Fenotipos Médicos: Ganan los Cirujanos (Apoyado por la Evidencia)

Un estudio publicado esta semana en el British Journal of Medicine explica porque "algunas caracteristicas fenotipicas" especiales se concentran entre los cirujanos. Un interesante y divertido artículo

http://www.bmj.com/cgi/reprint/333/7582/1291

Estrategias en Peritonitis por Enfermedad Diverticular Complicada: Operación de Hartmann vs Resección Primaria y Anastomosis

Operative Strategies for Diverticular Peritonitis: A Decision Analysis Between Primary Resection and Anastomosis Versus Hartmann's Procedures.
Annals of Surgery. 245(1):94-103, January 2007.
Constantinides, Vasilis A. MBBS *; Heriot, Alexander FRCS *; Remzi, Feza MD +; Darzi, Ara FRCS, KBE *; Senapati, Asha FRCS ++; Fazio, Victor W. MD +; Tekkis, Paris P. FRCS *+

Objective: To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmann's procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis.

Summary Background Data: The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure.

Methods: Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations.

Decision analysis from the patient's perspective was used to calculate the optimal operative strategy and sensitivity analysis performed.

Results: A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmann's procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively.

Conclusion: Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.

¿Es Posible Reducir la Tasa de Sepsis por Cateter Venoso Central?

An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU
New Engl J Med 2006;(355) 2725-32
Peter Pronovost, M.D., Ph.D., Dale Needham, M.D., Ph.D., Sean Berenholtz, M.D., David Sinopoli, M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara Cosgrove, M.D., Bryan Sexton, Ph.D., Robert Hyzy, M.D., Robert Welsh, M.D., Gary Roth, M.D., Joseph Bander, M.D., John Kepros, M.D., and Christine Goeschel, R.N., M.P.A.

Background Catheter-related bloodstream infections occurring in the intensive care unit (ICU) are common, costly, and potentially lethal.

Methods We conducted a collaborative cohort study predominantly in ICUs in Michigan. An evidence-based intervention was used to reduce the incidence of catheter-related bloodstream infections. Multilevel Poisson regression modeling was used to compare infection rates before, during, and up to 18 months after implementation of the study intervention. Rates of infection per 1000 catheter-days were measured at 3-month intervals, according to the guidelines of the National Nosocomial Infections Surveillance System.

Results A total of 108 ICUs agreed to participate in the study, and 103 reported data. The analysis included 1981 ICU-months of data and 375,757 catheter-days. The median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months after implementation of the study intervention (P0.002), and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up (P<0.002). The regression model showed a significant decrease in infection rates from baseline, with incidence-rate ratios continuously decreasing from 0.62 (95% confidence interval [CI], 0.47 to 0.81) at 0 to 3 months after implementation of the intervention to 0.34 (95% CI, 0.23 to 0.50) at 16 to 18 months.

Conclusions An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.

Riesgo de Fractura de Cadera Asociado al Uso Prolongado de Inhibidores de la Bomba de Protones

Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture
Yu-Xiao Yang, MD, MSCE; James D. Lewis, MD, MSCE; Solomon Epstein, MD; David C. Metz, MD
JAMA. 2006;296:2947-2953.

Context Proton pump inhibitors (PPIs) may interfere with calcium absorption through induction of hypochlorhydria but they also may reduce bone resorption through inhibition of osteoclastic vacuolar proton pumps.

Objective To determine the association between PPI therapy and risk of hip fracture.

Design, Setting, and Patients A nested case-control study was conducted using the General Practice Research Database (1987-2003), which contains information on patients in the United Kingdom. The study cohort consisted of users of PPI therapy and nonusers of acid suppression drugs who were older than 50 years. Cases included all patients with an incident hip fracture. Controls were selected using incidence density sampling, matched for sex, index date, year of birth, and both calendar period and duration of up-to-standard follow-up before the index date. For comparison purposes, a similar nested case-control analysis for histamine 2 receptor antagonists was performed.

Main Outcome Measure The risk of hip fractures associated with PPI use.

Results There were 13 556 hip fracture cases and 135 386 controls. The adjusted odds ratio (AOR) for hip fracture associated with more than 1 year of PPI therapy was 1.44 (95% confidence interval [CI], 1.30-1.59). The risk of hip fracture was significantly increased among patients prescribed long-term high-dose PPIs (AOR, 2.65; 95% CI, 1.80-3.90; P<.001). The strength of the association increased with increasing duration of PPI therapy (AOR for 1 year, 1.22 [95% CI, 1.15-1.30]; 2 years, 1.41 [95% CI, 1.28-1.56]; 3 years, 1.54 [95% CI, 1.37-1.73]; and 4 years, 1.59 [95% CI, 1.39-1.80]; P<.001 for all comparisons).

Conclusion Long-term PPI therapy, particularly at high doses, is associated with an increased risk of hip fracture.

Impacto de la Resección Laparóscopica del Cáncer Colorrectal en los Resultados Quirúrgicos y Sobrevida

Impact of Laparoscopic Resection for Colorectal Cancer on Operative Outcomes and Survival.
Annals of Surgery. 245(1):1-7, January 2007.
Law, Wai Lun MS, FRCS (Edin), FACS; Lee, Yee Man MBBS, FRCS (Edin); Choi, Hok Kwok MBBS, FRCS (Edin); Seto, Chi Leung MBBS, FRCS (Edin); Ho, Judy WC MBBS, FRCS (Edin), FCRS (Engl), FACS

Objective: This study aimed to compare the outcomes of patients who underwent laparoscopic and open resections for colorectal cancer. Comparison of colectomy in 2 consecutive periods (period 1: January 1996-May 2000; period 2: June 2000-December 2004), with laparoscopic surgery being a surgical option in period 2, was also performed.

