Tumores Apendiculares

Trabajo retrospectivo sobre algunas características de los tumores apendiculares publicado en la Revista Chilena de Cirugía.

Para acceder al texto completo en PDF hacer click en el título de este entry

Accidentes Cortopunzantes en Residentes (Becados) de Cirugía

Needlestick Injuries among Surgeons in Training
Martin A. Makary, Ali Al-Attar, Christine G. Holzmueller, J. Bryan Sexton, Dora Syin, Marta M. Gilson, Mark S. Sulkowski, and Peter J. Pronovost.
N Engl J Med 2007; 356(26):2693-9

Background Surgeons in training are at high risk for needlestick injuries. The reporting of such injuries is a critical step in initiating early prophylaxis or treatment.

Methods We surveyed surgeons in training at 17 medical centers about previous needlestick injuries. Survey items inquired about whether the most recent injury was reported to an employee health service or involved a "high-risk" patient (i.e., one with a history of infection with human immunodeficiency virus, hepatitis B or hepatitis C, or injection-drug use); we also asked about the perceived cause of the injury and the surrounding circumstances.

Results The overall response rate was 95%. Of 699 respondents, 582 (83%) had had a needlestick injury during training; the mean number of needlestick injuries during residency increased according to the postgraduate year (PGY): PGY-1, 1.5 injuries; PGY-2, 3.7; PGY-3, 4.1; PGY-4, 5.3; and PGY-5, 7.7. By their final year of training, 99% of residents had had a needlestick injury; for 53%, the injury had involved a high-risk patient. Of the most recent injuries, 297 of 578 (51%) were not reported to an employee health service, and 15 of 91 of those involving high-risk patients (16%) were not reported. Lack of time was the most common reason given for not reporting such injuries among 126 of 297 respondents (42%). If someone other than the respondent knew about an unreported injury, that person was most frequently the attending physician (51%) and least frequently a "significant other" (13%).

Conclusions Needlestick injuries are common among surgeons in training and are often not reported. Improved prevention and reporting strategies are needed to increase occupational safety for surgical providers.

Colelitiasis y Coledocolitiasis: Metaanálisis Chileno

Un buen meta-análisis publicado en la Revista Chilena de Cirugía.
Acceso al documento completo en pdf al hacer click en título de este entry

Importancia de Preservar Función Renal en Trauma

Renal Dysfunction in Trauma: Even a Little Costs a Lot.
Journal of Trauma-Injury Infection & Critical Care. 62(6):1362-1364, June 2007.
Brandt, Mary-Margaret MD; Falvo, Anthony J. DO; Rubinfeld, Ilan S. MD; Blyden, Dionne MD; Durrani, Noreen K. MD; Horst, H Mathilda MD

Background: Acute renal failure (ARF) is a devastating complication in critically ill patients. There is a paucity of data that describes the impact of ARF on the outcome of trauma patients admitted to the intensive care unit.

Methods: We studied trauma patients admitted to the surgical intensive care unit to determine the effect of increases in serum creatinine on the number of ventilator days, length of stay, mortality, and cost. We used the administrative database of the hospital and the trauma registry. Renal failure (RF) was defined as one or more of the following: creatinine >1.5 mg/dL, increase in creatinine of >50%, or increase of creatinine by 0.5 mg/dL.

Results: We obtained data on 1,033 patients. Two hundred and forty-six (23.8%) patients met at least one criterion for RF. Only 25 of these patients had one or more episodes of renal replacement therapy. The RF group had mortality of 24.4% compared with 2.3% in the no renal failure group (p < 0.0001). For each 1 mg/dL increase from the initial creatinine, length of stay increased by 2.21 days, ventilator days increased by 1.09 days, and the mortality risk increased by 1.83 times (CI, 1.47-2.29; p < 0.0001). For any diagnosis of renal dysfunction, the average cost increase was $3,088.00 and increased mortality risk was 7.19 times (CI, 4.11-12.58).

Conclusion: Vigilance in preventing creatinine increases and ameliorating or removing potential causes should occur as soon as creatinine begins to rise to avoid worsening renal function, to reduce cost, and to improve patient outcome.

