Reanimación con Albúmina Aumenta la Mortalidad Alejada en Trauma Cerebral

Saline or Albumin for Fluid Resuscitation in Patients with Traumatic Brain Injury
The SAFE Study Investigators
N Engl J Med 2007; 357(9):874-84.

Background
The Saline versus Albumin Fluid Evaluation study suggested that patients with traumatic brain injury resuscitated with albumin had a higher mortality rate than those resuscitated with saline. We conducted a post hoc follow-up study of patients with traumatic brain injury who were enrolled in the study.

Methods
For patients with traumatic brain injury (i.e., a history of trauma, evidence of head trauma on a computed tomographic [CT] scan, and a score of 13 on the Glasgow Coma Scale [GCS]), we recorded baseline characteristics from case-report forms, clinical records, and CT scans and determined vital status and functional neurologic outcomes 24 months after randomization.

Results
We followed 460 patients, of whom 231 (50.2%) received albumin and 229 (49.8%) received saline. The subgroup of patients with GCS scores of 3 to 8 were classified as having severe brain injury (160 [69.3%] in the albumin group and 158 [69.0%] in the saline group). Demographic characteristics and indexes of severity of brain injury were similar at baseline. At 24 months, 71 of 214 patients in the albumin group (33.2%) had died, as compared with 42 of 206 in the saline group (20.4%) (relative risk, 1.63; 95% confidence interval [CI], 1.17 to 2.26; P=0.003). Among patients with severe brain injury, 61 of 146 patients in the albumin group (41.8%) died, as compared with 32 of 144 in the saline group (22.2%) (relative risk, 1.88; 95% CI, 1.31 to 2.70; P<0.001); among patients with GCS scores of 9 to 12, death occurred in 8 of 50 patients in the albumin group (16.0%) and 8 of 37 in the saline group (21.6%) (relative risk, 0.74; 95% CI, 0.31 to 1.79; P=0.50).

Conclusions
In this post hoc study of critically ill patients with traumatic brain injury, fluid resuscitation with albumin was associated with higher mortality rates than was resuscitation with saline.

Esofagectomía Transhiatal: Reporte de Resultados de 2000 Casos

Two Thousand Transhiatal Esophagectomies: Changing Trends, Lessons Learned.
Annals of Surgery. 246(3):363-374, September 2007.
Orringer, Mark; Marshall, Becky; Chang, Andrew; Lee, Julia; Pickens, Allan; Lau, Christine.

Objective:
"Rediscovered" in 1976, transhiatal esophagectomy (THE) has been applicable in most situations requiring esophageal resection and reconstruction. The objective of this study was to review the authors' 30-year experience with THE and changing trends in its use.

Methods:
Using the authors' prospective Esophagectomy Database, this single institution experience with THE was analyzed retrospectively.

Results:
Two thousand and seven THEs were performed-1063 (previously reported) between 1976 and 1998 (group I) and 944 from 1998 to 2006 (group II), 24% for benign disease, 76%, cancer. THE was possible in 98%. Stomach was the esophageal substitute in 97%. Comparing outcomes between group I and group II, statistically significant differences (P < 0.001) were observed in hospital mortality (4% vs. 1%); adenocarcinoma histology (69% vs. 86%); use of neoadjuvant chemoradiation (28% vs. 52%); mean blood loss (677 vs. 368 mL); anastomotic leak (14% vs. 9%); and discharge within 10 days (52% vs. 78%). Major complications remain infrequent: wound infection/dehiscence, 3%, atelectasis/pneumonia, 2%, intrathoracic hemorrhage, recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration, <1% each. Late functional results have been good or excellent in 73%. Aggressive preoperative conditioning, avoiding the ICU, improved pain management, and early ambulation reduce length of stay, with 50% in group II discharged within 1 week.

Conclusion:
THE refinements have reduced the historic morbidity and mortality of esophageal resection. This largest reported THE experience reinforces the value of consistent technique and a clinical pathway in managing these high acuity esophageal patients.