Summary Background Data: Prospective data of 1134 patients (448 in period 1; 656 in period 2) who underwent elective resection for colon and upper rectal cancer (above 12 cm from anal verge) were analyzed.

Methods: The operative outcome and survival were compared between patients who underwent laparoscopic and open resection in period 2. The outcomes of colorectal resections in the 2 periods were also compared.

Results: During period 2, the operative mortality rates of patients with laparoscopic (n = 401) and open resection (n = 255) were 0.8% and 3.7%, respectively (P = 0.022), and the morbidity rates were 21.7% and 15.7%, respectively (P = 0.068). The patients who underwent laparoscopic resection had significantly earlier return of bowel function, earlier resumption of diet, and shorter hospital stay. The 3-year overall survivals in those with nondisseminated disease were 74.4% and 78.8% for open and laparoscopic resection, respectively (P = 0.046). The operative morality rates were 4.4% and 2.6% in period 1 and period 2, respectively (P = 0.132). The 3-year overall survivals for patients with nondisseminated disease were 69.7% and 76.1% for period 1 and period 2, respectively (P = 0.019). The overall survivals in patients who underwent open resection in the 2 periods were similar (P = 0.284).

Conclusions: The short-term favorable outcome of laparoscopic resection for colorectal cancer was confirmed and improvement of survival was observed with the practice of laparoscopic resection

ERCP Precoz o Manejo Conservador en Pancreatitis Aguda Biliar

Early Endoscopic Intervention Versus Early Conservative Management in Patients With Acute Gallstone Pancreatitis and Biliopancreatic Obstruction: A Randomized Clinical Trial.
Annals of Surgery. 245(1):10-17, January 2007.

Oria, Alejandro MD *; Cimmino, Daniel MD +; Ocampo, Carlos MD *; Silva, Walter MD *; Kohan, Gustavo MD *; Zandalazini, Hugo MD *; Szelagowski, Carlos MD ++; Chiappetta, Luis MD *

Objective: To test the hypothesis that early endoscopic intervention, performed on patients with acute gallstone pancreatitis and biliopancreatic obstruction, reduces systemic and local inflammation.

Summary Background Data: The role of early endoscopic intervention, in the treatment of acute gallstone pancreatitis, remains controversial. Previous randomized trials have not focused on the subgroup of patients with clinical evidence of biliopancreatic obstruction.

Methods: This single-center randomized clinical trial was performed between May 2000 and September 2005. Of 238 patients, admitted within 48 hours after the onset of acute gallstone pancreatitis, 103 with a distal bile duct measuring >=8 mm combined with a total serum bilirubin >=1.20 mg/dL, were randomized to receive either endoscopic retrograde cholangiopancreatography followed by endoscopic papillotomy for bile duct stones (EEI, n = 51) or early conservative management (ECM, n = 52). Patients with clinical evidence of coexisting acute cholangitis were excluded. Outcome measures included changes in organ failure score and computed tomography (CT) severity index during the first week after admission, incidence of local complications, and overall morbidity and mortality.

Results: The incidence of bile duct stones at EEI was 72% and 40% of patients in the ECM group had persisting bile duct stones at elective biliary surgery. No significant differences were found between the EEI and ECM groups regarding changes in mean organ failure score (P = 0.87), mean CT severity index (P = 0.88), incidence of local complications (6% vs. 6%, P = 0.99), overall morbidity (21% vs. 18%, P = 0.80), and mortality (6% vs. 2%, P = 1).

Conclusions: The present study failed to provide evidence that early endoscopic intervention reduces systemic and local inflammation in patients with acute gallstone pancreatitis and biliopancreatic obstruction. If acute cholangitis can be safely excluded, early endoscopic intervention is not mandatory and should not be considered a standard indication.

Patrones de Fracturas Cervicales que Obligan Descartar Lesiones Cerebrovasculares

Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury
C. Clay Cothren MDa, , , Ernest E. Moore MDa, Charles E. Ray, Jr. MDb, Jeffrey L. Johnson MDa, John B. Moore MDa and Jon M. Burch MDa

Background
Aggressive screening for blunt cerebrovascular injury (BCVI) and prompt anticoagulation for documented injuries has resulted in a significant reduction in ischemic neurologic events. An association between vertebral artery injuries (VAIs) and specific cervical spine fracture patterns has been suggested; however, current screening guidelines would subject all patients with cervical spine fractures to imaging because no distinction has been made for carotid artery injuries (CAIs). We hypothesized that specific cervical spine fracture patterns that warrant screening evaluation exist, hence limiting unwarranted diagnostic imaging.

Methods
Patients undergoing screening for BCVI on the basis of injury patterns and mechanism have been prospectively followed at our regional trauma center since January 1996.

Results
During the study period from January 1996 to January 2005, there were 17,007 blunt trauma admissions. Twenty-three patients presented with symptoms of BCVI. Screening angiography was performed in 766 patients (4.5%), and diagnosed 258 (34%) patients with BCVI. One hundred twenty-five patients with BCVI had cervical spine fractures; 18 patients had isolated CAI; 84 had isolated VAI, and 23 had combined CAI and VAI. Eight patients with VAI had minor cervical fractures but underwent screening for other injury patterns. Fractures in the remaining patients with BCVI were 1 of 3 patterns. Subluxations in 56 (48%) patients, C1 to C3 cervical spine fractures in 42 (36%), or extension of the fracture through the foramen transversarium in 19 (16%). Cervical spine fractures were the sole indication for screening in 90% of the study population. Screening yield of all patients admitted with 1 of these 3 fracture patterns was 37%.

