El síndrome piriforme constituye una de las causas de dolor pélvico debido al atrapamiento del nervio ciático por el músculo piriforme. En la actualidad es un síndrome de difícil diagnóstico. El objetivo de este estudio es conocer la prevalencia de variaciones anatómicas en nuestra población que puedan contribuir a la aparición del síndrome piriforme. También se estudian medidas antropométricas del músculo piriforme y el nervio ciático para su posible aplicación en procedimientos de la región glútea. El estudio se realizó en 59 pelvis de 32 cadáveres criopreservados. Las variaciones anatómicas del músculo piriforme y del nervio ciático encontradas se describieron según la clasificación de Beaton y Anson. Se realizaron mediciones antropométricas de ambas estructuras con referencia al trocánter mayor del fémur. El nervio ciático y el músculo piriforme presentaban una variación anatómica en un 28,13%. La variación más frecuente fue la de tipo II (21,64%) y la de tipo III (6,49%). La inserción observada con mayor frecuencia fue un tendón independiente del músculo piriforme insertado en la fosa trocantérea, con un 53,85%. La incidencia de variaciones anatómicas en la población estudiada indica que son importantes como diagnóstico diferencial de posibles dolores en la región glútea ya que los síntomas y signos del síndrome piriforme se asemejan a la patología discal vertebral con afectación radicular. Además, el conocimiento anatómico de esta región puede ser útil en la interpretación con técnicas de imagen, especialmente cuando se realizan inyecciones guiadas por ecografía. The piriformis syndrome is one of the etiologies of pelvic pain due to the sciatic nerve's entrapment by the piriformis muscle. Nowadays this syndrome might be difficult to be diagnosed. The aim of this study is to know the prevalence of anatomic variations in our population that may contribute to the appearance of piriformis syndrome. Furthermore, anthropometric measurements of the piriformis muscle and the sciatic nerve procedures are studied for a possible application in the gluteal region. The study was carried out in 59 pelvis of 32 cryopreserved bodies. The anatomical variations of piriformis and sciatic nerve founded were described following the Beaton and Anson's classification. Anthropometric measurements of both structures with reference to the greater trochanter of the femur were performed. The sciatic nerve and the piriformis had an anatomical variation in a 28.13%. The most frequent variation found was tipus II (21.64%) and tipus III (6.49%).Insertion most frequently observed was an independent piriformis tendon inserted into the trochanteric fossa with 53.85%. The anatomic variations' incidence in the population studied indicates that those have to be evaluated as a differential diagnosis of gluteal region pain due to the symptoms and signs resemblance with the vertebral disc pathology involving nerve root injury. In addition, anatomical knowledge of this region can be useful for the interpretation of imaging techniques, especially when ultrasound-guided injections are performed.

OBJECTIVE:The piriformis syndrome is one of the etiologies of pelvic pain due to the sciatic nerve's entrapment by the piriformis muscle. Nowadays this syndrome might be difficult to be diagnosed. The aim of this study is to know the prevalence of anatomic variations in our population that may contribute to the appearance of piriformis syndrome. Furthermore, anthropometric measurements of the piriformis muscle and the sciatic nerve procedures are studied for a possible application in the gluteal region. MATERIAL AND METHOD:The study was carried out in 59 pelvis of 32 cryopreserved bodies. The anatomical variations of piriformis and sciatic nerve founded were described following the Beaton and Anson's classification. Anthropometric measurements of both structures with reference to the greater trochanter of the femur were performed. RESULTS:The sciatic nerve and the piriformis had an anatomical variation in a 28.13%. The most frequent variation found was tipus II (21.64%) and tipus III (6.49%).Insertion most frequently observed was an independent piriformis tendon inserted into the trochanteric fossa with 53.85%. CONCLUSION:The anatomic variations' incidence in the population studied indicates that those have to be evaluated as a differential diagnosis of gluteal region pain due to the symptoms and signs resemblance with the vertebral disc pathology involving nerve root injury. In addition, anatomical knowledge of this region can be useful for the interpretation of imaging techniques, especially when ultrasound-guided injections are performed.

