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Resumen La endometriosis localizada en tejido cicatrizal tras cirugia pelvica del aparato genital, se presenta como una lesion nodular acompanada de dolor ciclico catamenial en el area cicatrizal, y no se asocia de forma habitual a endometriosis genital. Presentamos 2 casos de endometriosis localizada en tejido cicatrizal tras intervenciones obstetricas (episiotomia y cesarea, respectivamente) diagnosticados en nuestro hospital. El diagnostico, basado en la sospecha clinica, fue histologico tras biopsia-exeresis de la lesion que resulto terapeutica, y las mujeres presentaron remision completa de la sintomatologia. En ambos casos, se asocio tratamiento hormonal postoperatorio, aunque su eficacia esta discutida.

The onset of local and systemic inflammatory effects in secondary peritonitis is usually closely related to the presence of many inflammatory mediators such as cytokines. The main purpose of this paper is to review the mechanisms induced by secondary peritonitis related to the production of cytokines, to determine their role in the onset of local inflammatory responses and in the onset of systemic inflammatory responses leading to multiple organ failure. We also review the immunomodulatory effects induced by cytokine production and their counteraction. Finally we analyze the potential therapeutic effects of cytokine-related drugs and their role in the management of patients with secondary peritonitis and systemic inflammatory response syndrome. In this regard the following substances are important: nonspecific immunomodulators, anti-cytokine antibodies, and inhibitors of the cytokine effect and of adhesion molecules.

Introduction EuroTransplant old-to-old program allows patients older than 60 years to receive offers from donors older than 60. The long-term results of kidney transplantation in this model are still under discussion, due to the impaired kidney function of the donor and cumulative diseases in the recipient. Hypothesis Calcineurin-sparing protocols with IL-2 antibody induction (Simulect) may benefit long-term kidney function in these patients avoiding overimmunosuppression. The main outcome measures are: graft function and rejection rate during the first year after transplant. Patients and methods A cohort of 15 consecutive older subjects were prospectively compared with 30 conventional cadaveric kidney transplants. Study patients were induced with Simulect (20 mg, 30 minutes before reperfusion and 4 days after transplantation) and steroids allowing the introduction of CsA to be delayed to the time at which the creatinine is below 3 mg/dL. Conventional patients were immunosuppresed with Tacrolimus (trough 8–12 ng/mL), MMF (1 g/d) and identical steroid tape. The graft and patient survival, kidney function in terms of diuresis, creatinine clearance, rejection episodes and grades were compared between both groups during the first year posttransplantation. Results Except for the age of the donors and recipients in both groups (72 vs 54 in donors, and 67 versus 52 years in recipients), no significant differences were observed. Patient survival rates were 97% in control patients and 100% in the Simulect group. Graft survival was 97% in the control group and 100% in the old-to-old study group. Acute rejection episodes were decreased among study patients (6.6% vs 13.2%), and corticoid sparing protocols were applied in 75% of Simulect patients but only 50% of control patients. All 44 patients and grafts showed excellent kidney function after one year with equal creatinine levels in both groups (mean 1.42). Conclusions Calcineurin free protocols with IL-2 therapy as the main initial suppression allows patients in an old-to-old ET program to have superior results to conventional cadaveric kidney transplants.

During Miocene time, the Andean region between 38° and 39°S was an area where active volcanoes, lakes and rivers formed under a temperate to cold humid climate. The volcanic products and sedimentary deposits which accumulated in lakes and rivers adjacent to the volcanoes constitute the Cura-Mallin Formation. The deep roots of the volcanic chain are represented by middle to late Miocene granitoids which formed a north-south trending belt that separated a marine fore-arc basin (Temuco basin) to the west from the continental sedimentary deposits of the Cura-Mallin Formation to the east. Twenty-three KAr dates ranging between 20 and 11 Ma, constrain the age of the Cura-Mallin Formation to the early to middle Miocene. The alternation of pyroclastic strata and lava flows in the Guapitrio Member of the Cura-Mallin Formation suggests the former existence of strato-volcanoes, whilst the presence of ignimbrites suggests caldera formation. A major lacustrine basin ( >100 km long) represented by some facies of the Rio Pedregoso Member of the Cura-Mallin Formation existed from at least 17.5 ± 0.6 to 13 ± 1.6 Ma. Lacustrine accumulations terminated during the progradation of deltas and infilling of volcanic material. The Cura-Mallin Formation lakes could have been formed, in part, by intra-arc extension, by the damming of rivers caused by volcanic products and/or by the filling of calderas. The occurrence of Gilbert-type delta complexes in the Rio Pedregoso Member may indicate a steep basin margin generated by faulting and/or volcanic accretion.