Relaparotomía en Pacientes con Peritonitis Severa: Programada vs "De Necesidad"

Comparison of On-Demand vs Planned Relaparotomy Strategy in Patients With Severe Peritonitis: A Randomized Trial
Oddeke van Ruler, et al. for the Dutch Peritonitis Study Group
JAMA. 2007;298:865-872.

Context

In patients with severe secondary peritonitis, there are 2 surgical treatment strategies following an initial emergency laparotomy: planned relaparotomy and relaparotomy only when the patient's condition demands it ("on-demand"). The on-demand strategy may reduce mortality, morbidity, health care utilization, and costs. However, randomized trials have not been performed.

Objective

To compare patient outcome, health care utilization, and costs of on-demand and planned relaparotomy.

Design, Setting, and Patients

Randomized, nonblinded clinical trial at 2 academic and 5 regional teaching hospitals in the Netherlands from November 2001 through February 2005. Patients had severe secondary peritonitis and an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 11 or greater.

Intervention

Random allocation to on-demand or planned relaparotomy strategy.

Main Outcome Measures

The primary end point was death and/or peritonitis-related morbidity within a 12-month follow-up period. Secondary end points included health care utilization and costs.

Results

A total of 232 patients (116 on-demand and 116 planned) were randomized. One patient in the on-demand group was excluded due to an operative diagnosis of pancreatitis and 3 in each group withdrew or were lost to follow-up. There was no significant difference in primary end point (57% on-demand [n = 64] vs 65% planned [n = 73]; P = .25) or in mortality alone (29% on-demand [n = 32] vs 36% planned [n = 41]; P = .22) or morbidity alone (40% on-demand [n = 32] vs 44% planned [n = 32]; P = .58). A total of 42% of the on-demand patients had a relaparotomy vs 94% of the planned relaparotomy group. A total of 31% of first relaparotomies were negative in the on-demand group vs 66% in the planned group (P <.001). Patients in the on-demand group had shorter median intensive care unit stays (7 vs 11 days; P = .001) and shorter median hospital stays (27 vs 35 days; P = .008). Direct medical costs per patient were reduced by 23% using the on-demand strategy.

Conclusion

Patients in the on-demand relaparotomy group did not have a significantly lower rate of death or major peritonitis-related morbidity compared with the planned relaparotomy group but did have a substantial reduction in relaparotomies, health care utilization, and medical costs.

Prevención de Insuficiencia Renal Aguda por Medio de Contraste en la Urgencia

Prevention of Contrast-Induced Nephropathy in the Emergency Department
Richard Sinert and Christopher I. Doty. Department of Emergency Medicine, State University of New York-Downstate Medical Center, Brooklyn, NY.
Annals of Emergency MedicineVolume 50, Issue 3, September 2007, Pages 335-345.e2

Contrast-induced nephropathy is the third leading cause of hospital-acquired acute renal failure. Expanded use of contrast-enhanced imaging exposes an ever-widening number of patients to this renal toxin. We perform an evidence-based emergency medicine review comparing different therapies to prevent contrast-induced nephropathy. We limit our review to prophylactic therapies that are practical for an emergency department setting.

Methods
We searched MEDLINE, EMBASE, and the Cochrane Library for randomized trials comparing a wide range of medications to prevent contrast-induced nephropathy. We defined contrast-induced nephropathy by a commonly used surrogate measure of renal failure: a 25% or 0.5 mg/dL absolute increase in serum creatinine level from baseline 48 to 72 hours postcontrast. We limited our review to only trials for patients with baseline renal insufficiency, who are most at risk for contrast-induced nephropathy. We excluded prophylactic protocols requiring more than 2 hours precontrast to initiate and any trials of experimental medications or those that required invasive monitoring. We used standard criteria to appraise the quality of published trials.

Results
We found 7 randomized trials; 3 using N-acetylcysteine, 2 using theophylline, and 1 each using bicarbonate and ascorbic acid. Although many of these trials showed statistically significant reductions in the risk for contrast-induced nephropathy, none were sufficiently powered to detect reductions in mortality rate or the need for dialytic therapy.