BACKGROUND/AIMS Gastric cancer staging based on the number of positive lymph nodes is not reliable in patients undergoing limited lymphadenectomies. The aim of the present study was to determine the prognostic influence of lymph node ratio (LR)--defined as the number of metastatic nodes divided by total of obtained nodes--in patients with less than 16 analyzed lymph nodes. METHODOLOGY Seventy-two gastric cancer patients underwent surgery with a curative intention, obtaining less than <16 nodes. The pN (TNM 5th Ed) and LR were studied in a multivariate analysis (Cox regression). LR was classified in four groups: 0, <40%, 40-79%, and >80%, according to a previous study carried out by the authors. RESULTS Neither the number of affected lymph nodes nor LR behaved as independent prognostic factors. Nevertheless, when locally advanced tumors were studied separately, the lymph node ratio gave more precise prognostic information, resulting in the identification a group of patients with the same pN stage who presented with different prognoses. CONCLUSIONS LR offers better prognostic information than the number of affected lymph nodes in patients with locally advanced gastric tumors undergoing limited lymphadenectomies. Further studies are needed to confirm these results and standardize the stratification of LR.

Background Most gastric adenocarcinomas in western countries are locally advanced, and these tumours are often associated with metastatic spread at the time of diagnosis. It is controversial whether palliative surgery can improve symptom control in gastric cancer patients with peritoneal carcinomatosis. Objective To determine the need of palliative procedures and survival in patients affected by gastric cancer with peritoneal carcinomatosis managed without resection. Methods and materials After standard preoperative staging, 160 patients were diagnosed with resectable gastric adenocarcinoma. Laparoscopy was performed in 107 patients (66.9%), finding peritoneal spread in 22 of them (21%). Seventeen of these patients were not submitted to any additional surgical procedure. Data regarding postoperative morbidity and mortality, need of endoscopic, percutaneous or surgical procedures to palliate symptoms, hospital stay and survival were collected. The same data were collected for the 6 non-resected patients who were diagnosed with carcinomatosis by laparotomy. Results In the “laparoscopy alone” group, there were 2 minor complications and no postoperative mortality. Mean postoperative stay was 6 days. Eight patients had to be readmitted to hospital for symptoms derived from tumour progression, and 10 palliative endoscopic procedures were performed. Surgical interventions were not needed in any case. Mean survival was 11.5 months. Patients submitted only to laparotomy presented higher morbidity and mortality rates, with a longer postoperative stay and survival of less than 5 months. Conclusions Laparoscopic staging of gastric cancer can help to avoid unnecessary laparotomies. In patients with peritoneal carcinomatosis diagnosed by laparoscopy, nonsurgical treatment has low morbidity and mortality and permits good symptom relief with no shortening of survival.

Background There is an association between the number of resected lymph node and the number of metastatic lymph nodes in gastric cancer, suggesting that pN category could be influenced by the extension of the lymphadenectomy. This study evaluates this association and proposes a comprehensive use of the ratio as prognostic factor. Method Review of 183 consecutive patients with gastric adenocarcinoma. The association between the number of resected lymph nodes and the number of metastatic lymph nodes was analysed and evaluated with other prognostic factors. Results The number of lymph node metastases increased with the number of resected lymph nodes. The lymph node ratio was a better prognostic factor than the number of metastatic lymph nodes. Conclusions The metastatic lymph node ratio seems to be a good prognostic factor, but needs further evaluation.

La incontinencia fecal puede causar un déficit importante en la calidad de vida de los pacientes y originar sociopatías graves. Numerosos pacientes afectados de incontinencia fecal adoptan hábitos sociales y conductas que evitan las relaciones personales. Las claves diagnósticas de estos trastornos y las opciones terapéuticas, todavía en desarrollo, están escasamente sistematizadas. La neurofisiología de la defecación está todavía por aclarar y depende de la integridad de las estructuras anatómicas y neuronales, así como de la correcta coordinación de muchos sistemas mecánicos y presivos que permiten el desarrollo de este automatismo, que se aprende en los primeros años de vida. La exploración estructural del canal anal debe combinarse con un estudio neurofisiológico que nos permita ahondar en el conocimiento de estos trastornos, catalogar mejor a los pacientes e indicar diferentes alternativas terapéuticas con mayor eficacia. La aparición de la estimulación de raíces sacras, que basa su efecto terapéutico en la neuromodulación, debe implicar a los cirujanos en el conocimiento de las bases neurológicas de la defecación y las exploraciones que deberían realizarse en todos los pacientes con incontinencia fecal.