La persistencia de la cloaca es una de las formas más complejas de las malformaciones anorrectales que se produce en las niñas. El tratamiento es complicado y laborioso, sobre todo cuando el canal común es largo.El objetivo de esta comunicación es subrayar la importancia de la movilización conjunta del seno urogenital tras la separación del recto. La primera maniobra evita la separación del tracto urinario del genital, acortando el tiempo de intervención en más del 60 %. Esto sólo es possible realizarlo en las cloacas con canal común menor de 3 cm. Se presentan los casos de dos niñas intervenidas en el transcurso de los últimos 2 años con esta técnica.Los resultados en cuanto al acortamiento del tiempo quirúrgico fueron significativos pudiéndose realizar en aproximadamente 4 h, la intervención se simplificó de manera importante y los resultados funcionales y estéticos fueron excelentes.Creemos que para obtener buenos resultados en el tratamiento de la cloaca, es necesario establecer un diagnóstico clínico y radiológico preciso, evaluar el orden de preferencia de las necesidades quirúrgicas y elegir la técnica adecuada. Se considera que la mejor opción para aquellos casos cuyo canal común es inferior a 3 cm es la movilización total del seno urogenital, su abocamiento al perineo y la colocación del recto en el complejo esfinteriano anorrectal. : Persistent cloaca is one of the most complex forms of anorectal malformation in girls. Surgical treatment is complicated and laborious especially when the common channel is long.The aim of this report was to emphasize the importance of the joint mobilization of the urogenital sinus after separation from the rectum. This maneuver avoids separation of the urinary tract from the enital tract and reduces operating time by more than 60 %. This is only possible when the common channel of the cloaca is less than 3 cm. We present the cases of two girls treated in the last 2 years with this technique.Operating time was significantly shortened to approximately 4 hours and the procedure was considerably simplified. The functional and cosmetic results were excellent.To obtain good results in the treatment of cloaca, a precise clinical and radiologist diagnosis must be made, surgical needs should be prioritized and the appropriate technique chosen. The best procedure for patients whose common channel is less than 3 cm is total mobilization of the urogenital sinus, subsequently sutured to the perineum, and placement the rectum within the anorectal sphincter complex.

Introduction Markov models are employed in economic analyses to evaluate all possible expectations in a dilemna. The introduction of a new clinical protocol (Basiliximab induction with calcineurin-sparing protocols) for a group of kidney transplant recipients receiving organs from marginal donors was validated with a Markov simulation model, demonstrating the usefulness of combining simulation with Bayesian estimation methods for analysis of cost-effectiveness data collected alongside a clinical trial. We sought to determine whether calcineurin-sparing protocols using anti-interleukin-2/antibody induction (Simulect) would show a beneficial effect on initial kidney function and reduce transplantation costs upon admission, clinical incidences, graft function, and complications during the first month after transplant. Patients and methods A Markov Chain Monte Carlo (MCMC) was used to estimate a system of generalized linear models relating costs and outcomes to a kidney transplant process affected by treatment under alternative therapies. The Markov simulation model was established following three chains: a calcineurin-free regimen with Basiliximab induction (chain A); a calcineurin-sparing protocol with Basiliximab induction (chain B); and a conventional immunosuppressive regimen (chain C). The MCMC draws were used as parameters in simulations that yielded inferences about the relative cost-effectiveness of the novel therapy under a variety of scenarios. After designing the Markov chain and cohorts, 31 patients from the “old-to-old” program were assigned; eight to chain A; eight to chain B; and 15 to chain C. A year after transplantation a cost-benefit study was performed guided by the three branches of the Markov model. Results The Markov model showed a benefit of induction therapies in elderly patients. A cost-benefit model showed that after a year, there was a clear benefit from calcineurin-free plus Basiliximab induction therapies, with a slight benefit from calcineurin-sparing protocols. Conclusions Markov models are extremely useful when introducing new clinical therapies. The approach allows flexibility in assessing treatment using various premises and quantifies the global effect of parametric uncertainty on a decision maker’s confidence to adopt one therapy over another. In our transplant program, a cost-effective analysis of outcomes in old patients using the Markov model showed a clear benefit of calcineurin-sparing protocols with Basixilimab induction.