Conclusions
Blunt cerebrovascular injury is associated with complex cervical spine fractures that include subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Patients sustaining such cervical fractures should undergo prompt screening.

Enseñar Habilidades Quirúrgicas

Este artículo del New England Journal of Medicine presenta los avances en simulación y otras técnicas para enseñar a los residentes (becados) de cirugía distintas habilidades necesarias para operar

http://content.nejm.org/cgi/reprint/355/25/2664.pdf

Redefinición de Tuberculosis Ampliamente Resistente

El Centro para Control de Enfermedades (CDC) en conjunto con la Organización Mundial de la Salud (OMS/WHO) ha redefinido a la tuberculosis ampliamente resistente como aquellos Mycobacterium tuberculosis resistente a isoniazida y rifampicina, además de al menos 3 de las 6 drogas de segunda línea: aminoglicosidos, polipeptidos, fluoroquinolonas, tioamidas, cicloserina y ácido paraaminosalicilico.

Para más información diriganse a:

http://jama.ama-assn.org/cgi/reprint/296/23/2792

Manejo de Coledocolitiasis: Un Metaanálisis

Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ British Journal of Surgery November 2006 p.1185-1191E. S. J. Clayton, S. Connor, N. Alexakis, E. Leandros

Abstract
There is no clear consensus on the better therapeutic approach (endoscopic versus surgical) to choledocholithiasis. This study is a meta-analysis of the available evidence.A search of the Medline and ISI databases identified 12 studies that met the inclusion criteria for data extraction. The analysis was performed using a random-effects model. The outcome was calculated as an odds ratio (OR) or relative risk (RR) with 95 per cent confidence intervals (c.i.).Outcomes of 1357 patients were studied. There was no significant difference in successful duct clearance (OR 0·85 (95 per cent c.i. 0·64 to 1·12); P = 0·250), mortality (RR 1·79 (95 per cent c.i. 0·66 to 4·83); P = 0·250), total morbidity (RR 0·89 (95 per cent 0·71 c.i. to 1·13); P = 0·350), major morbidity (RR 1·34 (95 per cent c.i. 0·92 to 1·97); P = 0·130) or need for additional procedures (OR 1·37 (95 per cent c.i. 0·82 to 2·29); P = 0·230) between the endoscopic and surgical groups. There was also no significant difference between the endoscopic and laparoscopic surgery groups.
Both approaches have similar outcomes, and treatment should be determined by local resources and expertise

Manejo de Hiperkalemia Severa Sin Hemodialisis

Journal of Critical Care Volume 21, Issue 4 , December 2006, Pages 316-321
Management of severe hyperkalemia without hemodialysis: Case report and literature review
Virginia Carvalhana PharmDa, b, Lisa Burry PharmD, FCCPa, b and Stephen E. Lapinsky MD, FRCPC
Abstract
Purpose
To report a case of severe hyperkalemia successfully managed without the use of hemodialysis and to provide a review of the literature regarding the management of severe hyperkalemia.

Methods
A clinical case report from the medical-surgical intensive care unit of a teaching hospital and a literature review are presented. The case involves a 59-year old man with diabetes mellitus, essential hypertension, and gout, who presented to hospital with severe hyperkalemia (K+ = 10.4 mEq/L) and normal renal function. He was treated with intravenous fluids, sodium bicarbonate, calcium chloride, insulin, calcium resonium, and furosemide.

Results
The hyperkalemia resolved with conservative treatment within 8 hours, and dialytic therapy was not required. The literature review supported an initial conservative management approach in stable patients with intact renal function.

Conclusions
Hemodialysis is not necessary for all cases of severe hyperkalemia and should be reserved for patients with acute or chronic renal failure or those with life-threatening hyperkalemia unresponsive to more conservative measures

¿El Alcohol Afecta la Cuantificación de la Escala de Glasgow en Pacientes con Trauma Cerebral

Waiting for the Patient to "Sober Up": Effect of Alcohol Intoxication on Glasgow Coma Scale Score of Brain Injured Patients.
Journal of Trauma-Injury Infection & Critical Care. 61(6):1305-1311, December 2006.

Abstract
Background: Between 35% to 50% of traumatic brain injury (TBI) patients are under the influence of alcohol. Alcohol intoxication may limit the ability of the Glasgow Coma Scale (GCS) to accurately assess severity of TBI. We hypothesized that alcohol intoxication significantly depresses GCS scores of TBI patients.

Methods: A 10-year, retrospective analysis of a Level I trauma center registry was undertaken. The study population consisted of all blunt injured TBI patients tested for blood alcohol concentration (BAC, n = 1,075). Patients were divided into two groups; intoxicated (mean BAC 202 +/- 77 mg/dL, n = 504) and nonintoxicated (BAC = 0, n = 571). TBI was classified using ICD-9 codes as concussion alone (ICD-9 850, n = 90) and intracranial injury (ICI, ICD-9 851-854, n = 985). Severity was further classified using the Abbreviated Injury Score (AIS). Mean GCS score was compared between the two groups. Patients who were either intubated or hypotensive upon arrival were analyzed separately to rule out confounding effects on GCS score. Severely intoxicated patients (BAC >250 mg/dL, [mean +/- SD] 309 +/- 54 SD, n = 118) were similarly compared. Finally, multivariate linear regression analysis was undertaken to determine whether BAC level was an independent predictor of GCS score while controlling for confounding factors.