La fístula de ano (FA) es una entidad con una alta incidencia. La mayoría es simple y su tratamiento quirúrgico altamente resolutivo. Sin embargo, hay un grupo de fístulas con unas características que las convierten en complejas, tanto desde el punto de vista de su diagnóstico como de su tratamiento.

Los defectos funcionales de la musculatura esfinteriana del canal anal, sin defectos estructurales aparentes, conllevan en muchas ocasiones incontinencia en forma de urgencia e incluso incontinencia insensible. En consecuencia, los pacientes presentan déficit importantes en su calidad de vida. El presente estudio muestra los resultados obtenidos en 9 pacientes con incontinencia fecal que han recibido estimulación de las raíces sacras (ERS) de forma permanente. Se incluyó a pacientes con incontinencia de más de un episodio a la semana y esfínter anal externo normal por ecografía (intacto o reparado). En todos ellos, el tratamiento médico previo había fallado, así como la terapia de biofeedback. En una primera fase los pacientes recibieron estimulación percutánea. En caso de presentar una reducción mínima del 50% en los episodios de incontinencia, el paciente fue candidato a implante del electrodo definitivo, así como de un generador de impulsos que se colocó en el espacio subcutáneo y que mantuvo la estimulación de forma continua. El seguimiento se realizó al mes y a los 3, 6 y 12 meses. En él se incluyó un diario de incontinencia (21 días), una manometría anal y un estudio de la calidad de vida (CV) mediante cuestionarios (SF-36 y el de la American Society of Colorectal Surgeons [ASCRS]), realizados en cada seguimiento. Entre junio de 1999 y septiembre de 2002 se testó a 18 pacientes y se incluyó en el estudio a los nueve que fueron candidatos a implante definitivo, es decir, que completaron la terapia. Las pacientes (todas ellas mujeres) tenían una edad media de 53,1 años (rango, 37-65 años). El diario basal de incontinencia mostró en una media de 10,2 ± 6,2 episodios de incontinencia a la semana. Se evidenció una reducción de la incontinencia media del 81% a los 6 meses (p < 0,0001), y se mantuvo la mejoría al año de seguimiento. Asimismo, se observó una mejoría significativa en la CV de las pacientes. La ERS resulta una terapia eficaz para la reducción del número de episodios de incontinencia en las pacientes con incontinencia fecal funcional. La mejoría en la continencia tiene un efecto directamente relacionado con el incremento de calidad de vida de las pacientes. Functional defects of the sphincter musculature of the anal canal, without apparent structural defects, frequently produces urge incontinence and even incontinence due to loss of sensation. Consequently, quality of life may be significantly impaired. The aim of this study was to present the results obtained in nine patients with fecal incontinence who received definitive stimulator implants. Patients with more than one episode of incontinence per week and normal anal sphincter findings (intact or repaired) on ultrasonography were included. All patients were unresponsive to prior medical treatment and biofeedback therapy. In the first phase, the patients received percutaneous stimulation. If a minimum reduction of 50% in incontinence episodes was achieved, the patient was considered a candidate for implantation of a definitive electrode as well as an impulse generator placed in the subcutaneous space, maintaining continuous stimulation. Follow-up was performed at months 1, 3, 6 and 12 and included an incontinence diary (21 days), anal manometry and quality of life evaluation using two questionnaires (SF-36 and ASCRS), administered at each follow-up visit. From June 1999 to September 2002, 18 patients were evaluated, including nine patients who had completed therapy and were candidates for a definitive implant. All the patients were women with a mean age of 53.1 years (37-65). The baseline incontinence diary showed a mean of 10.2 ±6.2 incontinence episodes per week. A mean reduction in incontinence of 81% was observed at 6 months (p < 0.0001) and this improvement was maintained at 1 year of followup. In addition, the patients’ quality of life significantly improved. Sacral nerve stimulation is effective in reducing the number of incontinence episodes in patients with functional fecal incontinence. Improved continence is directly related to increased quality of life.