Introduction The EuroTransplant “old to old” program establishes that patients older than 60 years can receive offers of organs from donors older than 60 years. The compromised function of these organs makes it a priority to preserve their initial kidney function. Hypothesis Calcineurin-sparing protocols using anti-IL-2 receptor (IL-2R) antibody induction (Simulect) may benefit initial kidney function in these patients, as assessed by the rates of delayed graft function and of rejection during the first month after transplant. Patients and methods A cohort of 15 consecutive elderly patients were prospectively compared with 30 cadaveric kidney transplants in younger recipients. Study patients were induced with Simulect (20 mg, 30 minutes before reperfusion and 4 days after transplantation) and steroids, delaying the introduction of CsA until the serum creatinine was below 3 mg/dL. The other cohort of patients were immunosuppressed with tacrolimus (trough 8 to 12), mycophenolats mofetil (MMF, 1 g/d), and an identical taper of steroids. The analysis compared donor and recipient ages, mean cold ischemic time, incidence of initial kidney function (diuresis in the first 24 h) serum creatinine levels, glomerular filtration rate (GFR), number of dialysis sessions, and rejection rate in the two groups. Results Except for the donor and recipient ages (72 vs 54 in donors, and 67 versus 52 years in recipients), no significant differences were observed between the groups among the rates of acute rejection (6.6% vs 13.2%), delayed graft function (13.2% required dialysis), or infection (6.6%). Within 1 month all 45 grafts showed primary function with equal creatinine levels (mean 1.65). Conclusions Calcineurin-free protocols using IL-2 therapy as the initial suppression allow patients in the “old to old” ET program to display equal results to cadaveric kidney transplants with initial treatment with calcineurin antagonists.

Introduction Markov models are employed in economic analyses to evaluate all possible expectations in a dilemna. The introduction of a new clinical protocol (basiliximab induction with calcineurin-sparing protocols) for a group of kidney transplant recipients receiving organs from marginal donors was validated with a Markov simulation model. Hypothesis Calcineurin-sparing protocols using anti-IL-2/antibody induction (Simulect) show a beneficial effect on initial kidney function, reducing transplantation costs reception based upon mean length of stay, mean admission cost, and incidences of delayed graft function and complications during the first month after transplant. Patients and methods A Markov simulation model was established following three different chains. A calcineurin-free regimen with basiliximab induction (chain A), a calcineurin-sparing protocol with basiliximab induction (chain B), and a conventional immunosuppressive regimen (chain C). After designing the Markov chain and cohorts, 31 patients from the “old to old” program were assigned to each chain eight to chain A, (eight to chain B, and 15 to chain C). A month after transplantation a cost-benefit study was performed guided by the three branches of the Markov model. Results The Markov model showed a benefit of induction therapies in elderly patients. A cost-benefit model showed that after a month there was a clear benefit from Calcineurin=free plus basiliximab induction therapies, with a slight benefit from calcineurin-sparing protocols. Conclusions Markov models are extremely useful when introducing new clinical therapies. In our transplant program, a cost-effective analysis of outcomes in old patients using the Markov model showed a clear benefit of calcineurin-sparing protocols with basixilimab induction.

Persistent cloaca is one of the most complex forms of anorectal malformation in girls. Surgical treatment is complicated and laborious especially when the common channel is long. The aim of this report was to emphasize the importance of the joint mobilization of the urogenital sinus after separation from the rectum. This maneuver avoids separation of the urinary tract from the genital tract and reduces operating time by more than 60 %. This is only possible when the common channel of the cloaca is less than 3 cm. We present the cases of two girls treated in the last 2 years with this technique. Operating time was significantly shortened to approximately 4 hours and the procedure was considerably simplified. The functional and cosmetic results were excellent. To obtain good results in the treatment of cloaca, a precise clinical and radiologist diagnosis must be made, surgical needs should be prioritized and the appropriate technique chosen. The best procedure for patients whose common channel is less than 3 cm is total mobilization of the urogenital sinus, subsequently sutured to the perineum, and placement the rectum within the anorectal sphincter complex.

Incidence of surgical infection is greater among elderly patients undergoing surgery than among the general population, with a serious compromise regarding morbidity and mortality in this group of patients with increased risk.To determine the microbiological features of surgical infections in patients over 65 years of age compared with those younger than 65.Over the past 2 years, 2,064 patients underwent surgery in our Department. One thousand three hundred sixty seven of those patients (66.7%) had 65 years of age or less and 688 (33.3%) were over 65. Patient characteristics regarding the type of surgery (degree of contamination) and the nature and type of the condition requiring surgery are reported. One hundred five hundred sixty two samples were submitted for microbiological study. The microbiological infectious pathogens and their characteristics were determined. The Chi-square test was used for the analysis of potential differences related to the age of the patient.The rate of samples sent for microbiological study is higher among patients over 65. In addition, these patients show both quantitative and qualitative differences in their infectious microbiological spectrum, mainly in clean-contaminated, contaminated and dirty surgical procedures. Fungal infections play a significant role in this group of patients.Facultative gram-negative bacilli, aerobic gram-positive cocci, and fungi are the main pathogens responsible of surgical infections in elderly patients, compared to all other patients, thus requiring specific antibiotic prophylactic and therapeutic regimes.

