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Total mesorectal excision and surgeon experience are prognostic factors in rectal cancer surgery, in terms of local recurrence and conservative sphincter surgery. Pre-operative radiation-chemotherapy can even improve those results. The aim of this study is to assess the utility of pre-operative radiation therapy (PRT) on the results of surgical treatment for rectal cancer comparing two consecutive series of patients operated on by surgeons with experience in rectal cancer surgery according to whether they had received PRT. Retrospective review of 118 patients with rectal cancer, divided into two groups: group I, 57 patients without pre-operative radiation-chemotherapy, and group II, 61 patients with rectal cancer who received pre-operative radiation-chemotherapy. Both groups were homogeneous. The short-term results (surgical technique, post-operative stay, post-operative complications) and long-term results (local recurrences, liver metastases and both overall and tumour-related survival) were analysed. The rate of anterior resection in the lower third was significantly higher (p = 0.037) in group II than in group I (56 vs 23%), the rate of abdominoperineal resection in the middle third was significantly lower (p = 0.046) in group II (3.5 vs 21%). The incidence of post-operative complications was similar in both groups, but the rate of anastomotic leaks was higher in group II. The local recurrences was lower in group II (p = 0.002), but the disease free survival and the overall survival was similar in both groups. At the multivariate analysis, the only prognostic factor for the local recurrence was the use of pre-operative radiation-chemotherapy. Besides surgeon experience and total mesorectal excision, a very important prognostic factor is the administration of pre-operative radiation-chemotherapy in cases of locally advanced rectal cancer, as it does not increase post-operative morbidity and mortality and significantly influences the rate of local recurrences and the conservative sphincter surgery.

Thrombosis of the portal-mesenteric axis is an infrequent cause of intestinal ischemia or infarction. In addition to the multiple acquired factors that contribute to the development of this entity, hereditary risk factors, especially the factor V Leiden mutation and the G20210A mutation of the prothrombin gene, have been implicated. The G20210A mutation of the prothrombin gene is found in up to 40% of patients with splenic-portal-mesenteric thrombosis. The present case illustrates the unusual and nonspecific presentation of this mutation in the form of diarrhea and images of thrombosis of the superior mesenteric-portal vein and cavernous transformation of the portal vein. Delayed diagnosis is highly frequent since the clinical signs, laboratory investigations and radiological tests do not suggest the diagnosis. The patient received anticoagulant treatment and showed clinical improvement with complete portal-mesenteric recanalization. Currently the diagnostic technique of choice is magnetic resonance angiography or computerized tomography angiography and treatment consists of indefinite anticoagulation. This case illustrates that an unusual or atypical localization of venous thrombosis may be a manifestation of thrombophilia, emphasizing the importance of genetic screening in these cases.

Resumen Introduccion La colecistectomia realizada por via laparoscopica se acompana de una incidencia de lesiones iatrogonicas de la via biliar principal mayor que cuando se realiza por via abierta. Estas lesiones son mas graves, al ser mas altas en su localizacion, afectando a la via biliar intrahepatica y con frecuente desaparicion de tramos completos de la misma, lo que dificulta su diagnostico y tratamiento quirurgico. Pacientes y metodo Se presentan 10 casos de lesiones iatrogenicas de la via biliar principal tras colecistectomia laparoscopica intervenidos en nuestro servicio, tres de ellos con afectacion de la via biliar intrahepatica. En los 7 casos de localizacion extrahepatica se practico una hepaticoyeyunostomia en “Y” de Roux en 4 casos, una coledococoledocostomia terminoterminal sobre tubo en “T” de Kehr en otros 2 casos (en ambos hubo que realizar posteriormente una hepaticoyeyunostomia en “Y” de Roux) y, en el restante, un cierre de una seccion parcial del coledoco sobre un tubo en “T” de Kehr. En los 3 casos de lesion intrahepatica fracaso una primera reconstruccion en “Y” de Roux, precisando un abordaje intrahepatico con tutores multiples y nueva hepaticoyeyunostomia en “Y” de Roux. Resultados Todos los enfermos se encuentran asintomaticos y con unas analiticas normales tras un seguimiento medio de 39,2 meses. Conclusion Las lesiones iatrogenicas de la via biliar principal tras colecistectomia laparoscopica pueden requerir cirugia compleja para su tratamiento, por lo que deben ser referidas a centros con experiencia experiencia en cirugia hepatobiliar, sobre todo si son de localizacion intrahepatica.