Describir el abordaje laparoscópico de la oclusión de intestino delgado susceptible de tratamiento quirúrgico y analizar su capacidad como técnica diagnóstica y de tratamiento en pacientes seleccionados, evaluando las complicaciones y su impacto en la recuperación postoperatoria de los pacientes. Estudio prospectivo descriptivo de 18 pacientes seleccionados, intervenidos por laparoscopia en régimen de urgencias. Criterios de inclusión: ausencia de contraindicación médica o anestésica y disponibilidad técnica y/o tecnológica del equipo de guardia. Criterios de exclusión: enfermedad inflamatoria intestinal activa, antecedente de neoplasia o radioterapia abdominal y/o laparotomías previas múltiples. El abordaje laparoscópico permitió la exploración completa del intestino delgado en el 100% de los casos, identificar la causa de la oclusión en el 94,4% y resolverla en todos los pacientes (en 2 mediante laparoscopia asistida), excepto en uno. El tiempo operatorio promedio fue de 87 min. No ha habido mortalidad ni complicaciones postoperatorias mayores. Ha habido 2 complicaciones menores en 18 pacientes (11,1%). La estancia hospitalaria promedio fue de 5 días y el retorno a la actividad normal se efectuó al cabo de 12,3 días. Ningún paciente ha presentado recurrencia ni ha requerido reintervención tras un seguimiento medio de 20 meses. El abordaje laparoscópico es una alternativa eficaz para tratar una oclusión de intestino delgado en pacientes estrictamente seleccionados, dados sus buenos resultados terapéuticos y su baja morbilidad. No obstante, la complejidad técnica del procedimiento en determinados casos de oclusión impide su recomendación sistemática. To describe the laparoscopic approach in small bowel obstruction suitable for surgical treatment and to analyze its effectiveness as a diagnostic and therapeutic technique in selected patients by evaluating complications and its impact on postoperative recovery. We performed a prospective descriptive study in 18 selected patients who underwent emergency laparoscopy. Inclusion criteria were the absence of medical or anesthetic contraindication and technical and/or technologic availability of the duty team. Exclusion criteria were active inflammatory bowel disease, a history of abdominal neoplasia or radiotherapy and/or multiple previous laparotomies. The laparoscopic approach allowed complete exploration of the small bowel in 100% of the patients and identification of the cause of obstruction in 94.4%. In all but one patient, laparoscopy resolved the obstruction (assisted laparoscopy was used in two). The mean operating time was 87 minut. There was no mortality and there were no major postoperative complications. Minor complications occurred in 11.1% (two complications in 18 patients). The mean length of hospital stay was 5 days and return to normal activity occurred at 12.3 days. None of the patients has shown recurrence or required reintervention after a mean follow-up of 20 months. Given its good therapeutic results and low morbidity, the laparoscopic approach constitutes an effective alternative in the treatment of small bowel obstruction in strictly selected patients. Nevertheless, because of the technical complexity of the procedure in certain cases of occlusion, the systematic use of this technique is not advisable.

We report the case of a 52-year-old woman who underwent scheduled laparoscopic resection of a hydatid liver cyst under general anesthesia by infusion of remifentanil and sevoflurane. Surgery was uneventful, although invasive monitoring was required, just as it would have been in major open abdominal surgery, given the risk of bleeding secondary to organ manipulation, the risk of anaphylactic shock related to the etiology of the cyst and the possibility of gas embolism related to laparoscopy. The concept of "minimally invasive" surgery has developed thanks to continued progress in laparoscopy. The considerable advantages of such procedures in comparison with "open" or "conventional" surgery has led to their use with organs such as the liver, which in principle require caution. In such cases, the anesthesiologist must take an approach that is not as simple or minimalist as the term "minimally invasive" might lead us to expect.