Conclusion
Evidence from randomized trials shows that these interventions (theophylline, bicarbonate, and ascorbic acid) under review were appropriate to an ED setting and decreased the risk of contrast-induced nephropathy. The case for the effectiveness (N-acetylcysteine) was less certain.

Sugerencia de Nuevo Valor de PAS para Definir Hipotensión en Trauma

Hypotension Begins at 110 mm Hg: Redefining "Hypotension" With Data.
Journal of Trauma-Injury Infection & Critical Care. 63(2):291-299, August 2007.
Eastridge, Brian; Salinas, Jose; McManus, John; Blackburn, Lorne; Bugler, Eileen; Cooke, William; Concertino, Victor; Wade, Charles; Holcomb, John

Background:
Clinicians routinely refer to hypotension as a systolic blood pressure (SBP) <=90 mm Hg. However, few data exist to support the rigid adherence to this arbitrary cutoff. We hypothesized that the physiologic hypoperfusion and mortality outcomes classically associated with hypotension were manifest at higher SBPs.

Methods:
A total of 870,634 patient records from the National Trauma Data Bank with emergency department SBP and mortality data were analyzed. Patients (140,898) with severe head injuries, a Glasgow Coma Score <=8, and base deficit (BD) <5, or missing data items were excluded from analysis. Admission BD, as a measure of metabolic hypoperfusion, was evaluated in 81,134 patients and mortality was plotted against SBP.

Results:
Baseline mortality was <2.5%. However, at 110 mm Hg, the slope of the mortality curve increased such that mortality was 4.8% greater for every 10-mm Hg decrement in SBP. This effect was consistent to a maximum of 26% mortality at a SBP of 60 mm Hg. Hypoperfusion (change in the slope of BD curve) began to increase above baseline of 4.5 at a SBP 118 mm Hg.

Conclusion:
Taking the BD and mortality measurements together, this analysis shows that a SBP <=110 mm Hg is a more clinically relevant definition of hypotension and hypoperfusion than is 90 mm Hg. This analysis will also be useful for developing appropriately powered studies of hemorrhagic shock.

Cobertura Biologica en el Manejo de Fístulas Entéricas

Biological Dressings for the Management of Enteric Fistulas in the Open Abdomen A Preliminary Report
Ramin Jamshidi, MD; William P. Schecter, MD
Arch Surg. 2007;142:793-796.

Hypothesis
Biological dressings can be effective tools in the management of enteric fistulas, which are the nemesis of exposed viscera.

Design
Retrospective review of medical records.

Setting
University-affiliated level I trauma center.

Patients
Patients with open abdominal cavities and coexistent intestinal fistulas who were treated between January 1, 1999, and July 1, 2006.

Interventions
Application of biological dressings to fistula sites within open abdominal cavities during serial fascial closure. Biological dressings included cadaveric skin, human acellular dermal matrix, and fibrin sealant.

Main Outcome Measures
Enteric fistula closure and healing of the abdominal wound.

Results
During the 6 years under review, there were 69 patients with open abdomens. Of these patients, 7 (10%) developed enteric fistulas and underwent application of biological dressings. In 5 patients, fistulas closed and the abdominal wound healed after application of biological dressings. One additional patient healed after fistula resection. Biological dressing treatment and fistula resection both failed in 1 patient. There was no morbidity or mortality attributable to the intervention.

Conclusions
Intestinal fistulas significantly complicate the management of patients with open abdomens. In this case series, biological dressings were effective in achieving fistula closure. A prospective multi-institutional study is required to confirm these preliminary encouraging results.

Nueva Clasificación Para Lesiones Iatrogénicas de Vía Biliar

Surgical treatment and outcome of iatrogenic bile duct lesions after cholecystectomy and the impact of different clinical classification systems
British Journal of Surgery Volume 94, Issue 9 (September 2007) p.1119-1127
H. Bektas, H. Schrem, M. Winny, J. Klempnauer

Abstract

Different injury patterns of iatrogenic bile duct lesions after cholecystectomy have prompted the proposal of several different clinical classification systems.

