 84 patients (91%), whereas colonoscopy did so in 96 of 102 subjects (94%). In addition, 5 associated cancerous lesions were demonstrated by colonoscopy and none by barium enema. Associated benign lesions were seen in 14 patients. In 5 patients the surgical plan based on the barium enema was modified by the findings at colonoscopy. Eight false negatives to barium enema were correctly diagnosed by colonoscopy. We conclude that colonoscopy yields valuable information, beyond that of barium enema, in patients with colo-rectal cancer.

[Colorectal cancer: follow-up after curative resection]

From Jan 1978 to Dec 1984, 128 patients had a curative resection of colorectal carcinoma. A program for early detection and surgical correction of recurrences was initiated in 88 patients with a mean age of 61 years (range 24 to 85). Seventy two patients complied with the program involving clinical examination, chest X-ray, alkaline phosphatase and CEA determinations and endoscopy at 6 month intervals. Mean follow up was 36 months (range 6 to 60). A total of 28 recurrences (32%) were detected: 4 local, 17 distant and 7 local and distant. Recurrences occurred in 46% of grade C, 19% of grade B and 0% of grade A lesions. Sixty eight% of recurrences were detected within 12 months and 93% within 36 months after surgery. Recurrences were detected by clinical examination in 71% of cases. CEA determination was sensitive (81% and specific (92%) for detection of recurrences in the remaining patients. Four patients (14%) were reoperated on with a survival of 3 to 26 months, all dying from disseminated disease. We conclude that this program did not help to improve the 5 year survival rate of colorectal carcinoma submitted to curative resection. CEA determination may be indicated at 2 month intervals during the period of increased recurrence risk.