S r. Dire c t o r : La extubación precoz en cirugía card i a c a pediátrica es un tema de vigente actualidad y enorme interés según demu e s t ra el trabajo de Fi g u e i ra Moure et al. Hemos de felicitar a los autores por el trabajo pre s e n t a d o , los resultados obtenidos y la excelente discusión ofre c i d a sobre el tema, máxime tratándose de pacientes pediátricos, donde este tipo de estudios es escaso. También quisiéramos p l a n t e a rles una serie de cuestiones, que tras la lectura del m i s m o , nos parece que no han quedado sufi c i e n t e m e n t e matizadas: 1. Nos parece muy adecuada la inducción anestésica inhalatoria con sevoflurano previo a la canalización de la vía venosa, pero no comprendemos porqué se añade pentotal 35 mg/Kg. Pensamos que no hubiese sido necesario. 2. No está suficientemente detallado el tiempo que permanecieron intubados los pacientes en la UCIP en el grupo II (fentanilo 37,6±15 μg/Kg) ni porqué en este grupo todos los pacientes necesitaron mórficos en el postoperat o ri o , frente al 20% del grupo I (fentanilo 7± 2 μg/Kg más morfina caudal). Pensamos que quizá se deba a que al tratarse de un grupo históri c o , el protocolo inicial en la UCIP fuese mantener a los pacientes intubados un periodo de tiempo utilizando la clásica pauta de sedación con mórficos más benzodiacepinas. Si esto fuese así puede sesgar mucho los resultados. Nos planteamos esta cuestión porque el protocolo habitual de nuestro servicio es muy similar al protocolo II (dosis altas de fentanilo en torno 25-50 μg/Kg, d ep e ndiendo la duración de la CEC); con el mismo conseguimos una extubación precoz, entre 1-3 horas en el postoperatorio i n m e d i at o , p e ro ya en la Unidad de Reanimación. Por lo tanto opinamos que la dife rencia entre ambos pro t o c o l o s está en conseguir la extubación inmediata en quirófano o de forma precoz en la Unidad de Reanimación, lo cual no puede suponer mayor estancia en la UCI ni en el hospital. Además es ex c epcional que tengamos que utilizar opiáceos, pues la analgesia se controla con metamizol y ansiolíticos ocasionales (midazolam 0,1 mg/Kg IV), muy útiles para evitar cuadros de agitación, típicos del niño por ausencia de los padres, que corren el riesgo de auto extraerse los sistemas de monitorización y drenaje. 3. No está detallado si se aplicaron en alguno de los grupos antifi b rinolíticos y/o ultra fi l t ración modificada. Pe n s amos que es posible que así lo fuera beneficiándose el grupo I sobre el grupo histórico, debido a que son técnicas de uso rutinario en pediatría actualmente, permitiendo una extubación más pre c o z , d i s m i nu yendo las complicaciones y la estancia en UCI. Nuestra duda surge porque llama la atención el ahorro de hemoderivados de este grupo (transfusión en el 38% de los pacientes) que además incl u ye pat o l og í a t e ó ricamente más compleja, respecto al grupo II (tra n s f usión en el 48% de los pacientes), que aunque no sea estadísticamente signifi c at iva (posiblemente por el tamaño muestral), sí hay una llamativa diferencia. 4. Respecto al aspecto económico y para añadir más controversia, pensamos que el hecho de realizar una extubación p recoz en las 3 pri m e ras horas del postoperat o rio no tiene porqué incrementar las complicaciones ni el gasto sanitario, ya que los pacientes tienen asignado una enfe rm e ra y un re s p i rador por cama y ap o rta una serie de ventajas como, menor posibilidad de agitación y sangrado secundari o , calentamiento estable y uniforme, radiología torácica y analíticas completas realizadas, mayor control médico del riesgo de sangrado mediastínico, etc. En cambio, el protocolo I alarga en 20 min la estancia en quirófano afectando quizás su rendimiento y número de intervenciones por sesión, más todavía si hubiese que suspender la cirugía por una supuesta punción caudal traumática. Nos gustaría se aclarasen estas cuestiones, ya que facilitarían al lector la credibilidad de los brillantes resultados del protocolo I frente al II.