Examen Físico en Fracturas de Columna Cervical

Clinical Examination and its Reliability in Identifying Cervical Spine Fractures.
Journal of Trauma-Injury Infection & Critical Care. 62(6):1405-1410, June 2007.
Duane, Therese M. MD; Dechert, Tracey MD; Wolfe, Luke G. MS; Aboutanos, Michel B. MD, MPH; Malhotra, Ajai K. MD; Ivatury, Rao R. MD

Background: The Eastern Association for the Surgery of Trauma (EAST) guidelines recommend that cervical spine (c-spine) radiographic evaluation is unnecessary in the awake, alert blunt trauma patient who is not intoxicated, has no distracting injuries, and demonstrates no tenderness over the c-spine or neurologic deficits. The purpose of this study was to compare the reliability of the clinical examination (CE) with that of computed tomography in identifying the presence of c-spine fractures.

Methods: We prospectively evaluated 534 blunt trauma patients between February 2004 and January 2005. Positive CE was defined as complaints of neck pain, external trauma of the c-spine or neurologic deficit, tenderness or abnormalities to palpation over the cervical spine. Computed tomography was used to define the accuracy of CE.

Results: There were 52 patients with, and 482 patients without, c-spine fractures. Forty of the 52 patients with fractures were accurately identified by CE for a sensitivity of 76.9% and a negative predictive value (NPV) of 95.7%. In the group with an initial Glasgow Coma Score of 15, 16 of 24 patients with fractures were accurately identified for a sensitivity of 66.7% and an NPV of 96.5%. In the subset of patients who by EAST guidelines would not require any radiographic evaluation, there were 17 fractures and 10 were accurately identified by clinical examination. The sensitivity in this group was 58.8% with an NPV of 96.4%. Four of the seven missed injuries required intervention.

Conclusions: This trial suggests that with a normal Glasgow Coma Score, CE cannot be relied upon to rule out c-spine fracture. CE is unreliable to diagnose or exclude a cervical spine fracture.

Cirugía del Tumor de Klatskin

Un artículo de revisión respecto a la radicalidad de la cirugía del colangiocarcinoma hiliar publicado en la Revista Española de Cirugía.

Para acceder al artículo completo en pdf hacer click en el título de este "entry".

Radicalidad en la cirugía del colangiocarcinoma hiliar (tumor de Klatskin)
Emilio Ramos Rubio.
Servicio de Cirugía General. Hospital Universitario de Bellvitge. L'Hospitalet de Llobregat. Barcelona. España.

La supervivencia prolongada de los pacientes con colangiocarcinoma hiliar sólo puede ser lograda mediante la resección completa del tumor. No hay supervivientes a largo plazo cuando se observa infiltración microscópica de los márgenes de resección. Por otra parte, el colangiocarcinoma hiliar parece tener poca tendencia a diseminarse a distancia, mientras que con el tratamiento adyuvante postoperatorio no se ha demostrado claramente un beneficio clínico. Se debe considerar estas evidencias argumentos para realizar resecciones amplias. Con objeto de lograr resecciones R0, en los últimos años se ha incrementado el número de hepatectomías mayores, lo cual se ha asociado a una mayor resecabilidad y mejores resultados. Se recomienda la resección simultánea del lóbulo caudado, ya que es un lugar frecuente de recidiva tumoral. El estudio mediante biopsias por congelación de los márgenes de resección del conducto biliar debe ser realizado de manera sistemática. Sin embargo, no siempre es posible ampliar la resección en caso de invasión en el margen de sección proximal.

La invasión macroscópica de la vena porta tiene un impacto negativo en la supervivencia. Sin embargo, no debe ser una contraindicación para la cirugía. La realización de una hepatectomía con resección venosa puede ofrecer supervivencias prolongadas en algunos pacientes con tumores avanzados.

