Impacto de la Cirrosis en el Trauma

Impact of Cirrhosis on Outcomes in Trauma
Abstract presented at the Pennsylvania ACS Committee on Trauma resident paper competition, Harrisburg, PA, October 29, 2004; and the Regional ACS Committee on Trauma resident paper competition, Washington, DC, December 4, 2004.
Dale A. Dangleben MD, a, Omid Jazaeri MDa, Thomas Wasser PhDa, Mark Cipolle MD, PhDa and Michael Pasquale MD, FACSa aDepartment of Surgery, Lehigh Valley Hospital, Allentown, PA. Received 2 June 2006; revised 27 July 2006; accepted 1 August 2006. Available online 2 October 2006.

Background
Cirrhosis as an independent predictor of poor outcomes in trauma patients was identified in 1990. We hypothesized that the degree of preinjury hepatic dysfunction is, by itself, an independent predictor of mortality.
Study design
The trauma registry at our Level I trauma center was queried for all ICD-9 codes for liver disease from 1999 to 2003, and patients were categorized as having Child-Turcotte-Pugh (CTP) class A, B, or C cirrhosis. Data analyzed included age, mechanism of injury, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), hospital length of stay, ventilator days, procedures performed, transfusion of blood products, admission lactate, base deficit, and mortality. Trauma Related Injury Severity Score (TRISS) methodology was used to calculate the probability of survival. Outcomes data were analyzed, and statistical comparison was performed using group t-test.
Results
Of the 50 patients meeting study criteria, 31 had alcohol-related cirrhosis, 18 had a history of hepatitis C, and 1 had cryptogenic cirrhosis. Twenty (40%) met CTP A classification, 16 (32%) met CTP B criteria, and 14 (28%) had CTP class C cirrhosis. One death occurred in the CTP A and B groups. Comparison between the five survivors and nine nonsurvivors from CTP class C showed no statistical significance in terms of age, ISS, TRISS, or GCS.

Conclusions
The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS, although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP C criteria must be considered when determining outcomes for patients posttrauma.

Administración Oportuna de Antibioticos Profilácticos

Timely Administration of Prophylactic Antibiotics for Major Surgical Procedures
Mary T. Hawn MD, MPH, FACS, †, , , Stephen H. Gray MD, †, ‡, Catherine C. Vick MS, †, Kamal M. Itani MD, FACS§, , Michael J. Bishop MD¶, Diana L. Ordin MD, MPH and Thomas K.

Background
Prophylactic antibiotics (PA) given within 60 minutes before surgical incision decrease risk of subsequent surgical site infection. Nationwide quality improvement initiatives have focused on improving the proportion of patients who receive timely prophylactic antibiotics.

Study design
This is a cohort study of major surgical procedures performed in 108 Veterans Affairs hospitals between January and December 2005. Using data from the External Peer Review Program and the National Surgical Quality Improvement Program, we examined factors associated with timely PA administration. Univariate and multivariable analyses were performed.

Results
There were 8,137 major surgical procedures: cardiac (2,664), hip and knee arthroplasty (3,603), colon (1,142), arterial vascular (606), and hysterectomy (122). Timely PA occurred in 76.2% of patients, 18.2% received them too early, and 5.4% received them too late. Early administration accounted for 79% of untimely PA. Differences in timeliness were seen by procedure type (68% to 87%; p < 0.0001), admission status (67% to 80%; p < 0.0001), and antibiotic class (65% to 89%; p < 0.0001). PA administration occurred in the operating room for 63.5% of patients. When PA administration occurred in the operating room, they were timely in 89% of patients, compared with 54% of patients where administration was outside the operating room (odds ratio, 7.74; 95% CI = 6.49 to 9.22).

Conclusions
Early PA administration accounted for the majority of inappropriately timed PA. Efforts to improve performance on this measure should focus on administering antibiotics in the operating room.

¿Cuál es la utilidad de aVR en el electrocardiograma?

Electrocardiographic applications of lead aVR

Kelly Williamsona, Amal Mattu MDb, Claire U. Plautz MDc, d, e, Allan Binder MDc and William J. Brady MDc, d, e, ,

Abstract
Lead aVR, 1 of 12 electrocardiographic leads, is frequently ignored in clinical medicine. In fact, many clinicians refer to the 12-lead electrocardiogram (ECG) as the 11-lead ECG, noting the commonly held belief that lead aVR rarely offers clinically useful information. In this report, we discuss the findings in lead aVR, which are potentially of value, including ST-segment elevation in the patient with acute coronary syndrome suggestive of left main coronary artery occlusion, PR-segment elevation in the patient with acute pericarditis, prominent R wave in the patient with significant tricyclic antidepressant poisoning, and ST-segment elevation in narrow complex tachycardia suggestive of Wolff-Parkinson-White syndrome.

Industria Farmaceutica ¿Entrega toda la informaciòn a los médicos?

