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Gastrocutaneous fistulas are infrequent after gastrostomy tube removal. However, if the fistulous tract remains permeable, even low-volume output can produce significant cutaneous burns. The use of biodegradable adhesives has been described, where fibrin glue is applied directly over the fistulous tract or under the guidance of procedures such as upper or lower gastrointestinal endoscopy or fistuloscopy. We studied the use of fibrin glue in five consecutive adult patients with gastrocutaneous fistulas after gastrostomy tube removal, with no complications that might impede spontaneous closure. A comparison group included seven patients treated during the preceding 2 years with conservative medical management, who were not treated with fibrin glue. There was no difference between the two groups with regard to age and gender, nor with regard to type of gastrostomy (surgical or endoscopic). The mean output volume from the fistulas was 151.4 +/- 146.1 ml/24 h in the study group and 115.0 +/- 42.7 ml/24 h in the control group, which was not significantly different ( P = 0.80). The duration of previous conservative treatment was 93.8 +/- 85.1 days for the study group and 95.8 +/- 80.7 days for the control group and this also did not differ significantly ( P = 0.93). The time to achieve total fistula closure was 7.0 +/- 3.1 days in the study group and 32.7 +/- 15.7 days in the control group. This difference was statistically significant ( P < 0.004). The time required before oral feeding could be recommenced after spontaneous or induced closure was similar in the two groups, at 2.8 +/- 1.3 days and 4.71 +/- 2.36 days, respectively. Endoscopic guidance allows direct instillation of fibrin glue via the external opening through the whole fistulous tract. This procedure reduces the time required for the closure of gastrocutaneous fistulas.

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Central vein catheterization is frequently employed for monitoring, administration of drugs and parenteral nutrition in a variety of medical and surgical illnesses. Despite the widespread use of central vein access, both catheter-related infections and mechanical complications remain unacceptably common. In the last few years, data have become available to show that technical innovations and catheter maintenance protocols can reduce both catheter related bloodstream infections as well as mechanical complications. Future developments should be aimed at both educational intervention and biomaterials research. The former incorporates case-based instruction, problem-solving examination, and database analysis; while the latter will probably lead to a new set of catheters that are more resistant to infection and thrombosis.

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BACKGROUND/AIMS: A retained foreign body in the abdominal cavity following surgery is a continuing problem. Despite precautions, the incidence is grossly underestimated. The purpose of this study is to report the result of surgical treatment on 24 consecutive cases treated by the authors during a 10-year period. METHODOLOGY: All consecutive patients with a confirmed diagnosis of foreign body after abdominal surgery were studied. Data collected included the patients' age and sex, the initial diagnosis and primary surgical treatment, period of time between the probable causative operation and the definitive treatment, nature of the foreign body, clinical presentation, predisposing factors, and diagnosis and management; morbidity and mortality are presented as well as guidelines for prevention. RESULTS: All patients were symptomatic. Eight patients presented as intraabdominal sepsis (4 with intestinal obstruction, 4 with entero- or colo-cutaneous fistula), non-specified abdominal pain in 3, persistent sinus and granuloma in 2, abdominal palpable mass in another 2 cases, and 1 patient with vaginal discharge. The diagnosis was established pre-operatively in 15 cases by means of plain abdominal radiographs, ultrasound or computed tomography (CT) scan. Morbidity was observed in 50% and the rate of surgical reinterventions because of fistulas or residual sepsis in 18%. The mortality was almost 10%. CONCLUSIONS: The clinical manifestations ranged from mild abdominal pain, palpable mass, persistent drainage and granuloma to intestinal obstruction secondary to adhesions or occlusion of the intestinal lumen because of migration of the foreign body and intraabdominal sepsis. Despite this being a rare situation, when it happens it presents as a very serious problem to patients with high rates of morbidity and mortality. Prevention remains the key to the problem.