La incidencia de invasión linfática en las piezas de resección se presenta en un 30-50% de los casos y hay correlación entre la invasión del tumor primario y la afección ganglionar. Las metástasis linfáticas del colangiocarcinoma hiliar se extienden en primer lugar a los ganglios pericoledocales y después hacia la región posterior de la cabeza del páncreas, la vena porta y la arteria hepática común. La linfadenectomía habitual debe incluir todas esas áreas. Sólo la afección de los ganglios del tronco celíaco, la arteria mesentérica superior y los paraaórticos contraindica la resección del tumor. La supervivencia se relaciona estrechamente con la extensión de la invasión linfática.

La aplicación de la denominada técnica no-touch, que se basa en la realización de una triseccionectomía derecha junto con la resección de la vena porta, ha sido propuesta como el procedimiento quirúrgico de elección para una cirugía más radical y para prevenir la diseminación intraoperatoria de células tumorales.

Trombosis Venosa y Trauma

Laterality of Deep Venous Thrombosis Among Trauma Patients: Are We Screening Our Patients Adequately?
Eric S. Weiss et al. Department of Surgery, Division of Trauma Surgery and Critical Care The Johns Hopkins University School of Medicine.
Journal of Surgical Research Volume 141, Issue 1, July 2007, Pages 68-71

Objectives
Major trauma represents a significant risk for development of deep venous thrombosis (DVT). Duplex ultrasonography is a noninvasive test to identify DVT and has been suggested for screening asymptomatic high-risk trauma patients. While some risk factors for DVT are well described, it remains unclear whether site of DVT development is associated with anatomical location of injury. An association between anatomical locations of injury would serve to highlight the importance of directed screening of those extremities at highest risk. Therefore, we hypothesize that location of DVT correlates with side of lower extremity injury.

Methods
We performed an 11-year (1995–2005) retrospective review from the prospectively collected trauma registry at an urban, university-based, level I trauma center. All trauma patients with lower extremity DVT were included. Lateralizing lower extremity injuries were defined as penetrating or blunt injuries affecting only one lower extremity. Fisher’s exact test compared concordance between side of injury and side of DVT.

Results
A total of 6674 trauma patients were admitted, of whom 40 (0.6%) were diagnosed with lower extremity or pelvic DVT. Mean age of patients with DVT was 39 y, with 80% male, 80% African American, and 55% penetrating trauma. Fourteen patients (35%) with DVT sustained lateralizing lower extremity injuries (6 gunshot wounds, 5 tibia/fibula fractures, 2 femur fractures, and 1 calcaneus fracture). Twelve of these 14 patients (86%) developed DVT on the same side as their injury; (7/7 on right side and 5/7 on left side, P = 0.02). The 26 patients without lateralizing injuries had equal distribution of DVT (39% right, 42% left, and 19% bilateral).

Conclusion
Patients who sustained lateralizing lower extremity injury and developed lower extremity DVT had a high likelihood of developing their DVT on the same side as their injury. A larger multi-institutional analysis is needed to assess the correlation between injury site and anatomical location of DVT before suggesting any changes in recommendations for duplex screening.

Perfil Epidemiológico del Trauma en Chile

Un trabajo publicado en el último número de la Revista Chilena de Cirugía presenta las características epidemiológicas del trauma en Chile. De utilidad para realizar trabajos en esa línea de investigación.

Acceso al texto completo en pdf al hacer doble click sobre el título de este "entry".

Hematocrito Preoperatorio y Resultados Postoperatorios en Población Geriatrica

Preoperative Hematocrit Levels and Postoperative Outcomes in Older Patients Undergoing Noncardiac Surgery
Wen-Chih Wu et al.
JAMA. 2007;297:2481-2488.

Context Elderly patients are at high risk of both abnormal hematocrit values and cardiovascular complications of noncardiac surgery. Despite nearly universal screening of patients for abnormal preoperative hematocrit levels, limited evidence demonstrates the adverse effects of preoperative anemia or polycythemia.

Objective To evaluate the prevalence of preoperative anemia and polycythemia and their effects on 30-day postoperative outcomes in elderly veterans undergoing major noncardiac surgery.

