Endocarditis Bacteriana en Válvula Protésica

La endocarditis es un patología grave, más aún si esta ocurre en una válvula protésica. A continuación el link a un trabajo de revisión realizado por mí y que esta publicada en la Revista Chilena de Cirugía.

http://www.cirujanosdechile.cl/Revista/PDF%20Cirujanos%202003_06/Rev.Cir.6.03.(01).AV.pdf

Conclusiones Inexactas en Metaanálisis de Exámenes Diagnósticos de Cáncer

Un trabajo publicado en el British Journal of Medicine plantea que los análisis sistemáticos sobre exámenes diagnósticos de cáncer tienen serias fallas metodológicas con resultados que no pueden ser necesariamente verdaderos. Un recuerdo del la necesidad del análisis crítico de toda la literatura cuando leemos un trabajo.

http://bmj.bmjjournals.com/cgi/reprint/333/7565/413

Hernioplastia con Malla Técnica Preperitoneal Retrofascial en Hernia Incisional Recurrente

La técnica de corrección de hernias incisionales recurrentes con instalación de malla retrofascial y preperitoneal fue utilizado por un grupo quirúrgico de Carolina del Norte y fue publicado en el Journal of the American College of Surgeons. Muestran buenos resultados. Otro detalle es que la mayoría de los pacientes son obesos.

Open Preperitoneal Retrofascial Mesh Repair for Multiply Recurrent Ventral Incisional Hernias
Yuri W. Novitsky MDa, Justin R. Porter BAa, Zach C. Rucho BAa, Stanley B. Getz MD, FACSb, Broc L. Pratt MDb, Kent W. Kercher MD, FACSa and B. Todd Heniford MD, FACSa, aCarolinas Hernia Center, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NCbDepartment of Plastic Surgery, Carolinas Medical Center, Charlotte, NC.

Background
Because herniorrhaphy failure and complication rates appear proportional to the number of previous repairs, multiply recurrent hernias (MRH) represent a formidable challenge. We sought to determine the safety and efficacy of open preperitoneal retrofascial mesh repair of MRH.
Study design
We conducted a retrospective review of consecutive patients undergoing an open preperitoneal retrofascial mesh repair of multiply (two or more) recurrent hernias at a tertiary care referral center.
Results
From January 2001 to May 2005, 128 patients underwent surgical repair of an MRH; 32 of these underwent an open preperitoneal repair. The average body mass index was 39.1 ± 8.4 kg/m2 (range 28.9 to 61.0 kg/m2). All patients had significant comorbidities; 18.8% were smokers. The number of previous herniorrhaphies was 3.6 (range 2 to 24). Polypropylene mesh was used in all patients, including lightweight polypropylene in 10 (31.2%) patients. The average mesh size was 937 ± 531 cm2 (range 225 to 1,800 cm2). There were no major intraoperative complications. Wound infection occurred in 4 patients (12.5%, all smokers), requiring partial mesh excision in 1 patient. Univariate analysis revealed smoking as the only predictor of wound or mesh-related morbidity (p = 0.0004). At a mean followup of 28.1 months (range 8 to 60 months), there has been 1 recurrence (3.1%) in the patient requiring partial mesh removal.
Conclusions
Open preperitoneal retrofascial mesh repair resulted in an effective herniorrhaphy with low perioperative morbidity in patients with MRH. Smoking cessation appears to be important in minimizing infectious complications. Given the technical challenge, surgical care of patients with MRH may be best provided in referral centers with interest and expertise in complex hernia repairs

Servicios de Cirugía ¿Visión de Empresa?

En su número de agosto la Revista de Cirugía Española publica un interesante artículo en el que hace un simíl entre los servicios de cirugía y empresas con énfasis en la gestión del conocimiento. Al hacer click en el encabezado de este "entry" podrán acceder a Doyma, sitio donde esta publicado este artículo en español, formato PDF.

Eventos Adversos por Profilaxis TVP. Un Metaanalisis

Un metaanálisis que incluyó 33 estudios controlados fue publicado en Archives of Surgery mostró una tasa de eventos adversos de 3%. Un tema importante en cirugía es la prevención de trombosis venosa profunda (TVP) y de embolia pulmonar. A continuación el resumen:

The Rate of Bleeding Complications After Pharmacologic Deep Venous Thrombosis Prophylaxis
A Systematic Review of 33 Randomized Controlled Trials
Michael J. Leonardi, MD; Marcia L. McGory, MD; Clifford Y. Ko, MD
Arch Surg. 2006;141:790-799.