Ya ocurrió con los inhibidores selectivos de la Cox-2, y con una estatina, que tras iniciar su comercialización masiva se informó de efectos adversos severos que llevaron a su retiro del mercado. Un caso similar esta ocurriendo con la aprotinina. Un articulo publicado en NEJM toca este interesante tema, en relación a este último fármaco.

http://content.nejm.org/cgi/reprint/355/21/2169.pdf

Dilatación pneumatica vs miotomía quirúrgica en acalasia

Pneumatic Dilatation and Surgical Myotomy for Achalasia
Steven R. Lopushinsky, MD, MSc; David R. Urbach, MD, MSc
JAMA. 2006;296:2227-2233.

Context Pneumatic dilatation and surgical (Heller) myotomy are the 2 principal methods for treatment of achalasia. There are no population-based studies comparing outcomes of these 2 treatments in typical practice settings.
Objective To compare the outcomes of pneumatic dilatation and surgical myotomy for achalasia.
Design, Setting, and Participants Retrospective longitudinal study using linked administrative health data in Ontario. A total of 1461 persons aged 18 years or older received treatment for achalasia between July 1991 and December 2002, 1181 (80.8%) of whom had pneumatic dilatation and 280 (19.2%) of whom had surgical myotomy as the first procedure.
Main Outcome Measures Use of subsequent interventions for achalasia (pneumatic dilatation, surgical myotomy, or esophagectomy) following the first treatment during the study period, subsequent physician visits, and use of gastrointestinal medications among persons aged 65 years or older. We adjusted for confounding variables using regression models.
Results The cumulative risk of any subsequent intervention for achalasia after 1, 5, and 10 years, respectively, was 36.8%, 56.2%, and 63.5% for persons treated initially with pneumatic dilatation and was 16.4%, 30.3%, and 37.5% for persons treated initially with surgical myotomy (adjusted hazard ratio [HR], 2.37; 95% confidence interval [CI], 1.86-3.02; P<.001). Differences in risk were observed only when subsequent pneumatic dilatation was included as an adverse outcome; there was no statistical difference between the 2 groups with respect to the risk of subsequent surgical myotomy or esophagectomy. Compared with persons treated initially with surgical myotomy, those treated with pneumatic dilatation were not statistically different with respect to subsequent physician visits (adjusted rate ratio, 1.01; 95% CI, 1.00-1.03), or time to use of histamine-2 receptor blockers (adjusted HR, 1.19; 95% CI, 0.79-1.80), proton pump inhibitors (HR, 1.02; 95% CI, 0.70-1.49), and prokinetic medications (HR, 0.92; 95% CI, 0.60-1.41).
Conclusions Subsequent intervention after the initial treatment of achalasia is common. Although the risk of subsequent interventions among persons treated with surgical myotomy in typical practice settings is higher than previously thought, the risk of subsequent intervention is greater among persons treated with pneumatic dilatation than with surgical myotomy. This difference is attributable to the use of subsequent pneumatic dilatation rather than surgical procedures.

Uso rutinario de suplementación de calcio en la tiroidectomia total:un estudio

Routine oral calcium and vitamin D supplements for prevention of hypocalcemia after total thyroidectomy
Jong-Lyel Roh M.D., Ph.D.a, , and Chan Il Park M.D., Ph.D.b aDepartment of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736 Republic of KoreabDepartment of Otolaryngology-Head and Neck Surgery, Cancer Research Institute, Chungnam National University College of Medicine, Daejeon, Republic of Korea

Background
The purpose of this study was to evaluate the clinical usefulness of routine oral calcium and vitamin D supplements in the prevention of hypocalcemia after total thyroidectomy.
Methods
Ninety patients who underwent total thyroidectomy were randomly assigned to routinely receive or not receive a supplement containing oral calcium (3 g/d) and vitamin D (1 g/d) for 2 weeks. Hypocalcemic signs and symptoms, serum calcium, and parathyroid hormone (PTH) levels were monitored and compared between the 2 groups.
Results
The incidences of symptomatic and laboratory hypocalcemia were significantly lower in the oral calcium/vitamin D group than in the group not receiving the supplement: 3 of 45 patients (7%) versus 11 of 45 (24%) and 6 of 45 (13%) versus 16 of 45 (36%), respectively (P ≤ .02). The hypocalcemic symptoms were minimal in the supplement group but more severe in the group not receiving the supplement. Serum calcium levels decreased in both groups after surgery but recovered earlier in the supplement group. No hypercalcemia or PTH inhibition developed in the supplement group.
Conclusion
Routine administration of a supplement containing oral calcium and vitamin D is effective in reducing the incidence and severity of hypocalcemia after total thyroidectomy.