Valorar la seguridad, la efectividad y la tolerancia del fosfato sódico (NaP) y el polietilenglicol (PEG) en la preparación para la cirugía colorrectal. Cincuenta pacientes fueron prospectivamente aleatorizados, ingiriendo 90 ml de NaP o 4 l de PEG el día anterior a la cirugía. La seguridad del preparado se valoró con un análisis previo y tras la administración. En un detallado cuestionario los pacientes valoraron la facilidad de cumplimiento, la cantidad de fármaco ingerida, las molestias asociadas y el sabor; si habían recibido un preparado previo, valoraron la dificultad en completar la pauta, el grado de malestar y el sabor. La eficacia fue valorada por el cirujano abriendo la pieza quirúrgica. El estudio estadístico se realizó mediante la prueba de la U de Mann Whitney y el test de Shapiro-Wilk. Se apreció una mayor facilidad de cumplimiento en el grupo NaP con una significación estadística de p = 0,0001. El grado de cumplimiento de la preparación fue mayor en el grupo NaP (97,20 ± 10,6) respecto al PEG (90,21 ±16,4) (p = 0,034). No hubo diferencias en el grado de malestar ni en las molestias asociadas al preparado evacuante (p = 0,45). De los pacientes que habían recibido preparación para colonoscopia, los del grupo NaP tuvieron una menor dificultad en completar el tratamiento y en el grado de malestar (p < 0,001). No hubo diferencias en el sabor del producto (p = 0,4) ni en el grado de limpieza conseguido. El grupo NaP presentó un incremento en los valores de fósforo previo (3,4 ± 0,7) respecto a la determinación posterior a la ingesta de evacuante (4,2 ± 0,9) y un descenso en los valores de calcio tras la ingesta de NaP (9,4 ± 0,4 frente a 8,9 ± 0,2), ambos con significación estadística (p = 0,01 y p = 0,02, respectivamente), sin repercusión clínica. Se observó un descenso en los valores de potasio en ambos grupos (NaP, 4,3 ± 0,4; PEG, 3,8 ± 0,4), con significación estadística (p = 0,01), aunque sin repercusión clínica. En ningún caso se describieron reacciones adversas. Ambas soluciones son efectivas y seguras. La solución de NaP tiene una facilidad, un grado de cumplimiento y un grado de aceptación mayores que el PEG. Se ha observado una hiperfosfatemia e hipocalcemia estadísticamente significativa en el grupo NaP sin repercusiones clínicas. To assess the safety, efficacy and tolerability of sodium phosphate (NaP) and polyethylene glycol (PEG) in the preparation for colorectal surgery. 50 patients were prospectively randomized taking 90 ml of NaP or 4 liters of PEG the day before surgery. The safety of the solution was assessed with a previous and posterior blood analysis. In a questioner the patient evaluated the easiness of compliance, the amount of drug taken, the discomfort associated and taste. Patients who had previously talen a cleansing treatment assessed the difficulty to complete the regimen, the degree of discomfort and the taste. Cleansing efficacy was assessed by a surgeon opening the surgical piece. The statistical analysis was performed using the Mann-Whitney’s test and the Shapiro-Wilk test. An easier compliance was seen in the NaP group with a statistically significant difference p = 0.0001. Compliance with the preparation was higher in the NaP group (97.20 ± 10.6) than the PEG group (90.21 ± 16.4; p = 0.034). No differences were seen in the discomfort associated with the preparation (p = 0.45). The NaP group of patients who had previously received preparation for colonoscopy had less difficulty to complete the cleansing treatment and less discomfort (p < 0.001). There were no differences in taste (p = 0.4) nor in the degree of cleansing achieve. In the NaP group a statistically significant increase was seen (p = 0.01) from previous phosphorus levels (3.4 ± 0.7) in the measurement made after receiving the solution (4.2 ± 0.9) and also a significant decrease was seen in calcium levels (9.4 ± 0.4 vs 8.9 ± 0.2; p = 0.02). There was no clinical significance. In both groups a reduction in potassium levels was observed (NaP, 4.3 ± 0.4; PEG, 3.8 ± 0.4; p = 0.01) but not clinically significant. No adverse reactions were reported. Both solutions are effective and safe. The NaP solution is easier to administrate, has a better patient compliance, and is better accepted by the patient than the PEG. A statistically significant hyperphosphatemia and hypocalcemia were found in the NaP group. But casused no clinical signs.