Hypothesis Major bleeding complications from pharmacologic deep venous thrombosis (DVT) prophylaxis are infrequent.
Design Systematic review of the MEDLINE database from 1965 to August 2005, using the terms DVT, prophylaxis, general surgery, and heparin.
Setting and Patients Randomized controlled trials evaluating pharmacologic DVT prophylaxis in patients undergoing general surgery.
Main Outcome Measures Eight complication categories: injection site bruising, wound hematoma, drain site bleeding, hematuria, gastrointestinal tract bleeding, retroperitoneal bleeding, discontinuation of prophylaxis, and subsequent operation.
Results Fifty-two randomized controlled trials studied DVT prophylaxis; 33 randomized controlled trials with 33 813 patients undergoing general surgery evaluated pharmacologic prophylaxis and quantified bleeding complications. Of the minor complications, injection site bruising (6.9%), wound hematoma (5.7%), drain site bleeding (2.0%), and hematuria (1.6%) were most common. Major bleeding complications, such as gastrointestinal tract (0.2%) or retroperitoneal (<0.1%) p =" .02)" p =" .06).">Conclusions Knowledge of bleeding complication rates is important for surgeons because DVT prophylaxis may soon be implemented by Medicare as a quality measure. This level 1 evidence report shows that bleeding complications requiring a change in care occur less than 3% of the time and seem reduced with lower-dose prophylaxis. Given these findings, most patients undergoing general surgery could receive pharmacologic prophylaxis safely.

Tomografia Axial Computada en Trauma Penetrante Absdominal por Arma Blanca

Un estudio prospectivo en un centro de trauma nivel 1 en EEUU analizó la utilidad del TAC en el trauma abdominal penetrante por arma blanca en paciente hemodinamicamente estable. Los autores reportan un valor predictivo negativo de 100%. A continuación el resumen:

Use of Computed Tomography in Anterior Abdominal Stab Wounds
Results of a Prospective Study
Ali Salim, MD; Burapat Sangthong, MD; Matthew Martin, MD; Carlos Brown, MD; David Plurad, MD; Kenji Inaba, MD; Peter Rhee, MD; Demetrios Demetriades, MD
Arch Surg. 2006;141:745-752.

Hypothesis Computed tomography (CT) can be used to evaluate patients with anterior abdominal stab wounds (AASWs).
Design Prospective observational study.
Setting Academic level I trauma center.
Patients and Methods All of the patients sustaining AASWs, excluding those with hemodynamic instability, peritonitis, or omental evisceration, were admitted for serial abdominal examinations with or without CT depending on attending preference. Patients with associated left thoracoabdominal stab wounds underwent diagnostic laparoscopy.
Main Outcome Measures Change in patient management as a direct result of the CT scan findings, as well as sensitivity, specificity, positive predictive value, and negative predictive value of CT scanning calculated against clinical outcome (the need for laparotomy, uneventful discharge without laparotomy, or return to the hospital for adverse events).
Results One hundred fifty-six consecutive patients with AASWs were included over 24 months. Computed tomography was performed for 67 patients (CT group) whereas 89 patients were admitted for serial examination only (no-CT group). Nineteen of the 67 patients in the CT group had positive CT results, leading to laparotomy in 10 patients. Of the 48 patients with negative CT results, 3 underwent diagnostic laparoscopy for an associated thoracoabdominal stab wound and 2 eventually underwent laparotomy for clinical deterioration with negative results. Excluding patients with associated thoracoabdominal stab wounds, the negative predictive value of CT was 100%.
Conclusions In patients with AASWs, CT can be used to identify visceral injuries. It is a promising tool that may identify patients who can be discharged after a shorter period of observation. Further evaluation of its use in patients with AASWs is warranted.

Trauma Duodenal

Las lesiones traumáticas de duodeno son difíciles de diagnósticar y de manejar. El Dr Asensio de la Division de Trauma y Manejo Crítico de USC publicó un muy buen trabajo al respecto en la Revista Chilena de Cirugía 2003.