The pre-operative differentiation of tumors of the pancreas, Papilla of Vater and the biliary tract is still unsatisfactory. Tumor marker analysis of the pancreatic juice did not improve the pre-operative diagnosis by a great deal.Bile from resected gallbladders of patients suffering from carcinomas of the pancreato-biliary system was analysed for CA 19-9, CEA, CA 72-4, CA 125 and AFP concentrations. The results were compared to patients suffering from acute cholecystitis, cholecystolithiasis as well as those suffering from benign tumors of the pancreato-biliary region.Extreme high CA 19-9 concentrations were found in bile. Evaluations of the tumor-antigens CA 19-9, CA 72-4 and CEA in gallbladder bile were superior to any serum and pancreatic juice examination with respect to sensitivity and specificity. Observed sensitivities amounted to 100% for patients suffering from bile duct carcinoma (CA 19-9) and papillary carcinoma (CEA) at a specificity of 100%. CA 19-9 showed a sensitivity of 76.5% for pancreatic carcinomas at a specificity of 96.4%. CA 19-9 showed significant differences for the local tumor burden and for the degree of lymph node metastasis. Examination of tumor antigens in the gallbladder results in a high degree of discrimination for malignant and benign lesions of the subhepatic pancreato-biliary system.CA 19-9 must follow a entero-hepatic circulation, since it showed raised bile concentrations (factor: 10(4)) compared to serum analysis. Analysis of CA 19-9, CEA and CA 72-4 gives an opportunity for improvement in the detection of cancers of the pancreato-biliary system. Since the clinical important differentiation of tumors of the head of the pancreas (carcinoma vs. pancreatitis) remains unclear, an improvement by bile analyses must be assumed.

Evaluation von Trypsinogen-aktivierendem Protein (TAP) in der Gallenblasenflussigkeit von cholecystektomierten Patienten bei unterschiedlichen bilio-pankreatischen Erkrankungen.

Background: Acute abdominal pain due to complicated Meckel’s diverticulum is an unusual event. Even the presence of biliary enterolithiasis at the onset of inflamed congenital diverticulum has rarely been reported previously. Results: Despite this unusual presentation, an episode of gallstone passage through the biliary tract has not yet been described. Conclusions: Whether the stones were primarily formed in the diverticulum as enterolithiasis, or secondary to gallstone passage is discussed. The complications of Meckel’s diverticulum requiring surgical treatment are reviewed, focusing on the unusual finding of biliary stones in Meckel’s diverticulum and the etiogenic mechanism of enterolithiasis.

To find out the incidence of wound infection in patients with HIV and reduced counts of CD4 lymphocytes.Open study.University hospital, Spain.70 patients with HIV infection and enlarged lymph nodes.Biopsy of lymph nodes and withdrawal of a sample of blood for counts of CD4 lymphocytes and neutrophils.Development of infection at the biopsy site, and correlation of infecting organism with culture taken at the time of biopsy.Patients were divided into three groups depending on their CD4 count: more than 500 cells/ml (n = 26), 200-500 cells/ml (n = 24), and less than 200 cells/ml (n = 20). Their neutrophil counts were 5.1, 3.8, and 2.5 x 10(9)/1, respectively. There were found four wound infections (6%); 2 were in the group with more than 500 CD4 cells/ml, and these were caused by Staphylococcus aureus (which had been grown from nodes in 6 patients at the time of biopsy). The other 2 were in the group with less than 500 cells/ml and these were caused by Mycobacterium tuberculosis; cultures of the nodes had shown Staphylococcus epidermidis (n = 3) and M tuberculosis (n = 17). There were no infections in the group with 200-500 CD4 cells/ml, in which S epidermidis (n = 5) and M tuberculosis (n = 8) had been cultured from the lymph nodes.The CD4 count was of no prognostic importance in the development of wound infection, but severe depression of the CD4 count may increase the risk of atypical wound infections.

Surgical procedures on patients with severe immune deficiencies are increasing. The fact that an immunocompromised state is a major factor in the pathogenesis of infection makes it imperative that the clinician has an adequate working knowledge of the host’s antibacterial defense systems and how they are affected by surgery.