Results: Intoxicated and nonintoxicated TBI patients were clinically similar. Alcohol intoxication had little effect on GCS score, with less than a single point difference in all types of TBI, except the most severely injured (AIS 5 injuries, GCS score difference 1.4 points). These results were not altered by endotracheal intubation, systemic hypotension, or severe intoxication. Similarly, BAC was not a significant independent predictor of GCS score in a multivariate model.

Conclusion: Alcohol intoxication does not result in clinically significant changes in GCS score for patients with blunt TBI. Hence, alterations in GCS score after TBI should not be attributed to alcohol intoxication, as doing so might result in inappropriate delays in monitoring and therapeutic interventions.

Utilidad de la Vasopresina en la Reanimación Cardiopulmonar Avanzada

Un artículo recientemente publicado en Medicina Intensiva (publicación española) discute aspectos respecto al uso de ADH en el manejo del PCR.

Hacer click en título de esta entrada para acceder al texto completo en PDF

Baño Preoperatorio con Clorhexidina ¿Tiene Alguna Utilidad?

Meta-analysis of preoperative antiseptic bathing in the prevention of surgical site infection British Journal of Surgery November 2006 (p.1335-1341)J. Webster, S. Osborne

Abstract
Preoperative bathing with an antiseptic solution is widely used to prevent surgical site infection, but trial results are conflicting.Trials were identified by searches of Medline, Embase and the Cochrane controlled trials register. Studies were eligible if they compared an antiseptic solution used in preoperative bathing with a non-antiseptic washing agent or with no bathing and if they reported data on surgical site infection.Six trials with a total of 10 007 patients were included; all of them used 4 per cent chlorhexidine gluconate. Three trials with 7691 patients compared chlorhexidine with placebo. Bathing with chlorhexidine did not reduce surgical site infection rate; the relative risk (RR) was 0·91. Including only trials of high quality, the RR was 0·95. Three trials with 1443 patients compared bar soap with chlorhexidine; no differences in the surgical site infection rates were detected, and the RR was 1·02. Two trials of 1092 patients compared bathing with chlorhexidine with no washing. The surgical site wound infection rate in the two groups was similar, and the RR was 0·70.

The evidence does not support preoperative bathing with chlorhexidine as a means of reducing surgical site wound infection

Predictores Tempranos de Ventilación Mecánica Prolongada en Trauma Torácico

Early predictors of prolonged mechanical ventilation in major torso trauma patients who require resuscitation
Presented at the 58th Annual Meeting of the Southwestern Surgical Congress, Kauai, Hawaii, April 3–7, 2006
Steven C. Agle M.D.a, Lillian S. Kao M.D.b, Frederick A. Moore M.D.c, Ernest A. Gonzalez M.D.b, Gary A. Vercruysse M.D.d and S. Rob Todd M.D.c, ,

Background
The study purpose was to identify early predictors of prolonged mechanical ventilation in major torso trauma patients.

Methods
This was a retrospective review of torso trauma patients who met specific criteria for shock resuscitation and required 48 hours of mechanical ventilation. Independent variables evaluated included patient demographics, injury characteristics, and initial 24-hour resuscitation parameters. Univariate and multivariate logistic regression analyses were performed using a significance level of P <.05.

Results
Over 59 months, 224 patients met study criteria. Age was 34 years (range 25 to 69), 68% were male, 78% sustained blunt trauma, and injury severity score was 27 (range 18 to 38). Thirty-three percent required prolonged mechanical ventilation. In the analysis, predictors of prolonged mechanical ventilation included total fluid resuscitation, facial trauma, age, positive end-expiratory pressure ≥10 mm Hg on admission, arterial partial pressure of oxygen divided by the fraction of inspired oxygen ratio less than 300 at 24 hours, and chest abbreviated injury scale score.

Conclusions
The need for prolonged mechanical ventilation can be accurately predicted and these predictors may assist clinicians in resource allocation and patient management decisions.

Uso de Ecografía para Evaluar Adherencias Intraabdominales

Use of transabdominal ultrasound to identify intraabdominal adhesions prior to laparoscopy: a prospective blinded study
Presented at the 58th Annual Meeting of the Southwestern Surgical Congress, Kauai, Hawaii, April 3–7, 2006
Shanu N. Kothari M.D.a, , , Larry J. Fundell M.D.a, Pamela J. Lambert R.N.b and Michelle A. Mathiason M.S.b

Overview
The aim of the current study was to assess the accuracy of transabdominal ultrasound (TAU) in identifying intra-abdominal adhesions (IAA) prior to laparoscopy in patients with previous abdominal surgery.

Methods
Patients with previous open surgical procedures presenting for laparoscopic gastric bypass (LGB) underwent TAU by 1 radiologist. Attempts were made to identify IAA using TAU. The intended trocar sites were categorized as free movement (no adhesions), chaotic movement (omental adhesions), or no movement (frozen bowel). During LGB, adhesions at the 6 trocar sites were graded by 1 blinded surgeon.

Results
A significant degree of agreement was found between the radiologist’s predictions and the intraoperative findings with regards to identification of trocar sites free of adhesions versus omental adhesions and frozen bowel.

Conclusions
TAU can accurately identify IAA prior to laparoscopy. Widespread application of this technique may decrease trocar-related injuries during laparoscopic procedures in patients with previous abdominal surgery.