PDF en español
http://www.cirujanosdechile.cl/Revista/PDF%20Cirujanos%202003_04/Rev.Cir.4.03.(02).pdf

Consenso Manejo Crisis Hipertensiva

La Sociedad Chilena de Hipertensión publicó en 2002 su guías de manejo de crisis HTA, emergecia HTA y urgencia HTA que son definidas por dicho organismo como:

Crisis Hipertensiva, es la situación clínica derivada de un alza de la presión arterial (PA), que obliga a un manejo eficiente, rápido y vigilado de la presión arterial, ya sea por los riesgos que implican las cifras tensionales por si mismas, o por su asociación a una condición clínica subyacente que se agrava con ascensos discretos de la presión arterial. Dentro de ella podemos distinguir:

Emergencia Hipertensiva, es la situación clínica en que la PA es de tal magnitud o, las circunstancias en las que la hipertensión se presenta son de tales caracteres, que la vida del paciente o la integridad de órganos vitales están amenazadas, lo que obliga a su control inmediato en minutos u horas.

Urgencia Hipertensiva es la situación clínica en la que los riesgos de la PA elevada hacen que deba ser controlada en forma rápida, en días, no siendo necesario hacerlo en forma inmediata.

No constituye crisis hipertensiva la hipertensión arterial grado III aislada, que se define como el hallazgo de cifras tensionales elevadas, PA diastólica (PAD) >110 mmHg y <130 sin síntomas y sin amenaza de daño rápidamente progresivo de órganos blanco.

Por esta razón, se debe insistir en lo peligrosa que es la práctica frecuente en algunos Servicios de Urgencia, de considerar como una urgencia o emergencia a cualquier cifra de PA sistólica (PAS) ³180 mmHg o PAD³130 mmHg, en pacientes asintomáticos o con molestias inespecíficas.

http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872002000300013&lng=es&nrm=iso

Prevención de náuseas y vómitos postoperatorios

Las náuseas y vómitos son muy molestos para el paciente en el postoperatorio inmediato, sin olvidar el riesgo siempre presente de aspiración ante la presencia de vómito. Un estudio prospectivo reciente realizado en Chile y publicado en la Révista Médica de Chile compara los efectos de dexametasona, droperidol y ondansetrón en este grupo de pacientes. Les doy la dirección al artículo en español y formato pdf que se encuentra a libre acceso en Scielo.
Además, coloco el resumen de un artículo similar publicado en el NEJM.

http://www.scielo.cl/pdf/rmc/v134n6/art04.pdf
Eficacia de la dexametasona en el tratamiento agudo de náuseas y vómitos posoperatorios: Comparación con droperidol y ondansetrón.
MUNOZ, Hernán R, IBACACHE, Mauricio E y MERTZ, Verónica F.
Rev. méd. Chile, jun. 2006, vol.134, no.6, p.697-702. ISSN 0034-9887.

Background: Dexamethasone is useful as prophylaxis for postoperative nausea and vomiting (PONV).
Aim: To study the short term efficacy of dexamethasone to treat PONV in adults without prophylaxis, and compare its efficacy with that of droperidol and ondansetron.
Material and methods: A prospective study was performed with 120 consecutive adult patients presenting PONV in the postanesthesia care unit (PACU) at a University teaching hospital. During the occurrence of PONV, patients were randomized to receive in a double blind manner dexamethasone 8 mg IV (Group 1, n=40), droperidol 1.25 mg IV (Group 2, n=40), or ondansetron 2 mg IV (Group 3, n=40). Risk factors for PONV were recorded. Evaluations were made until discharge from the PACU and included presence of PONV, degree of sedation, and other potential adverse effects of the study drugs. Short term efficacy was defined as the percentage of patients free of PONV during all the stay in PACU after treatment.
Results: General data was similar for the 3 groups. Mean ± SD stay in PACU after treatment was 101±34 minutes in Group 1, 93±33 minutes in Group 2, and 99±32 minutes in Group 3 (NS). Short term efficacy (CI 95%) was 55% (40-70%) in Group 1, 90% (81-99%) in Group 2, and 63% (48-78%) in Group 3 (p <0.05>Conclusions: Short term efficacy of dexamethasone to treat PONV was similar to ondansetron, but inferior to droperidol. Further studies are needed to define the duration of this effect of dexamethasone.