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A case of malakoplakia of the colon in a 55-year-old female patient with a massive hemorrhage of the rectum is reported. A barium enema showed polypoid lesions (pseudopolyps). Colonoscopy revealed white-yellowish nodules simulating small pustulae all along the colon at 2 cm from the anal verge. A laparatomy disclosed lobulated intraluminal masses and yellowish lesions in the form of transcolonic plates infiltrating the duodenal wall as well as a fair amount of lymph nodes in the mesentery. We performed a proctocolectomy. The histologic study showed massive infiltrate of histiocytes and numerous Michaelis-Gutmann bodies. This disease is usually found in the urinary tract and rarely found in the colon. The importance of proper histologic examination in order to arrive at a correct diagnosis is emphasized.

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We performed a retrospective study in patients undergoing mayor elective surgery of the upper gastrointestinal tract for benign disease receiving perioperative total parenteral nutrition (TPN). We analyzed the clinical charts from patients admitted to the Hospital de Especialidades del Centro Médico de Occidente for this purpose from January 1983 to March 1987, selecting those who had clinical or laboratory criteria of severe malnutrition. They were divided in two groups depending on whether TPN was being indicated as preoperative preparation and continued through the postoperative period (GE = 32 patients), or initiated after surgery (GC = 13 patients). The results show statistical differences in morbidity (GC = 100%, GE = 27%), mortality (GC = 30%, GE = none), need of reoperation (GC = 30%, GE = none) and costs (higher in GE). Complications related to TPN in GC were 23% and 15% in GE, and there were no deaths related on either group. Based on our results, we consider the need of a good selection of candidates to receive preoperative and postoperative TPN when undergoing major elective surgery, which should be continued until they are able to cover their nutritional requirements by oral or enteral route. This applies whenever there is sufficient clinical and laboratory data of severe malnutrition.

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Choledochal cyst are a rare congenital abnormality, seldom treated by the General Surgeon. We report six cases of re-operation found on a eighth year period. Six cysts type I, and one type II (Todani's Classification) were found. On five of them, an internal derivation had been performed, in one patient only a celiotomy was performed, and in another one a colecistectomy. Complete resection of the cyst was performed in six cases. In one female patient, this was impossible, because a carcinoma was found, she died postoperatively. We recommend external bile duct drainage for those cases where a complete resection can not be performed. This option alleviates the symptoms, allows morphological studies and do not compromise the final procedure which must be the complete excision of the cyst.

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From 1977 to 1987, 20 patients (18 men and 2 women) with left post-traumatic diaphragmatic rupture, were managed by the General Surgery Service of the Hospital de Especialidades, Centro Médico de Occidente, IMSS; 13 as urgencies (65%) and 7 as elective procedures (35%). Hernia was due to closed trauma in 80% of the cases. Predominant symptoms were chest pain (85%) and dyspnea (50%). The Stomach was the herniated viscus in 16 instances. CXR showed suggestive data in 95% of the cases. Primary closure was achieved in 95% of the cases, in 8 patients thoraco-abdominal aproach was necessary. There were 50% morbidity (35% athelectasis, 30% wound sepsis) and 10% mortality rates.

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The complications presented by 36 patients submitted to anti-reflux procedures that were treated in our Hospital in a 10 year period, from September 1978 to May 1988, are analyzed. The patients were divided in 2 groups depending on the initial treatment being performed inside or outside our Hospital. The indication for the initial operation was reflux esophagitis in all patients, 4 or whom, had developed a shortened esophagus with stenosis. The selected procedures were of several types with a clear predilection for the Nissen type fundoplication with its variants. Different kinds of complications were observed; mortality was associated with gastric or esophageal leak, with a fatal outcome in 11 patients, another one died of postoperative pancreatitis and abdominal sepsis (33.3 percent mortality rate).

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The association of excessive morbidity and mortality with malnourished states has been well documented. Nutritional assessment should now be an integral part of the evaluation of all hospitalized patients, particularly those scheduled for surgical procedures. Determination of the method of feeding the patient depends on the patient's nutritional status, the level of gastrointestinal function and the type and magnitude of treatment which he will undergo. The enteric route is always preferred when it can be used. If oral and enteral feeding are not possible, either peripheral or central nutrition should be employed. To central route is necessary protocol strictly adhered to be Knowledgeable persons. Artificial Nutrition should be instituted before significant protein deficits develop. It is far easier to maintain a patient's nutritional status than it is to repair nutritional deficits.

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