Gallbladder stasis and gallstone formation are well-known complications of both fasting-associated total parenteral nutrition (TPN) and long-term treatment with octreotide. Additive noxious effects to hepatobiliary function may develop when both therapies are given together as treatment of enteric fistulae. The aim of this study was to assess the risk of gallstone formation during treatment with TPN and octreotide separately and in combination. We studied four groups of New Zealand rabbits (n = 32) during a 2-week intervention period: 14 chow-fed controls; 6 fasted and TPN-fed; 6 chow-fed and administered octreotide, and 6 fasted and treated with both TPN and octreotide. After treatment, the bile duct was cannulated and the gallbladder and liver tissue were obtained for histological analysis. Hepatic and gallbladder bile were retrieved for microscopic examination and measurement of biliary lipids, bilirubin, calcium, total protein, and cholesterol nucleation time. The chemical composition of gallstones was also analyzed. The results of the study suggest that simultaneous administration of these two therapies in rabbits has additive effects on gallbladder stasis and bile lithogenicity. The administration of both treatments can play an important role in the formation of calcium palmitate gallstones in these animals.

Gallbladder stasis and gallstone formation are well-known complications of both fasting-associated total parenteral nutrition (TPN) and long-term treatment with octreotide. Additive noxious effects to hepatobiliary function may develop when both therapies are given together as treatment of enteric fistulae. The aim of this study was to assess the risk of gallstone formation during treatment with TPN and octreotide separately and in combination. We studied four groups of New Zealand rabbits (n = 32) during a 2-week intervention period: 14 chow-fed controls; 6 fasted and TPN-fed; 6 chow-fed and administered octreotide, and 6 fasted and treated with both TPN and octreotide. After treatment, the bile duct was cannulated and the gallbladder and liver tissue were obtained for histological analysis. Hepatic and gallbladder bile were retrieved for microscopic examination and measurement of biliary lipids, bilirubin, calcium, total protein, and cholesterol nucleation time. The chemical composition of gallstones was also analyzed. The results of the study suggest that simultaneous administration of these two therapies in rabbits has additive effects on gallbladder stasis and bile lithogenicity. The administration of both treatments can play an important role in the formation of calcium palmitate gallstones in these animals.

Introduction: Duodenal villous adenoma arising from the ampulla of Vater has a high risk of malignant development. Excluding associated malignant disease prior to resection of an adenoma of the ampulla is not always possible. Therefore, the surgical procedure of choice to treat this rare tumour is still controversial. Objective: To evaluate retrospectively results of treatment of villous adenoma arising from ampulla of Vater with dysplasia or associated carcinoma limited to the ampulla. Patients and Methods: From 1985 to 1996, eight patients have been diagnosed with ampullary villous adenoma suitable for resection. We have reviewed treatment, morbidity, mortality, follow-up and final outcome. Results: Pancreatoduodenectomy (PD) was performed in 4 patients. Transduodenal ampullectomy and endoscopic resection was performed in 2 patients each. There was no perioperative mortality. None of the patients had biliary, pancreatic or intestinal leakage but two patients who underwent PD had minor postoperative complications. The mean follow-up was 44 (range: 6–132) months. Villous adenoma was associated with adenocarcinoma in 50% of the cases (4/8 patients). During the followup both patients who underwent transduodenal ampullectomy developed recurrent disease. All patients initially treated by PD are alive without evidence of recurrent disease. Conclusions: Treatment of villous adenoma of the ampulla must be individualized within certain limits. In our series, PD achieve good results and it appears to be the procedure of choice in order to treat villous adenomas with proved presence of carcinoma, carcinoma in situ or severe dysplasia. Endoscopic or local resection may be appropriate for small benign tumours in high risk patients.