A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting
Christian C. Apfel, M.D., Kari Korttila, F.R.C.A., Ph.D., Mona Abdalla, Ph.D., Heinz Kerger, M.D., Alparslan Turan, M.D., Ina Vedder, M.D., Carmen Zernak, M.D., Klaus Danner, M.D., Ritva Jokela, M.D., Ph.D., Stuart J. Pocock, Ph.D., Stefan Trenkler, M.D., Markus Kredel, M.D., Andreas Biedler, M.D., Daniel I. Sessler, M.D., Norbert Roewer, M.D., for the IMPACT Investigators
N Engl J Med 1994; 350(24):2441-2451
ABSTRACT
Background Untreated, one third of patients who undergo surgery will have postoperative nausea and vomiting. Although many trials have been conducted, the relative benefits of prophylactic antiemetic interventions given alone or in combination remain unknown.
Methods We enrolled 5199 patients at high risk for postoperative nausea and vomiting in a randomized, controlled trial of factorial design that was powered to evaluate interactions among as many as three antiemetic interventions. Of these patients, 4123 were randomly assigned to 1 of 64 possible combinations of six prophylactic interventions: 4 mg of ondansetron or no ondansetron; 4 mg of dexamethasone or no dexamethasone; 1.25 mg of droperidol or no droperidol; propofol or a volatile anesthetic; nitrogen or nitrous oxide; and remifentanil or fentanyl. The remaining patients were randomly assigned with respect to the first four interventions. The primary outcome was nausea and vomiting within 24 hours after surgery, which was evaluated blindly.
Results Ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26 percent. Propofol reduced the risk by 19 percent, and nitrogen by 12 percent; the risk reduction with both of these agents (i.e., total intravenous anesthesia) was thus similar to that observed with each of the antiemetics. All the interventions acted independently of one another and independently of the patients' baseline risk. Consequently, the relative risks associated with the combined interventions could be estimated by multiplying the relative risks associated with each intervention. Absolute risk reduction, though, was a critical function of patients' baseline risk.
Conclusions Because antiemetic interventions are similarly effective and act independently, the safest or least expensive should be used first. Prophylaxis is rarely warranted in low-risk patients, moderate-risk patients may benefit from a single intervention, and multiple interventions should be reserved for high-risk patients.

Gastrectomia en manga II

Dada las múltiples consultas respecto a la gastrectomia en manga (sleeve gastrectomy) les doy el link a una presentación gratis disponible en la web realizada por Lee y cols y que esta disponible en la página del American College of Surgeons.

Presentación en inglés.

http://www.facs.org/education/gs2004/gs33lee.pdf

Let the music play...en pabellón

Un trabajo publicado en JAMA hace 12 años mostró que hay efectos positivos del punto de vista de respuesta fisiológica y velocidad cuando el cirujano escucha música elegida por él o ella. La respuesta era menor cuando no era música seleccionada por el cirujano y aún menor cuando no existía música en pabellón. Trabajos posteriores han mostrado efectos beneficiosos también para pacientes con anestesia regional, y en aquellos con anestesia general al menos hay beneficio durante la inducción y fin de la anestesia.

Effects of music on cardiovascular reactivity among surgeons
JAMA 1994; 272 (10):882-4.
K. Allen and J. Blascovich Department of Psychology, State University of New York at Buffalo 14260.
OBJECTIVE--To determine the effects of surgeon-selected and experimenter-selected music on performance and autonomic responses of surgeons during a standard laboratory psychological stressor.
DESIGN--Within-subjects laboratory experiment.
SETTING--Hospital psychophysiology laboratory.
PARTICIPANTS--A total of 50 male surgeons aged 31 to 61 years, who reported that they typically listen to music during surgery, volunteered for the study.
MAIN OUTCOME MEASUREMENTS--Cardiac responses, hemodynamic measures, electrodermal autonomic responses, task speed, and accuracy.
RESULTS--Autonomic reactivity for all physiological measures was significantly less in the surgeon-selected music condition than in the experimenter-selected music condition, which in turn was significantly less than in the no-music control condition. Likewise, speed and accuracy of task performance were significantly better in the surgeon-selected music condition than in the experimenter-selected music condition, which was also significantly better than the no-music control condition.
CONCLUSION--Surgeon-selected music was associated with reduced autonomic reactivity and improved performance of a stressful nonsurgical laboratory task in study participants.