The aim of this study was to validate these systems comparatively.

Results after surgical intervention for iatrogenic bile duct lesions in 74 consecutive patients at a tertiary referral centre were reviewed retrospectively.

A new classification (Hannover classification) for iatrogenic bile duct lesions is proposed and compared with four other systems using the present clinical data.Additional vascular lesions were found in 19 per cent. The hospital mortality rate was 3 per cent and the overall hospital complication rate after repair was 26 per cent. Sixteen of 74 patients required early surgical reintervention.

The Hannover classification demonstrated a highly significant association between the discrimination of classifiable injury patterns and the different surgical treatments chosen (P < 0·005). The Strasberg and Neuhaus classifications do not consider vascular involvement, whereas the Stewart-Way, Siewert and Neuhaus systems do not discriminate between lesions at or above the bifurcation of the hepatic duct.Additional vascular involvement and location of the lesion at or above the bifurcation of the hepatic duct have a major impact on the extent of surgical intervention required and should be reflected in any classification of bile duct injuries.

Congreso Argentino de Cirugía 2007

Efecto del Taser en Ritmo Cardiaco

Cardiac Monitoring of Human Subjects Exposed to the Taser®
Saul D. Levine, Christian M. Sloane, Theodore C. Chan, James V. Dunford and Gary M. Vilke. Department of Emergency Medicine, University of California, San Diego (UCSD) Medical Center, San Diego.
Journal of Emergency Medicine Volume 33, Issue 2, August 2007, Pages 113-117

Abstract
The Taser® (TASER International, Scottsdale, AZ) is a high-voltage, low-amperage device used by many law enforcement agencies. Our objective in this study was to evaluate for rhythm changes utilizing cardiac monitoring during deployment of the Taser® on volunteers.

A prospective, observational study evaluated law enforcement personnel who had continuous electrocardiographic monitoring immediately before, during, and after having a voluntary exposure to the Taser X-26®. Changes in cardiac rate, rhythm, ectopy, morphology, and conduction intervals were measured.

A total of 105 subjects were evaluated. The mean shock duration was 3.0 s (range 0.9–5 s). Mean heart rate increased 15 beats/min (95% CI 12.6–18.3), from 122 beats/min before shock to 137 beats/min immediately after shock. One subject had a single premature ventricular contraction both before and after the shock, but no other subject developed ectopy or dysrhythmia. Poor inter-rater agreement prevented determination of the overall effect of shock on conduction intervals. However, several interpretable tracings demonstrated change in QT duration—either shortening or prolongation after shock. Human subjects exposed to a brief shock from the Taser® developed significant increases in heart rate, but there were no cardiac dysrhythmias or morphologic changes.

Alterations in the QT interval were observed in some subjects but their true incidence and clinical significance are unknown.

Radioterapia Cerebral Profiláctica en Cáncer Pulmonar Células Pequeñas Extenso

Prophylactic Cranial Irradiation in Extensive Small-Cell Lung Cancer
Ben Slotman, Corinne Faivre-Finn, Gijs Kramer, Elaine Rankin, Michael Snee, Matthew Hatton, Pieter Postmus, Laurence Collette, Elena Musat, Suresh Senan, for the EORTC Radiation Oncology Group and Lung Cancer Group
N Eng J Med 2007;357(7):664-72

Background
We conducted a randomized trial of prophylactic cranial irradiation in patients with extensive small-cell lung cancer who had had a response to chemotherapy.

Methods
Patients between the ages of 18 and 75 years with extensive small-cell lung cancer were randomly assigned to undergo prophylactic cranial irradiation (irradiation group) or receive no further therapy (control group). The primary end point was the time to symptomatic brain metastases. Computed tomography or magnetic resonance imaging of the brain was performed when any predefined key symptom suggestive of brain metastases was present.