Empiemas por Streptococcus milleri

Streptococcus milleri infections of the pleural space: operative management predominates
Presented at the 58th Annual Meeting of the Southwestern Surgical Congress, Kauai, Hawaii, April 3–7, 2006
R. Taylor Ripley M.D.a, C. Clay Cothren M.D., a, , Ernest E. Moore M.D.a, Jeffrey Long R.R.T.a, Jeffrey L. Johnson M.D.a and James B. Haenel R.R.T.a

Background
Management of patients with thoracic empyema ranges from tube thoracostomy drainage, with or without fibrinolytics, to operative intervention, with the optimal intervention remaining uncertain. Streptococcus milleri, typically a benign bacterium colonizing the oropharynx, has recently been reported as a potential pathogen in pneumonia and pleural space disease. Our initial experience indicated this infection, when in the pleural space, was particularly tenacious and often required major operative intervention to eradicate. Therefore, we hypothesized that patients with S milleri pleural space infections often require operative intervention as definitive treatment.

Methods
We reviewed all patients from June 17, 1999 to April 15, 2005 with S milleri infections at our level I academic trauma/acute care surgery department at a safety-net hospital. S milleri infections were diagnosed by thoracentesis, bronchoalveolar lavage, tube thoracostomy fluid, or intraoperative culture.

Results
Over the 70-month period evaluated, of 697 patients with S milleri infections, 39 patients had S milleri infections of the pleural space; 26 (67%) patients underwent operative intervention. The majority (72%) were men with a mean age of 46 (range 22 to 63); the underlying etiology in those patients requiring operation was pneumonia (26 patients; 67%), trauma (9 patients; 23%), postoperative infection (2 patients), foreign body ingestion (1 patient), and malignancy (1 patient). The vast majority of patients in the operative group were treated preoperatively with tube thoracostomy (88%) and antibiotics (96%). The average duration of chest tube drainage prior to operation was 4.4 days (95% confidence interval [CI] 2.6 to 6.2) and antibiotic treatment was 6.0 days (95% CI 3.8 to 8.2). Thirteen patients (50%) underwent video-assisted thoracoscopic surgery (VATS) and 13 patients required thoracotomy. VATS was performed more often when operative intervention occurred early (average hospital day 6.2) compared to initial thoracotomy or conversion from VATS to thoracotomy (average hospital day 9.8). Hospital length of stay was less in the operative group (average 24 days; 95% CI 17 to 31) than in the nonoperative group (34 days; 95% CI 19 to 49), discharge to home was greater in the operative group (77% vs. 16%), and mortality was less in operative group (0% vs. 23%).

Conclusions
Despite attempts at nonoperative management, the majority of patients with a S milleri pleural space infection require operative intervention for definitive therapy. Patients diagnosed with S milleri empyema should be considered for early operative intervention due to the unrelenting nature of their infection. Operative treatment is associated with a shorter hospital length of stay, increased discharge to home, and decreased mortality.

Diabetes como Factor de Mal Pronóstico en el Trauma

The impact of diabetes on outcome in traumatically injured patients: an analysis of the National Trauma Data Bank
Presented at the 58th Annual Meeting of the Southwestern Surgical Congress, Kauai, Hawaii, April 3–7, 2006
Lillian S. Kao M.D., F.A.C.S., a, , S. Rob Todd M.D., F.A.C.S.a and Frederick A. Moore M.D., F.A.C.S.a aDepartment of Surgery, University of Texas Health Science Center at

Background
Studies on stress hyperglycemia in trauma patients have largely ignored diabetes, a potential confounder. The purpose of this study was to assess the relationship between diabetes and outcome in trauma patients.

Methods
Data were obtained from the National Trauma Data Bank (version 4.0). The primary outcome measures were mortality and infections. Age, injury severity, and comorbidities were analyzed as independent variables using logistic regression.

Results
A total of 343,250 patients were analyzed, of whom 2.7% were diabetic. On multivariate analysis, insulin-dependent diabetes was an independent although weak predictor of infectious morbidity and intensive care unit length of stay. However, diabetes was not associated with mortality or hospital length of stay. Age and injury severity were the main predictors for all outcome measures.

Conclusions
Diabetes was an independent, although weak, risk factor for infectious complications in trauma patients. Age and injury severity were the most important predictors of outcome.

GES y Cirugía

Las patologías GES (antes llamados AUGE) son aún y probablemente seguiran siendo por mucho tiempo fuente de discusión. A continuación el link a la editorial de este mes de la Revista Chilena de Cirugía que trata este tema.

http://www.cirujanosdechile.cl/Revista/PDF%20Cirujanos%202006_06/Cir.62006.(01).pdf

Klebsiella oxytoca como Agente Causal de Colitis Hemorragica por Antibioticos

Klebsiella oxytoca as a Causative Organism of Antibiotic-Associated Hemorrhagic Colitis N Engl J Med dec 7 2006
Christoph Högenauer, M.D., Cord Langner, M.D., Eckhard Beubler, Ph.D., Irmgard T. Lippe, Ph.D., Rudolf Schicho, Ph.D., Gregor Gorkiewicz, M.D., Robert Krause, M.D., Nikolas Gerstgrasser, M.D., Guenter J. Krejs, M.D., and Thomas A. Hinterleitner, M.D.

Background
Antibiotic-associated hemorrhagic colitis is a distinct form of antibiotic-associated colitis in which Clostridium difficile is absent. Although the cause is not known, previous reports have suggested
a role of Klebsiella oxytoca.

Methods
We studied 22 consecutive patients who had suspected antibiotic-associated colitis and who were negative for C. difficile. Patients underwent diagnostic colonoscopy, and among those who received a diagnosis of antibiotic-associated hemorrhagic colitis, stool samples were cultured for K. oxytoca. We isolated K. oxytoca strains and tested them for cytotoxin production using a tissue-culture assay. In addition, we also cultured stool samples obtained from 385 healthy subjects for K. oxytoca. An in vivo animal model for antibiotic-associated hemorrhagic colitis was established with the use of Sprague-Dawley rats.

