Estudio prospectivo controlado y aleatorizado sobre la necesidad de la preparación mecánica de colon en la cirugía programada colorrectal

Introduction

Mechanical preparation of the colon (MPC) in colorectal surgery has been a dogma that has been questioned over the last few years. The objective of this study is to demonstrate that morbidity in scheduled colorectal surgery is the same or lower without MPC.

Material and method

Patients subjected to scheduled left colon and rectal surgery with primary anastomosis randomised into two groups. The “Preparation” group (MPC) received MPC and the “non-preparation” group (No-MPC) had only cleaning enemas. The variables collected were: demographic, oncological, nutritional, risk prediction models and morbidity-mortality.

Results

Of the 193 patients included: 69 received MPC and 71 did not; 89 patients with colocolic anastomosis (MPC, 38; no MPC, 51) and 50 colorectal (MPC, 31; no MPC, 19). Statistically significant differences were seen in the overall analysis in favour of “no preparation” as regards morbidity (43.55 % with MPC and 27% with No MPC) and nosocomial infection (27.5% and 11.4%). There was 11.6% wound infections in the MPC compared to 5.7% in the no MPC, which was not statistically significant. The only mortalities were in the MPC group 2/69 (2.9% of patients). As regards the location of the anastomosis, in the colocolics the differences were more pronounced, with statistically significant differences in the morbidity, anastomosis dehiscence, and nosocomial infection variables. The effect of no MPC was not so evident in colorectal anastomosis.

Conclusions

Our results suggest that there is no benefit in MPC before surgery in colocolic anastomosis. No-MPC is not associated with a higher morbidity in wound infection or anastomotic dehiscence. In colorectal anastomosis the differences are not so evident, therefore a much bigger series needs to be studied.     

Beneficio de la biopsia del ganglio linfático centinela en pacientes con carcinoma in situ de mama

Introduction

Patients with a diagnosis of breast ductal carcinoma in situ (DCIS) have a low risk of developing axillary metastases. The use of sentinel node biopsy in this group of patients is controversial. The objective of this study is to determine if the sentinel node biopsy benefits a subgroup of patients with DCIS.

Patients and method

Between April 2002 and December 2007, patients with a diagnosis of DCIS and who underwent a sentinel node biopsy were included in the study. In our centre the sentinel node biopsy was performed in patients with DCIS who required a mastectomy, high grade and >2 cm DCIS and palpable DCIS.

Results

Forty-seven patients were included in the study. In all cases the sentinel node was identified. Twenty-five (53.1%) patients underwent a mastectomy due to extensive DCIS; 14 of these (56%) with immediate reconstruction with implants. Twenty-five (53.1%) patients had high grade DCIS. In 7 (14.8%) patients the tumour was palpable. Fourteen patients (29.7%) were upgraded to invasive breast cancer in the definitive histology. In 2 (4.2%) patients who underwent a mastectomy a positive sentinel node was found.

Conclusions

Performing sentinel node biopsy in this group of DCIS patients has lead us to identify 4% of patients with positive sentinel nodes. Furthermore, 29.7% of the patients have avoided a second invasive diagnostic procedure for definitive histology. For these reasons we consider it appropiate to perform sentinel node biopsy in this subgroup of patients with DCIS of the breast.     

Protective effect of fallopian tubal fluid against activated leucocyte-induced sperm DNA fragmentation: preliminary results

The integrity of the paternal genome is of paramount importance in the initiation and maintenance of a viable pregnancy. Oxygen radicals (ROS) have been identified as one of the main factors responsible for the induction of sperm DNA damage. Spermatozoa are mainly protected against ROS-induced damage by seminal plasma. However, this protective effect disappears once spermatozoa enter the female genital tract. The fallopian tube mucosa may play a protective role against ROS-induced sperm damage. The main objective of this study was to determine whether human tubal explants and tubal fluid exert a protective effect on ROS-induced sperm DNA damage. Spermatozoa were exposed to tubal explants and/or tubal fluid in the presence of phorbol myristate acetate (PMA)-activated polymorphonuclear leucocytes or control medium and sperm DNA fragmentation was measured using the TdT-mediated dUTP-biotin nick end labelling (TUNEL) test. Exposure of human spermatozoa to PMA-activated leucocytes resulted in a 2-fold increase in sperm DNA fragmentation. Co-incubation of spermatozoa with tubal explants did not reduce this damage. However, pre-incubation of spermatozoa with tubal fluid resulted in a statistically significant reduction in sperm DNA fragmentation levels, comparable to those observed in control. In conclusion, tubal fluid appears to protect against activated leucocyte-induced sperm DNA fragmentation, thus preserving the integrity of the paternal genome.     

Response to methotrexate in a chronic inflammatory demyelinating polyradiculoneuropathy patient

We report a patient with chronic inflammatory demyelinating polyradiculoneuropathy and progressive resistance to standard treatment who showed a striking response to methotrexate, 20 mg/week. The improvement, which started 5 months after initiation of therapy, was consistent and permanent. It allowed the previously wheelchair‐dependent patient to achieve pharmacological remission. The 2‐year follow‐up of this case further illustrates the role that methotrexate may play as a treatment option for CIDP patients. Muscle Nerve 39: 386–388, 2009     

Correlations between gray matter reductions and cognitive deficits in dementia with Lewy Bodies and Parkinson's disease with dementia