Results
The two groups (each with 143 patients) were well balanced regarding baseline characteristics. Patients in the irradiation group had a lower risk of symptomatic brain metastases (hazard ratio, 0.27; 95% confidence interval [CI], 0.16 to 0.44; P<0.001). The cumulative risk of brain metastases within 1 year was 14.6% in the irradiation group (95% CI, 8.3 to 20.9) and 40.4% in the control group (95% CI, 32.1 to 48.6). Irradiation was associated with an increase in median disease-free survival from 12.0 weeks to 14.7 weeks and in median overall survival from 5.4 months to 6.7 months after randomization. The 1-year survival rate was 27.1% (95% CI, 19.4 to 35.5) in the irradiation group and 13.3% (95% CI, 8.1 to 19.9) in the control group. Irradiation had side effects but did not have a clinically significant effect on global health status.

Conclusions
Prophylactic cranial irradiation reduces the incidence of symptomatic brain metastases and prolongs disease-free and overall survival.

Congreso Cirugia Chile FELAC 2007

http://www.cirujanosdechile.cl/

Tratamiento de Vasculitis ANCA +

Treatment of Antineutrophil Cytoplasmic Antibody–Associated Vasculitis
A Systematic Review
Xavier Bosch; Antonio Guilaber; Gerard Espinosa; Eduard Mirapeix
JAMA. 2007;298:655-669.

Context Immunosuppressive therapies for antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis have greatly advanced patient survival but have turned ANCA-associated vasculitis (AAV) into chronic, relapsing disorders. Long-term treatment and disease-related morbidity are major threats. The last decade has seen a collaborative international effort to determine effective treatment.

Objective To analyze the reported evidence on AAV therapy in order to provide physicians with a rational approach for dealing with various clinical scenarios.

Data Sources We searched English-language articles on the medical treatment of AAV published between 1966 and March 2007 using MEDLINE. Articles from the reference lists of the most relevant articles retrieved were also analyzed.

Study Selection Studies of current available drug treatments or medical interventions for patients with AAV were included. Duplicate publications, case reports, and uncontrolled trials and series including fewer than 10 patients were excluded.

Data Synthesis We included 2 meta-analyses, 20 randomized controlled prospective trials, and 62 uncontrolled trials with more than 10 patients or observational studies. Outcome measures and treatment protocols were heterogeneous across trials. Cotrimoxazole can be used alone or in combination with corticosteroids to induce and maintain remission in cases of isolated upper respiratory tract involvement. To induce remission, methotrexate plus corticosteroids can be used instead of cyclophosphamide for patients with generalized, non–organ-threatening disease. When methotrexate is used as maintenance therapy, the likelihood of relapse is high and rigorous monitoring is mandatory. Pulse cyclophosphamide with corticosteroids can be used to induce remission in patients with generalized organ-threatening disease. The combination of azathioprine and daily prednisone is effective in maintaining remission. Plasma exchange is at present the best complement to immunosuppressants in advanced renal disease. In Churg-Strauss syndrome, treatment can be started with high doses of corticosteroids, tapering them when the clinical situation improves. In patients with a high risk of death, cyclophosphamide should be introduced.

Conclusions Although AAV therapies should be tailored to the patient's specific clinical situation, evidence for treatment of several disease states is lacking. There is a need for safer and more effective drugs.

Amilasa en Drenaje como Predictor de Fístula Pancréatica Tras Resección Pancréatica

Amylase Value in Drains After Pancreatic Resection as Predictive Factor of Postoperative Pancreatic Fistula: Results of a Prospective Study in 137 Patients.
Annals of Surgery. 246(2):281-287, August 2007.
Molinari, Enrico; Bassi, Claudio; Salvia, Roberto; Butturini, Giovanni; Crippa, Stefano; Talamini, Giorgio; Falconi, Massimo; Pederzoli, Paolo.

Background: The correlation of the amylase value in drains (AVD) with the development of pancreatic fistula (PF) is still unclear.

