Mejoras en el manejo del trauma esplenico contuso

Estudio retrospectivo que analiza los resultados de un centro medico en el manejo conservador del trauma esplenico contuso.

Improved outcome of adult blunt splenic injury: A cohort analysis
Presented at the 63rd Annual Meeting of the Central Surgical Association, Louisville, Kentucky, March 9-11, 2006.
Ravi R. Rajani MDa, Jeffrey A. Claridge MDa, Charles J. Yowler MDa, Pamela Patrick MDa, Amanda Wiant BAa, Jessica I. Summers MDa, Amy A. McDonald MDa, John J. Como MDa and Mark A. Malangoni MD, a aDepartment of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio Received 28 February 2006; accepted 10 July 2006. Available online 28 September 2006.

Background
The purpose of this study was to review our 15-year experience in the treatment of blunt splenic injury in adults. Our hypothesis was that the implementation of a change in practice, with stress on splenic preservation and splenic artery embolization for the management of splenic injury, would result in improved splenic salvage rates without negatively affecting mortality rates.
Methods
A retrospective cohort analysis was performed on all consecutive adults with blunt splenic injury who were admitted to a Level One Trauma Center. The cohorts were defined by 2 separate 7.5-year periods (1991-1998 and 1998-2005).
Results
Six hundred twenty-five patients with blunt splenic trauma were identified; 403 patients who were treated from 1998 to 2005 were compared with 222 patients whose cases had been reviewed previously (1991 to 1998). The present cohort differed in age (35 vs 40 years; P < .001) and injury severity score (27 vs 21; P < .0001). Nonoperative treatment was implemented in 136 patients (61%) in the initial cohort and 344 patients (85%) in the present cohort. The frequency of splenic artery embolization increased from 2.7% to 22.6% (P < .001). The success of nonoperative management increased from 77% to 96% (P < .001); the splenic salvage rate for all patients improved from 57% to 88% (P < .0001). Hospital mortality rates decreased from 12% to 6% (P < .001), and the mean hospital length of stay decreased from 15 to 9 days (P < .001). Conclusion
These results demonstrate that the success of nonoperative management and the splenic preservation for blunt injury has improved over time. This improvement correlated with a greater use of splenic artery embolization

Insuficiencia Renal Aguda

El British Journal of Medicine publicó este mes una revision sobre insuficiencia renal aguda y su manejo. A continuación el link al PDF en inglés.

http://bmj.bmjjournals.com/cgi/reprint/333/7572/786

Necesidad de Manejar la Hiperglicemia Postoperatoria

Un aspecto poco buscado en el postoperatorio es evitar la hiperglicemia generada por el estrés quirúrgico. En esta revisión publicada en la Revista Española de Cirugía se señalan los aspectos fisiopatológicos y provee sugerencias paraprevenirlo. PDF en español.

Hacer click en título de esta entrada para acceder al documento completo.

Hiperglucemia postagresión quirúrgica. Fisiopatología y prevención
La respuesta del organismo a la agresión quirúrgica incluye no sólo una marcada reducción de la sensibilidad a la acción de la insulina, con la consecuente hiperglucemia, sino también alteraciones en los valores plasmáticos de lípidos, ácidos grasos, aminoácidos y proteínas, y de las moléculas involucradas en la respuesta inflamatoria, como interleucinas, calicreína y factores de coagulación. La resistencia a la insulina se desarrolla prácticamente en respuesta a cualquier tipo de agresión quirúrgica, y existe evidencia creciente de que no es beneficiosa para la evolución postoperatoria. Estudios recientes han mostrado que el ayuno induce un estado metabólico que no es favorable para los pacientes sometidos a cirugía programada. La resistencia a la insulina postoperatoria puede minimizarse si el estado de ayuno preoperatorio se sustituye por una carga de hidratos de carbono, administrados por vía oral o intravenosa.

Fístula Pancréatica Tras Operación de Whipple

Current management of pancreatic fistula after pancreaticoduodenectomy
Presented at the 63rd Annual Meeting of the Central Surgical Association, Louisville, Kentucky, March 9-11, 2006.
Gerard V. Aranha MD, FRCS (C), FACSa, b, , , Joshua M. Aaron BSa, Margo Shoup MD, FACSa and Jack Pickleman MD, FACSa aDivision of Surgical Oncology, the Department of Surgery, Loyola University; Stritch School of Medicine, Maywood, IllinoisbGeneral Surgical Service, Hines VA Hospital, Hines, Ill Received 13 February 2006; accepted 13 July 2006. Available online 28 September 2006.
Background
Pancreatic fistula (PF) is a major and serious complication following pancreaticoduodenectomy (PD). The purpose of this study was to outline our management of PF after PD.
Methods
A retrospective review of a prospectively collected database of 396 patients undergoing PD for various indications at Loyola University Medical Center and Hines Veterans Administration Hospital from July 1, 1990, to December 31, 2005. Patients were divided group 1 (no PF) and group 2 (PF). Each group was compared regarding preoperative, intraoperative, and postoperative outcomes.
Results
Of the patients included in the study, 65 patients (16%) developed a PF. PF was more common after PD for ampullary neoplasms (28%), duodenal neoplasms (35%), and serous cystic neoplasms (44%), and was uncommon after PD for pancreatic cancer (6%). Associated complications with PF was 51% when compared with patients with no PF (21%; P ≤ .001). Duration of hospital stay was 16 days in PF versus 9 days in no PF (≤.001). Intraoperative blood loss was greater in the PF versus no PF group (P = .01). Clinically serious postoperative complications in the PF versus no PF group were mortality (P = .03), intraabdominal abscess (P ≤ .001), wound infection (P ≤ .001), hemorrhage (P = .01), cardiac (P ≤ .001), bile leak (P ≤ .001), and reoperation (P = .02). Of the 62 surviving patients with PF, 36 (58%) were treated with maintenance of oral diet, 25 (40%) with parenteral nutrition, and 1 (1.6%) required surgery for closure of PF.
Conclusions
PF is a serious complication after PD and is associated with substantial mortality and other complications. The majority of patients with PF can be managed conservatively with either maintenance of oral diet or parenteral nutrition until closure of the PF.