There is controversy regarding whether Dementia with Lewy Bodies (DLB) and Parkinson's disease with dementia (PDD) may or not be different manifestations of the same disorder. The purpose of the present study was to investigate possible correlations between brain structure and neuropsychological functions in clinically diagnosed patients with DLB and PDD. The study sample consisted of 12 consecutively referred DLB patients, 16 PDD patients, and 16 healthy control subjects recruited from an outpatient setting, who underwent MRI and neuropsychological assessment. Voxel‐based morphometry results showed that DLB patients had greater gray matter atrophy in the right superior frontal gyrus, the right premotor area and the right inferior frontal lobe compared to PDD. Furthermore, the anterior cingulate and prefrontal volume correlated with performance on the Continuous Performance Test while the right hippocampus and amygdala volume correlated with Visual Memory Test in the DLB group. In conclusion, DLB patients had more fronto‐temporal gray matter atrophy than PDD patients and these reductions correlated with neuropsychological impairment. © 2009 Movement Disorder Society     

Robotic-Assisted Laparoscopic Gynecologic Procedures in a Fellowship Training Program

Background and Objective:

The robotic surgical platform is an alternative technique to traditional laparoscopy and requires the development of new surgical skills for both the experienced surgeon and trainee. Our goal was to perform an early evaluation of the feasibility of training fellows in robotic-assisted gynecologic procedures at the outset of our incorporation of this technology into clinical practice.

Methods:

A systematic approach to fellow training included (1) didactic and hands-on training with the robotic system, (2) instructional videos, (3) assistance at the operating table, and (4) performance of segments of gynecologic procedures in tandem with the attending physician. Time to complete the entire procedure, individual segments, rate of conversion to laparotomy, and complications were recorded.

Results:

Twenty-one robotic-assisted gynecologic procedures were performed from April 2006 to January 2007. Fellows participated as the console surgeon in 14/21 cases. Thirteen patients (62%) had prior abdominal surgery. Median values with ranges were age 51 years (range, 33 to 90); BMI 28 (range, 19.4 to 43.8); EBL 25 mL (range, 25 to 250); and hospital stay 1 day (range, 1 to 4). No significant difference existed between fellow and attending mean total operative and individual segment times. One conversion to laparotomy was necessary. No major surgical complications occurred.

Conclusion:

These data suggest that it is feasible to incorporate a systematic approach to robotic-assisted laparoscopic training for trainees at the outset of incorporation of this technology into current practice.     

The importance of the length of the first metatarsal and the proximal phalanx of hallux in the etiopathogeny of the hallux rigidus

The purpose of this study was to determine if the relative length of the first metatarsal and the proximal phalanx of the hallux, in respect to the total foot length, were associated with the incidence of hallux rigidus. For this retrospective study, lateral radiographs from 132 cases with hallux rigidus and a control group of 132 normal feet were reviewed.We measured the following parameters: the index between the foot length and first metatarsal length, the proximal phalanx of the hallux length, and the sum of the first metatarsal length and the proximal phalanx of the hallux length.We found a statistically significant difference (p: 0.002) between the two groups in the Foot L/1st Mtt L index, and no statistical difference in the Foot L/Phalanx L index.We think that a greater length of first metatarsal is involved in the etiopathogeny of hallux rigidus.     

Endovascular treatment of splenic and renal aneurysms

Four cases (three women and one man) of embolization of visceral artery aneurysms are presented, of which two affected the splenic artery and two the renal artery. The two renal aneurysms were related to hypertension; one of the splenic aneurysms was diagnosed in the context of hypertension, and the other affected a woman of a fertile age. Microguides, microcatheters, and Guglielmi platinum coils, liberated by electrolysis, with different lengths and characteristics, were used. Also, one of the renal aneurysm cases was related to the placing of a stent due to the existence of a stenosis of the renal artery adjacent to the aneurysmatic neck. Immediate occlusion of the aneurysm was achieved in the four cases. Evaluation with nuclear magnetic resonance angiography carried out 3 months later confirmed the sealing of the aneurysm and the patency of the native artery. Currently available devices provide a good therapeutic option for the embolization of visceral aneurysms with low morbidity and mortality rates.     

Postictal psychosis: a retrospective study in patients with refractory temporal lobe epilepsy

Postictal psychosis (PIP) represents 25% of the psychoses seen in epileptic patients. A high frequency of bilateral independent epileptiform activity has been observed in patients with PIP. The objective of this study was to determine the frequency of PIP in patients with temporal lobe epilepsy (TLE) who underwent video-EEG monitoring and to investigate possible differences between PIP and control patients. METHODS: Clinical, electroencephalographic and neuroimaging data of 5 PIP patients with TLE were compared with data of 50 patients with TLE without psychotic antecedents. Patients with a past history of interictal psychosis were excluded. RESULTS: From 55 patients, 5 were patients with PIP and 50 controls. 31 (62%) were men, 9 (16.4%) had a previous history of encephalitis and 6 (10.9%) of status epilepticus. The mean age was 42.2 years (S.D. 12.93). Mean age at epilepsy onset was 16.95 years (S.D. 12.93) and mean seizure frequency 5seizures/month (S.D. 1.87). The frequency of PIP was 5/55 (9.1%). Previous history of status epilepticus was more frequent in PIP patients than in controls (p: 0.019). PIP patients more frequently had a non-lateralizing ictal EEG than controls (p: 0.001). Bitemporal lobe dysfunction revealed by neuropsychological studies was greater than expected by the observed lesion on MRI studies in patients with PIP. Moreover, the presurgical study was less conclusive in PIP than in control patients (p: 0.049). CONCLUSIONS: PIP is observed in up to 9% of patients with TLE undergoing video-EEG monitoring and most often develops in patients with bitemporal lobe dysfunction.