Análisis de resistencia entre distintos tipos de malla de prolene: un modelo porcino

Textile Analysis of Heavy Weight, Mid-Weight, and Light Weight Polypropylene Mesh in a Porcine Ventral Hernia Model
Presented at the 38th Annual Meeting of the Association for Academic Surgery in Houston, TX, November 11–13, 2004.
William S. Cobb M.D.a, Justin M. Burns M.D.a, Richard D. Peindl Ph.D.a, Alfredo M. Carbonell D.O.a, Brent D. Matthews M.D.a, Kent W. Kercher M.D.a and B. Todd Heniford M.D., a, aDepartment of General Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina

Background
The purpose of this study was to assess the burst strength and stiffness of heavy weight (HW), mid-weight (MW), and light weight (LW) polypropylene mesh pre-implantation and 5 months post-implantation in a porcine ventral hernia model.
Materials and methods
HW (95 g/cm2), MW (45 g/cm2), and LW (28 g/cm2) polypropylene were tested as dry samples (n = 8/mesh) before implantation using a stamp strain machine. Three weeks after creating four hernia defects in each mini-pig (n = 18), the polypropylene meshes (8 × 10 cm; 24/mesh type) were implanted in the preperitoneal space, ensuring 2 cm overlap circumferentially. At 5 months, the mesh was harvested en bloc with the abdominal wall. Testing of burst strength and stiffness was repeated on the ex vivo specimens.
Results
After implantation in the pig for 5 months, the mean burst strength and stiffness of HW and MW meshes remains the same. LW mesh with an absorbable monofilament in its weave has significant reductions in mean burst strength (P = 0.01) and mean stiffness.

Conclusion
A reduction in mean burst strength and stiffness occurs after 5 months implantation of LW polypropylene mesh with an absorbable monofilament. All meshes exhibited burst strengths that were much greater than the burst strength of the abdominal wall fascia alone. After tissue incorporation, the LW polypropylene mesh maintains mean burst strength comparable to MW polypropylene mesh, while becoming less stiff than HW mesh. Long-term, this may contribute to more physiological abdominal wall compliance after LW polypropylene mesh implantation.

Medición de saturación de oxígeno en mucosa colónica durante cirugía aortica

Intraoperative Colon Mucosal Oxygen Saturation During Aortic Surgery
Presented at the 1st Annual Academic Surgical Congress held February 7–11, 2006, San Diego, CA.
Eugene S. Lee M.D., Ph.D., , , Arie Bass M.D.†, Frank R. Arko M.D.‡, Maarit Heikkinen M.D.§, E. John Harris M.D.§, Christopher K. Zarins M.D.§, Pieter van der Starre M.D.¶ and Cornelius Olcott M.D.§ †Department of Surgery, Saklar School of Medicine, Tel Aviv, Israel‡Department of Surgery, UT Southwestern Medical Center at Dallas, Dallas, TexasDepartment of Surgery, University of California, Davis, California§Department of Surgery, Stanford University, Stanford, California¶Department of Anesthesiology, Stanford University, Stanford, California

Background
Colonic ischemia after aortic reconstruction is a devastating complication with high mortality rates. This study evaluates whether Colon Mucosal Oxygen Saturation (CMOS) correlates with colon ischemia during aortic surgery.
Materials and methods
Aortic reconstruction was performed in 25 patients, using a spectrophotometer probe that was inserted in each patient’s rectum before the surgical procedure. Continuous CMOS, buccal mucosal oxygen saturation, systemic mean arterial pressure, heart rate, pulse oximetry, and pivotal intra-operative events were collected.
Results
Endovascular aneurysm repair (EVAR) was performed in 20 and open repair in 5 patients with a mean age of 75 ± 10 (±SE) years. CMOS reliably decreased in EVAR from a baseline of 56% ± 8% to 26 ± 17% (P < p =" 0.81).

Conclusions
Intra-operative CMOS is a sensitive measure of colon ischemia where intraoperative events correlated well with changes in mucosal oxygen saturation. Transient changes demonstrate no problem. However, persistently low CMOS suggests colon ischemia, thus providing an opportunity to revascularize the inferior mesenteric artery or hypogastric arteries to prevent colon infarction.

Cirugía Robotica y Laparóscopica

La revista de Cirugía Española en su número de noviembre de este año publica un artículo referente a la cirugía minimamente invasiva y el uso de robótica. En español. PDF. Para acceder a él hacer click sobre el título de esta entrada.

Trócares en Cirugía Laparoscópica: Preguntas Frecuentes

La revista Contemporary Surgery publicó este mes un simposio en el cual especialista responde preguntas frecuentes respecto a los trócares en cirugía laparoscópica. En inglés. Formato PDF.

http://www.contemporarysurgery.com/pdf/6211/6211CS_Symposium2.pdf

Hemorragia Digestiva

Un breve análisis a la hemorragia digestiva alta y baja y su manejo multidisciplinario. Publicado en Contemporary Surgery noviembre 2006. Inglés. PDF.

http://www.contemporarysurgery.com/pdf/6211/6211CS_Review.pdf