Design Retrospective cohort study using the VA National Surgical Quality Improvement Program database. Based on preoperative hematocrit levels, we stratified patients into standard categories of anemia (hematocrit <39.0%), normal hematocrit (39.0%-53.9%), and polycythemia (hematocrit 54%). We then estimated increases in 30-day postoperative cardiac event and mortality risks in relation to each hematocrit point deviation from the normal category.

Setting and Patients A total of 310 311 veterans aged 65 years or older who underwent major noncardiac surgery between 1997 and 2004 in 132 Veterans' Affairs medical centers across the United States.

Main Outcome Measures The primary outcome measure was 30-day postoperative mortality; a secondary outcome measure was composite 30-day postoperative mortality or cardiac events (cardiac arrest or Q-wave myocardial infarction).

Results Thirty-day mortality and cardiac event rates increased monotonically, with either positive or negative deviations from normal hematocrit levels. We found a 1.6% (95% confidence interval, 1.1%-2.2%) increase in 30-day postoperative mortality associated with every percentage-point increase or decrease in the hematocrit value from the normal range. Additional analyses suggest that the adjusted risk of 30-day postoperative mortality and cardiac morbidity begins to rise when hematocrit levels decrease to less than 39% or exceed 51%.

Conclusions Even mild degrees of preoperative anemia or polycythemia were associated with an increased risk of 30-day postoperative mortality and cardiac events in older, mostly male veterans undergoing major noncardiac surgery. Future studies should determine whether these findings are reproducible in other populations and if preoperative management of anemia or polycythemia decreases the risk of postoperative mortality.

Indicaciones de Cirugía por Hemorragia Tras Pancreaticoduodenectomía

Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated?
Thomas Blanc et al.
The American Journal of Surgery 2007; 194(1):3-9

Background
This study analyzed presentation and management of hemorrhage after pancreaticoduodenectomy (PD) to determine the respective role of surgery and embolization.

Methods
From January 1992 to March 2005, 411 patients underwent PD and were analyzed with regard to postoperative hemorrhage.

Results
Hemorrhage occurred in 27 patients (7%), either within the first 3 postoperative days (“early” hemorrhage, n = 11) or after day 8 (“delayed” hemorrhage, n = 16, including 4 with “sentinel” bleeding). At the time of bleeding, 12 patients (44%) (all with delayed hemorrhage) had associated abdominal complications. Two patients had successful conservative treatment. Two stable patients with pseudoaneurysm, diagnosed by computed tomography scan, underwent successful embolization. Four patients with active bleeding underwent unsuccessful angiography. Overall, 23 patients were reoperated on without any completion pancreatectomy, 3 rebled, and 3 (11%) died (including 2 with delayed hemorrhage).

Conclusions
Both embolization and surgery have a role in the management of hemorrhage after PD. For early hemorrhage, reoperation is appropriate. In case of sentinel bleeding, pseudoaneurysms can be detected by computed tomography scan and treated by embolization. For delayed active hemorrhage, reoperation is still indicated.

Recomendaciones para Redactar un Artículo para Publicación en una Revista Biomédica

El Dr. Manterola y cols de la Universidad de La Frontera de Temuco pubicaron un artículo en la Revista Chilena de Cirugía donde dan recomendaciones al momento de escribir un artículo para su publicación en revistas biomédicas.

Se puede acceder al texto completo en formato pdf al hacer click sobre el título de este "entry"

Gastrectomía Laparoscópica en Cáncer Gástrico

Gastrectomía laparoscópica en cáncer gástrico: Experiencia preliminar.
ESCALONA, Alex et al.
Rev. méd. Chile, abr. 2007, vol.135, no.4, p.512-516

Background: The development of the laparoscopic surgery has allowed its incorporation to the surgical treatment of gastric cancer.

Aim: To evaluate the feasibility and safety of laparoscopic gastrectomy in gastric cancer in our institution.

Patients and methods: Prospective data in four patients who underwent laparoscopic gastrectomy for gastric cancer from May to August of 2005 was reviewed. Demographic data, clinical characteristics and postoperative results were registered. Patients were staged according to TNM-AJJC staging system.