We present 200 patients, from the period January 1988 to July 1990, who received surgery for biliary lithiasis and required opening of the common bile duct. The patients were divided into two groups a

Twenty-four-hour gastric pH measurement was used to study duodenogastric reflux. To differentiate between gastric hyposecretion and duodenogastric reflux, we also measured bile acid concentrations in the gastric juice, and regarded pH increases to above 4 as possible episodes of reflux. The procedure was used in 60 patients, divided into the following groups: (1) control group (ten patients); (2) duodenal ulcer (ten patients); (3) type 1 gastric ulcer (five patients); (4) type 3 gastric ulcer (five patients); (5) bilateral truncal vagotomy plus pyloroplasty (ten patients); (6) truncal vagotomy plus Billroth I partial gastrectomy (ten patients); and (7) truncal vagotomy plus Billroth II partial gastrectomy (ten patients). The amount of reflux (areas of pH > 4) in the type I gastric ulcer and Billroth 1 and Billroth II groups was significantly greater than that found in the control, duodenal ulcer, type 3 gastric ulcer and truncal vagotomy plus pyloroplasty groups. The mean concentration of total bile acids was also greater in the gastrectomized patients than in the rest of the groups studied. In the type 1 gastric ulcer group the mean bile acid concentration was similar to that of the control group.

Over a period of 12 years, 1,039 patients were operated on at our hospital for gastroduodenal peptic ulcer. We analyzed the indications for surgery and divided the patients into two groups: subjects o

A prospective study of 200 consecutive patients with suspected acute appendicitis was performed to compare open and laparoscopic appendicectomy. Formal randomization was precluded by instrument availability. Some 100 patients underwent laparoscopic appendicectomy (conversion to laparotomy was carried out in five) and 100 had conventional surgery. The groups were similar in sex ratio, age, degree of appendiceal inflammation and antibiotic treatment. The mean duration of open appendicectomy was 46 min and of the laparoscopic procedure 51 min (P not significant). Postoperative complications in patients who underwent laparoscopic appendicectomy included: intraabdominal abscess (two patients), wound infection (one), early bowel obstruction (four all resolved with medical treatment) and umbilical haematoma (two). There were no reoperations in the immediate or late postoperative period. Complications after open operation were: wound infection (seven patients) (P < 0·05), early bowel obstruction (five; three resolved with medical treatment, two required surgery) and haematoma of the Surgical wound (one). The mean hospital stay was 4·8 days for laparoscopic appendicectomy and 6·0 days for the open operation (P < 0·05). There were no deaths.

We present a series of 56 patients with gastrointestinal bezoar following previous gastric surgery for gastroduodenal peptic ulcer. The following parameters were studied: factors predisposing to bezoar formation (type of previous surgery, alimentation, and mastication), form of clinical presentation, diagnostic tests, and treatment. A bilateral truncal vagotomy plus pyloroplasty had been performed previously on 84% of patients, 44% revealed excessive intake of vegetable fiber, and 30% presented with bad dentition. The most frequent clinical presentation was intestinal obstruction (80%). This was diagnosed mainly by clinical data and simple abdominal radiology. The main exploratory technique for diagnosing cases of gastric bezoar was endoscopy. Surgery is necessary for treating the intestinal forms, and one should always attempt to fragment the bezoar and milk it to the cecum, reserving enterotomy and extraction for cases where this is not possible. The small intestine and stomach should always be explored for retained bezoars. Gastric bezoars should always receive conservative treatment, endoscopic extraction, and/or enzymatic dissolution; gastrotomy and extraction should be performed when this fails.

A prospective study was made of three procedures for treating the perineal wound and presacral cavity in 102 patients undergoing abdominoperineal excision for cancer of the rectum: (1) packing of the presacral space after suture of the pelvic peritoneum; (2) suture of the pelvic peritoneum and perineal wound, leaving two drains through the perineum; and (3) no suture of the pelvic peritoneum, and primary closure of the perineal wound, leaving drains through the abdomen for physiological saline irrigation. The parameters analysed were incidence of infection, primary healing of the perineum, extraperineal complications and mean hospital stay. Primary healing of the perineum was best with method 3, and overall incidence of infection highest with method 2. There were no differences between the methods with regard to extraperineal complications. Hospital stay was shortest with method 3.