Results
Of the 22 patients, 6 had findings on colonoscopy that were consistent with the diagnosis of antibiotic-associated hemorrhagic colitis, and 5 of these 6 patients had positive cultures for K. oxytoca. No other common enteric pathogens were found in the five patients. Before the onset of colitis, all five were receiving penicillins, and two were also taking nonsteroidal antiinflammatory drugs (NSAIDs). All isolated K. oxytoca strains produced cytotoxin. K. oxytoca was found in 1.6% of the healthy subjects. In the animal model, K. oxytoca was found only in the colon of rats that received amoxicillin–clavulanate in addition to being inoculated with K. oxytoca. In these rats, infection with K. oxytoca induced a right-sided hemorrhagic colitis that was not observed in uninfected animals that received amoxicillin–clavulanate, indomethacin (an NSAID), or both.

Conclusions
Our fulfillment of Koch's postulates for cytotoxin-producing K. oxytoca suggests that it is the causative organism in at least some cases of antibiotic-associated hemorrhagic colitis. Infection with K. oxytoca should be considered in patients with antibiotic-associated colitis who are negative for C. difficile.

Cambio en Estadio de Cáncer Gástrico al Ampliar la Disección D2

Stage migration caused by D2 dissection with para-aortic lymphadenectomy for gastric cancer from the results of a prospective randomized controlled trial Journal of British Surgery Dec 2006 p.1526-1529
T. Yoshikawa, M. Sasako, T. Sano, A. Nashimoto, A. Kurita, T. Tsujinaka, N. Tanigawa, S. Yamamoto, for the Gastric Cancer Surgical Study Group of the Japan Clinical Oncology Group

Extended lymphadenectomy (D2) provides accurate nodal staging of gastric cancer. The aim of this study was to clarify the degree of stage migration seen with D2 combined with para-aortic lymph node dissection for gastric cancer invading the subserosa, the serosa and adjacent structures (T2ss-4) in patients considered not to have distant metastases (M0).Between July 1995 and April 2001, 523 patients were recruited and randomized in a prospective phase III trial comparing D2 with D2 and para-aortic nodal dissection for T2ss-4 gastric cancer without macroscopic para-aortic nodal metastases. Stage migration was evaluated by Japanese Gastric Cancer Association staging in 260 patients who underwent D2 with para-aortic dissection by analysing pathological information from the dissected lymph nodes.Node (N)-stage migration was observed in 1 per cent (1 of 82) of patients with N1 disease, 20 per cent (12 of 59) with N2, 43 per cent (10 of 23) with N3 and 8·8 per cent (23 of 260) of all patients. Final stage migration occurred in 9 per cent (5 of 58) of patients with stage IIIa, 19 per cent (8 of 42) with stage IIIb, 56 per cent (9 of 16) with stage IVa and 8·5 per cent (22 of 260) of all patients. Metastasis to N4 nodes was found in 4 per cent (four of 95) of tumours invading the subserosa and 17·4 per cent (19 of 109) of tumours penetrating the serosa. The overall incidence of N4 involvement was 8·8 per cent (23 of 260).Extended para-aortic lymphadenectomy for gastric cancer provides accurate nodal staging and results in stage migration, which may improve stage-specific survival regardless of overall survival benefit.

Efectos Adversos en el Tratamiento de la Enfermedad Diverticular Complicada

Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease British Journal of Surgery(p.1503-1513)
V. A. Constantinides, P. P. Tekkis, A. Senapati, on behalf of the Association of Coloproctology of Great Britain Ireland

Abstract
The choice of operation for complicated diverticular disease is contentious. The aim of this study was to investigate adverse events following restorative (primary resection and anastomosis, PRA) and non-restorative (Hartmann's procedure, HP) surgery for complicated diverticular disease.Five hundred and thirty-nine patients who presented with complicated diverticular disease in 42 centres over a 12-month period from January 2003 were considered for the study. Data were collected prospectively from 248 patients (46·0 per cent) who underwent PRA and 167 (31·0 per cent) who had HP. A propensity score was developed for case-mix adjustment. Multifactorial logistic regression was used to evaluate differences in operative outcomes.Mortality, surgical and medical complication rates were 4·0, 31·0 and 13·7 per cent respectively after PRA, and 23·4, 53·3 and 40·7 per cent for HP (all P < alt="chi" src="http://www3.interscience.wiley.com/giflibrary/10/chi.gif" border="0">2 = 8·31, 1 d.f., P = 0·004).PRA with or without a proximal diversion is more often performed non-electively by specialist colorectal surgeons. It may be a safe procedure for complicated diverticular disease in selected patients as it may be associated with fewer postoperative adverse events.

Estrategias de Evaluación de Cáncer Gástrico con Carcinomatosis Peritoneal

Surgical strategies for gastric cancer with synchronous peritoneal carcinomatosis BJS (p.1530-1535)S. Gretschel, R. Siegel, L. Estévez-Schwarz, M. Hünerbein, U. Schneider, P. M. Schlag

Abstract
Gastric cancer frequently spreads to the peritoneal cavity. Whether laparoscopy is useful in planning therapy remains controversial. The aim of this study was to investigate the value of laparoscopy and to develop a therapeutic algorithm.Six hundred and sixty consecutive patients with gastric cancer were included in this prospective observational study. The sensitivity of abdominal ultrasonography, computed tomography (CT) and laparoscopy for detecting peritoneal carcinomatosis was compared. The lesions were biopsied and classified as P1, P2 or P3 according to the recommendations of the Japanese Research Society for Gastric Cancer. Prognosis was determined according to the stage of peritoneal carcinomatosis and therapeutic procedure adopted.One hundred and ten (16·7 per cent) of 660 patients presented with synchronous peritoneal carcinomatosis. The sensitivity for detecting peritoneal carcinomatosis was 85 per cent for laparoscopy compared with 19 per cent for ultrasonography and 28 per cent for CT. Patients with P3 disease did not benefit from additional surgery compared with chemotherapy alone. Those with P1 carcinomatosis had improved survival rates after complete resection followed by chemotherapy.Laparoscopy improves the detection and classification of peritoneal carcinomatosis, and offers patients with gastric cancer a more individualized and effective therapy.