Results: Four patients aged 48 to 80 years (three males), underwent a completely laparoscopic R0 gastrectomy with lymph node dissection. Two patients underwent total gastrectomy. A subtotal Billroth II gastrectomy was performed in the other two patients. The mean operative time was 260 minutes (Range 180-330). There were no conversions to open surgery. The mean postoperative hospital stay was 6.5 days (Range 6-7 days). There were no complications. According to pathology, one patient presented carcinoma in stage IA, two patients in stage IB and one patient in stage IIIB. The mean number of lymph nodes dissected was 40 (Range 35-54).

Conclusions: Laparoscopic gastrectomy is a feasible procedure with good postoperative results in this preliminary experience

Cápsula Endoscópica

Cápsula endoscópica: fundamentos y utilidad clínica
Begoña González-Suáreza et al.
Cir Esp 2007; 81: 299 - 306

La aparición de la cápsula endoscópica (PillCam) ha supuesto un gran avance en el estudio de las enfermedades de intestino delgado, ya que permite obtener imágenes de tramos hasta ahora inexplorables. Aprobada por la FDA en agosto de 2000, actualmente aparece como técnica de primera línea en el estudio de enfermedades del intestino delgado. Se trata de un dispositivo no reutilizable de 26 × 11 mm de longitud y que se desplaza por el tubo digestivo gracias a los movimientos peristálticos normales.

Sus principales indicaciones son el estudio de la hemorragia de origen desconocido, la anemia crónica y la enfermedad inflamatoria intestinal. Son contraindicaciones de esta técnica, además de los trastornos deglutorios, la presencia de estenosis de intestino delgado de cualquier etiología. Por ello, se recomienda realizar un tránsito de intestino delgado previo a la cápsula en casos de sospecha de este tipo de afecciones.

Para acceder al texto completo en PDF hacer click en el título de este "entry"

Aranceles FONASA 2007

Se actualizaron los aranceles FONASA.

A continuación el link para descargar el archivo comprimido en formato .zip

http://200.51.172.210/mle/Libro%20Arancel%20MLE%202007.zip

Miotomia de Heller Laparoscopica para Acalasia

Resultados inmediatos y tardíos de la miotomía de Heller laparoscópica en pacientes con acalasia esofágica
Rev Méd Chile 2007; 135: 464-472
Luis Ibáñez, et al. Departamento de Cirugía Digestiva, División de Cirugía, Facultad de Medicina, Pontificia Universidad Católica de Chile. Santiago de Chile.

Background: Achalasia is characterized by an incomplete relaxation of the lower esophageal sphincter. The best treatment is surgical and the laparoscopic approach may have good results.

Aim: To assess the results of laparoscopic Heller myotomy among patients with achalasia.

Material and methods: Prospective study of patients subjected to a laparoscopic Heller myotomy between 1995 and 2004. Clinical features, early and late operative results were assessed.

Results: Twenty seven patients aged 12 to 74 years (12 females) were operated. All had disphagia lasting for a mean of 32 months. Mean lower esophageal sphincter pressure ranged from 18 to 85 mmHg. Eight patients received other treatments prior to surgery but symptoms persisted or reappeared. The preoperative clinical score was 7. No patient died and no procedure had to be converted to open surgery. In a follow up of 21 to 131 months, all patients are satisfied with the surgical results and the postoperative clinical score is 1. Only one patient with a mega esophagus maintained a clinical score of six.

Conclusions: In this series of patients, laparoscopic Heller myotomy was an effective and safe treatment for esophageal achalasia.

http://www.scielo.cl/pdf/rmc/v135n4/art08.pdf

Primera Cirugía Transorificial

El 2 de abril de 2007 se realizó la primera cirugía completamente transorificial, técnica conocida como N.O.T.E.S. La cirugía fue realizada por el equipo del Dr. Jacques Marescaux en el Hospital Universitario de Strasbourgh. La primera paciente fue una mujer a quien se realizó una colecistectomía con abordaje transvaginal.

A continuación encontraran el link al video que muestra este procedimiento. El acceso es gratuito pero requiere inscribirse (da acceso a otros videos de distintos procedimientos).

http://www.websurg.com/index.php