The continuous 99mTc-HIDA infusion test is presented as a method for measuring duodenogastric reflux as well as for studying biliary elimination of the compound when it is administered by constant intravenous infusion. Thirty patients were studied: (a) ten patients with a T tube placed in the biliary tree were used to study the elimination of 99mTc-HIDA in the bile; (b) ten normal subjects were used as a control group; and (c) ten patients were studied who had undergone Billroth I gastrectomy for peptic ulcer ation. Studies of subjects in groups (b) and (c) were used to assess duodenogastric reflux by this test, correlating it with the measurement of bile acids in gastric juice. When 99mTc-HIDA was administered by constant intravenous infusion it resulted in an increased elimination in bile for the first 80–100 min, and the concentration in bile then remained relatively constant for the rest of the test. With respect to the duodenogastric reflux study group, reflux rates in the patients who had been operated on were higher than those in the control group, with statistically significant differences. Minimum reflux rates were found in the normal subjects. Assessment of reflux by 99mTc-HIDA correlated closely with the results of bile acid concentrations in Billroth I patients (r = 0·75, P < 0·001) and control subjects (r = 0·85, P < 0·001). Our results demonstrate that continuous 99mTc-HIDA perfusion is a useful, accurate and objective method for measuring duodenogastric reflux.

Frequently, patients present with symptoms after cholecystectomy (pain or discomfort in the upper part of the abdomen, postprandial fullness, bile vomiting, among others). Duodenogastric reflux has been associated with these symptoms in some patients. Therefore, this study was done to investigate this relationship.We evaluated duodenogastric reflux (DGR) in ten healthy patients, in ten patients who had asymptomatic simple cholecystectomy, in ten patients who had asymptomatic cholecystectomy with supraduodenal choledochoduodenostomy (CD), and in ten patients who had cholecystectomy plus CD followed by discomfort in the upper abdomen, postprandial fullness and bile vomiting, but no colicky pain or acute cholangitis. Duodenogastric reflux was quantified using continuous intravenous infusion of technetium-99m labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequently determining its concentration in gastric juice.All of the patients who underwent operation, whatever the technique used, had higher reflux rates than those in the control group (p0.001). Moreover, reflux rates were comparable in the patients who underwent simple cholecystectomy compared with patients in the asymptomatic cholecystectomy plus CD group. Conversely, when patients with cholecystectomy plus CD presented with discomfort in the upper part of the abdomen as well as bile vomiting, they had higher reflux rates than patients who underwent simple cholecystectomy (p0.001) and asymptomatic patients with associated CD (p0.001).Our results suggest that DGR must be involved in the genesis of these dyspeptic symptoms.

In patients undergoing gastric operations, we studied the relationship between data suggesting alkaline reflux gastritis (symptoms, endoscopic alterations and histologic lesions) and two factors that produce chronic gastritis (helicobacter pylori and duodenogastric reflux). Of 225 patients who underwent operations for gastroduodenal gastric ulcer at our General Surgery Unit between 1980 and 1982, 63 agreed to undergo endoscopy and biopsies. Of these 63 patients, 38 agreed to a test to quantify duodenogastric reflux (24 hour gastric pH monitoring associated with the determination of bile acids in gastric juice). According to the clinical questionnaire, patients were classified as symptomatic and asymptomatic. Endoscopy was considered either normal with mucosal lesions or mucosal lesions plus bile. In the histologic study, we considered normal mucosa, superficial chronic gastritis and atrophic chronic gastritis. Furthermore, the presence of atrophy, metaplasia, foveolar hyperplasia and helicobacter pylori was studied. Symptoms, endoscopic alterations and histologic lesions were not significantly related to helicobacter pylori, but were significantly related to the quantity of duodenogastric reflux. The symptomatic patients presented with a greater quantity of reflux than the asymptomatic patients (p0.05). The patients with mucosal lesions plus bile who had endoscopy showed a greater quantity of reflux than those with normal endoscopy (p0.001) and those with mucosal lesions without bile (p0.02 for pH values and p0.001 for bile acids). The patients with atrophic chronic gastritis presented with a greater quantity of reflux than those with normal mucosa and superficial chronic gastritis (p0.05, respectively), and the patients with atrophy and metaplasia and foveolar hyperplasia had more reflux than those without (p0.001, respectively). The patients who were helicobacter positive and negative presented with similar quantities of reflux.

Duodenogastric reflux is quantified in ten patients with biliary lithiasis and a functioning gallbladder, before and six months after performing cholecystectomy. The results are compared with those of a control group (n = 10) with similar age and gender, without gastric or hepatobiliary pathologic factors. To evaluate reflux, we used six hour continuous intravenous infusion and subsequent determination in gastric juice of 99mTc-diethyliminodiacetic acid. Our results showed that patients with cholelithiasis have higher reflux rates than those in the control group (p0.001). When comparing patients before and after cholecystectomy, we confirmed that removal of the gallbladder produces a significant increase (p0.001) in reflux rates compared with preoperative values.