Estatinas para Disminuir el Riesgo Cardiovascular Perioperatorio: Análisis Sistemático de Estudios Controlados

Strength of evidence for perioperative use of statins to reduce cardiovascular risk: systematic review of controlled studies
Anmol S Kapoor, postgraduate trainee1, Hussein Kanji, postgraduate trainee2, Jeanette Buckingham, medical librarian3, P J Devereaux, assistant professor4, Finlay A McAlister
BMJ

Objective To determine the strength of evidence underlying recommendations for use of statins during the perioperative period to reduce the risk of cardiovascular events.

Design Systematic review of studies with concurrent control groups.

Data sources Four electronic databases, the references of identified studies, international experts on perioperative medicine, and the authors of the primary studies.

Review methods Two reviewers independently extracted data from studies that reported acute coronary syndromes or mortality in patients receiving or not receiving statins during the perioperative period.

Main outcome measure Random effects summary odds ratios for death or acute coronary syndrome during the perioperative period.

Results 18 studies—two randomised trials (n=177), 15 cohort studies (n=799 632), and one case-control study (n=480)—assessed whether statins provide perioperative cardiovascular protection; 12 studies enrolled patients undergoing non-cardiac vascular surgery, four enrolled patients undergoing coronary bypass surgery, and two enrolled patients undergoing various surgical procedures. In the randomised trials the summary odds ratio for death or acute coronary syndrome during the perioperative period with statin use was 0.26 (95% confidence interval 0.07 to 0.99) and the summary odds ratio in the cohort studies was 0.70 (0.57 to 0.87). Although the pooled cohort data provided a statistically significant result, statins were not randomly allocated, results in retrospective studies were larger (odds ratio 0.65, 0.50 to 0.84) than those in the prospective cohorts (0.91, 0.65 to 1.27), and dose, duration, and safety of statin use was not reported.

Conclusion The evidence base for routine administration of statins to reduce perioperative cardiovascular risk is inadequate.

Uso de PET y Colonografía por TAC para Etapificar Cancer Colorrectal

Diagnostic Accuracy of Colorectal Cancer Staging With Whole-Body PET/CT Colonography
Patrick Veit-Haibach, MD; Christiane A. Kuehle, MD; Thomas Beyer, PhD; Hrvoje Stergar, MD; Hilmar Kuehl, MD; Johannes Schmidt, MD, PhD; Gereon Börsch, MD, PhD; Gerlinde Dahmen, MSc; Joerg Barkhausen, MD, PhD; Andreas Bockisch, MD, PhD; Gerald Antoch, MD
JAMA. 2006;296:2590-2600.

Context Staging of patients with colorectal cancer often requires a multimodality, multistep imaging approach. Colonography composed of a combined modality of positron emission tomography (PET) and computed tomography (CT) provides whole-body tumor staging in a single session.

Objectives To determine the staging accuracy of whole-body PET/CT colonography compared with the staging accuracies of CT followed by PET (CT + PET) and CT alone and to evaluate the effect of PET/CT colonography on therapy planning compared with conventional staging (CT of the abdomen and thorax and optical colonoscopy).

Design, Setting, and Patients Prospective study of 47 patients enrolled between May 2004 and June 2006 with clinical findings and optical colonoscopy that suggested primary colorectal cancer (mean [SD] age, 71 [11] years; range, 47-92 years). Patients underwent whole-body PET/CT colonography 1 day after colonoscopy. The study was conducted at a university hospital with a mean (SD) follow-up of 447 (140) days (range, 232-653 days).

Main Outcome Measures Correct classification of overall TNM stage using PET/CT colonography compared with CT + PET and CT alone. Secondary outcome measures were the accurate assessment of T-stage, N-stage, and M-stage by PET/CT colonography compared with CT + PET and CT alone and the effect of PET/CT colonography on therapy planning.

Results Of the 47 patients with a total of 50 lesions, the overall TNM stage was correctly determined for 37 lesions with PET/CT colonography (74%; 95% confidence interval [CI], 60%-85%), 32 lesions with CT + PET (64%; 95% CI, 49%-77%), and 26 lesions with CT alone with a 0.7-cm node threshold (52%; 95% CI, 37%-66%). Compared with optimized abdominal CT staging alone, PET/CT colonography was significantly more accurate in defining TNM stage (difference, 22%; 95% CI, 9%-36%; P=.003), which was mainly based on a more accurate definition of the T-stage. Differences were not detected for defining N-stage between PET/CT colonography and CT alone with a threshold of 0.7 cm for malignant nodes but were detected with a threshold of 1 cm. Differences were not detected in defining M-stage separately or when comparing the accuracies of PET/CT colonography with CT + PET. PET/CT colonography affected consecutive therapy decisions in 4 patients (9%; 95% CI, 2.4%-20.4%) compared with conventional staging (CT alone and colonoscopy).

Conclusions In this preliminary study, PET/CT colonography is at least equivalent to CT + PET for tumor staging in patients with colorectal cancer. Thus, PET/CT colonography in conjunction with optical colonoscopy may be a suitable concept of tumor staging for patients with colorectal cancer.