Background Fungal infection is a devastating complication with an increased incidence in the past decade. Immune-depressed patients undergoing high-risk procedures have an increased incidence of surgical infection, particularly due to fungal colonization. Methods Twenty patients undergoing pancreas transplantation, 20 kidney transplant patients undergoing biliary tract surgery, 20 patients with human immunodeficiency virus (HIV) undergoing biliary tract surgery and 20 patients undergoing pancreatic resection for neoplasms were enrolled in a prospective study concerning perioperative surgical infection. All patients underwent surgical procedures by the same surgeon. All had preoperative blood counts, assay of CD lymphocyte populations, complete nutritional evaluation and similar antibiotic prophylaxis. Perioperative care was done to a similar standard and only patients undergoing pancreas transplantation received fungal prophylaxis (nystatin wash and swallow). In patients with clinical signs of infection, cultures were sent with special consideration to fungal infection. Results Two of the patients undergoing pancreas transplantation (one of whom died from disseminated candidiasis), three of the kidney transplant patients (two on the wound, one in the catheter), three patients with HIV (two on bile culture, one in the bloodstream) and one of the patients undergoing pancreatic resection (pancreatic fistula and bloodstream) had fungal infection. All patients had concomitant bacterial infections at the time of fungal infection (60 per cent Staphylococcus epidermidis). Patients with fungal infection had increased levels of immunosuppression with decreased CD4 recounts (pancreas transplants and patients with HIV), increased perioperative levels of blood glucose requiring insulin treatment, prolonged antibiotic therapy with broad-spectrum antibiotics (piperacillin–tazobactam), previous positive cultures from the bile of the biliary tract or the duodenum of the transplanted pancreas, and concomitant bacterial infections (especially opportunistic). Conclusion Surgical patients with positive cultures from surgical specimens, prolonged broad-spectrum antibiotic therapy and severely decreased lymphocyte immune function had an increased incidence of fungal infection with significant morbidity and mortality rates. Fungal prophylaxis is strongly recommended in these high-risk patients undergoing biliopancreatic tract surgery.

Background In previous studies the authors have selected patients and surgical procedures with a high risk of fungal infection. Whether these patients and procedures require fungal prophylaxis was studied. Methods From June to December 1999, 850 surgical patients from two university hospitals were enrolled in a prospective open randomized study. Fifty were selected according to demographics (age, sex, co-morbidity) and surgical procedures (defined by GDRs and ICD9-CM) as at high risk of fungal infection according to a previously defined algorithm (presented to the Surgical Infection Society of Europe 1999). In these 50 patients the CD lymphocyte population was recollected, and urine, blood, sputum and wound (if infected) cultures were performed. Then, 25 were treated with nystatin wash and swallow, and the others with placebo. Fungal infection and fungal colonization were defined and used as the endpoint of the study. Results Patients not selected for the study did not develop fungal infection. Of the high-risk patients, 20 presented with fungal colonization (12 urine, seven wound and five bloodstream cultures) and 12 presented with subsequent fungal infections. Of these 20 colonized patients, only those with nystatin prophylaxis did not require fungal treatment, whereas controls required treatment. CD4 lymphocyte recount (below 300) was uniformly decreased in all patients with fungal infection. Conclusion Immunodepressed patients at high risk with concomitant fungal colonization develop fungal infections 2–5 days after high-risk surgical procedures. Nystatin prophylaxis in such patients may reduce the degree and severity of fungal infection. If fungal colonization is present and the CD4 lymphocyte count is below 300, fungal treatment might be advisable.

A striking pancreatic juice reflux toward the biliary tree (PR) has frequently been found in subjects with common bile-pancreatic conduit (CBPC) and gallstone-induced acute pancreatitis (SAP). Our aim was to determine the role of the CBPC functional diameter as a potential trigger of PR. The CBPC was calibrated in three groups of patients: (A) patients with gallbladder stones using intraoperative direct cholangiometry (n = 24), (B) patients after surgical removal of common bile duct stones using postoperative cholangiometry via T-drain (n = 6), and (C) patients with SAP using the same procedures as in group B (n = 6). In all patients in groups B and C, aliquots of bile were collected and assayed for pancreatic amylase content. The mean functional diameter of the CBPC varied from 0.80 mm in patients in groups A and B to 0.47 mm in group C (p < 0.001). The bile samples of group B contained low concentrations of amylase, whereas high values could be found in all samples of group C. We conclude that PR is a frequent event occurring after bile duct revision concerning small amounts of pancreatic juice. However, CBPC functional stenosis as seen in patients with SAP obviously induces PR with high amounts of pancreatic juice.