Laparoscopia Temprana vs Observación Clínica en Dolor Abdominal No Especifico

Acute Nonspecific Abdominal Pain: A Randomized, Controlled Trial Comparing Early Laparoscopy Versus Clinical Observation.
Original Articles and Discussions Annals of Surgery. 244(6):881-888, December 2006.Morino, Mario MD; Pellegrino, Luca MD; Castagna, Elisabetta MD; Farinella, Eleonora MD; Mao, Patrizio MD, FACS

Abstract: Aims: To evaluate, in a prospective, randomized, single-institution trial, the role of early laparoscopy in the management of nonspecific abdominal pain (NSAP) in young women.
Patients and Methods: Women aging from 13 to 45 years, admitted for NSAP at the emergency department, were included in the study. Exclusion criteria were pregnancy, previous appendectomy, contraindications to laparoscopy, diagnosis of malignancy, or chronic disease. NSAP was defined as an abdominal pain in right iliac or hypogastric area lasting more than 6 hours and less than 8 days, without fever, leukocytosis, or obvious peritoneal signs and uncertain diagnosis after physical examination and baseline investigations including abdominal sonography. Patients were randomly assigned to early (<12 hours from admission) laparoscopy group (LAP) or to clinical observation group (OBS). After discharge a follow-up was carried out.
Results: From January 2001 to February 2004, 508 female patients without previous abdominal surgery were evaluated in admitting area for acute right iliac or hypogastric abdominal pain, in 373 patients diagnosis was established for obvious signs or with baseline investigations. Of the remaining 135 patients, 31 were excluded from study for various reasons, 53 patients were randomly assigned to LAP and 51 to OBS. Groups were similar for age, mean BMI, white blood cell count, and duration of pain. During hospitalization diagnosis was established in 83.4% of the LAP and in 45.1% of OBS (P < 0.05). Twenty patients of OBS (39.2%) were operated during observation because of worsening of symptoms or appearance of peritoneal sign. Diagnoses in LAP were appendicitis in 16 patients (30.1%), pelvic inflammatory disease in 7 (13.2%), carcinoid in 1 (1.9%), other in 18 (33.9%), no diagnosis in 11 (20.7%); diagnoses in OBS were appendicitis in 3 patients (5.8%), pelvic inflammatory disease in 8 (15.6%), other in 12 (23.5%), and no diagnosis in 28 (54.9%). Mean length of hospital stay was 3.7 +/- 0.8 days in LAP and 4.7 +/- 2.4 days in OBS (P < 0.05); no differences were found regarding mortality, morbidity, radiation dose, and analgesia. Mean follow-up time was 29.3 months (range, 12-60 months) for LAP and 30.6 months for OBS (range, 12-60 months). After 3 months from discharge, 20% of patients in LAP and 52% in OBS had recurrent abdominal pain (P < 0.05); after 12 months, 16% in LAP and 25% in OBS (P = not significant). Six patients in OBS required readmission for surgery.

Conclusions: Compared with active clinical observation, early laparoscopy did not show a clear benefit in women with NSAP. A higher number of diagnosis and a shorter hospital stay in the LAP group did not led to a significant reduction in symptoms recurrences at 1 year.

Pseudoaneurisma de la Arteria Temporal Superficial

Esta patología vascular poco frecuente esta en el diagnóstico diferencial de toda masa en la zona temporal. Un artículo de revisión hecho por mí fue publicado este mes en la Revista Chilena de Cirugía. El acceso directo al articulo completo en PDF a continuación:

http://www.cirujanosdechile.cl/Revista/PDF%20Cirujanos%202006_06/Cir.62006.(13).pdf

Efecto sobre la mortalidad del conductor de contar con un pasajero trasero sin cinturón

The Effect of Unrestrained Rear-Seat Passengers on Driver Mortality.
Journal of Trauma-Injury Infection & Critical Care. 61(5):1249-1254, November 2006.

Abstract
Background: It is well documented that seat belt usage effectively reduces the severity of motor vehicle occupant injuries and fatalities in roadway crashes. This research examines how the presence of an unrestrained rear-seat passenger seated directly behind an airbag and/or belt-restrained driver affects the driver's risk of injury in two different idealized crash scenarios. Empirical data used in the study was obtained from four sled tests conducted with various size Hybrid III crash test dummies.Methods: Three tests simulated a frontal (head-on) impact between two vehicles. The first established the baseline condition: a driver dummy restrained by a belt and an airbag system, with an identical belt-restrained dummy seated directly behind. The other two frontal-mode tests involved different size driver dummies restrained in the same manner, with different size unrestrained dummies behind them. A fourth test featured an angled driver-side impact crash with a restrained driver and unrestrained rear seat passenger.Results: In both of the latter cases the driver incurred a high likelihood of severe head and chest injuries relative to that inferred in the baseline exposure. The last test featured two identical dummies in a simulated lateral (driver-side) inter-vehicular impact using a belt-restrained (only) driver and an unrestrained rear-seat passenger. Driver mortality was not significantly affected in this configuration.Conclusion: Unrestrained rear-seat passengers place themselves as well as their driver at great risk of serious injury when involved in a head-on crash.

Cirugía Endoscópica Transluminal a través de Orificios Naturales

La cirugía endoscópica transluminal (conocida como NOTES por sus siglas en inglés: Natural Orifice Transluminal Endoscopic Surgery) se esta escuchando cada vez más fuerte en la comunidad quirúrgica. Este articulo publicado en Cirugía Española toca este tema del que cada vez aparecerán más trabajos.

Hacer click en título para acceder al texto completo en PDF.