Aim: The purpose of this study was to identify within the first postoperative day (POD1) the predictive role of different risks factors, including AVD, in the development of PF.
Patients and Methods: We prospectively investigated 137 patients who underwent major pancreatic resections. PF was defined and graded in accordance with the International Study Group on PF.

Results: We considered 101 pancreaticoduodenectomies and 36 distal resections. The overall incidence of PF (A, B, and C grades) was 19.7% and it was 14.8% after pancreaticoduodenectomy and 33.3% after distal resection. All PF occurred in "soft" remnant pancreas. The PF developed in patients with a POD1 median AVD of 10,000 U/L, whereas patients without PF had a median AVD of 1222 U/L (P < 0.001). We established a cut-off of 5000 U/L POD1 AVD for univariate and multivariate analysis. The area under the receiver operating characteristic (ROC) curve was 0.922 (P < 0.001). The predicting risk factors selected in the univariate setting were "soft" pancreas (P = 0.005; odds ratio [OR]: 1.54; 95% CI: 1.32-1.79) and AVD (P < 0.001; OR: 5.66; 95% CI: 3.6-8.7; positive predictive value 59%; negative predictive value 98%), whereas in multivariate analysis the predicting risk factor was the POD1 AVD (P < 0.001; OR: 68.4; 95% CI: 14.8-315). Only 2 PFs were detected with AVD <5000 U/L and both were in pancreatogastric anastomosis (P = 0.053).

Conclusions: AVD in POD1 >=5000 U/L is the only significant predictive factor of PF development.

Utilidad del Electrocardiograma Preoperatorio para Predecir Eventos Adversos Cardíacos Postoperatorios

The Value of Routine Preoperative Electrocardiography in Predicting Myocardial Infarction After Noncardiac Surgery.
Annals of Surgery. 246(2):165-170, August 2007.
van Klei, Wilton A.; Bryson, Gregory L.; Yang, Homer; Kalkman, Cor J.; Wells, George A.; Beattie, W Scott

Objective:
The added value of a preoperative electrocardiogram (ECG) in the prediction of postoperative myocardial infarction (POMI) and death was compared with clinical risk factors identified from the patient's history.

Summary of Background Data:
An ECG is frequently performed before surgery to screen for asymptomatic coronary artery disease. However, the value of ECG abnormalities to predict POMI has been questioned.

Methods:
The study included 2967 noncardiac surgery patients >50 years of age from 2 university hospitals, who were expected to stay in the hospital for >24 hours. All data were obtained from electronic record-keeping systems. Patient history and ECG abnormalities were considered as potential predictors. Multivariate logistic regression analysis was used to obtain the independent predictors of POMI and all-cause in-hospital mortality. The area under the receiver operating characteristic curve (ROC area) was estimated to evaluate the ability of different models to discriminate between patients with and without the outcome.

Results:
A preoperative ECG was available in 2422 patients (80%) and 1087 (45%) of the ECGs showed at least one abnormality. The ROC area of the model that included the independent predictors of POMI obtained from patient history, ie, ischemic heart disease and high-risk surgery, was 0.80. ECG abnormalities that were associated with POMI were a right and a left bundle branch block. After adding these abnormalities in the regression model, the ROC area remained 0.80. Similar results were found for all-cause mortality.

Conclusions:
Bundle branch blocks identified on the preoperative ECG were related to POMI and death but did not improve prediction beyond risk factors identified on patient history.

Marcación Preoperatoria No Afecta Esterilidad Quirúrgica en Cirugía Traumatológica

Sterility of the Surgical Site Marking Between the Ink and the Epidermis
Daniel B. Cullan II and Montri D. Wongworawat.
Journal of the American College of Surgeons 2007; 205(2):319-321

To prevent wrong-site surgery, multiple organizations have endorsed the practice of signing the operative site with an indelible marker. Potential contamination of the surgical field and the inability to prepare the area under the ink film raises concerns. The purpose of this study was to determine if the use of preoperative site marking affects the sterility of the surgical field.

Study Design
After institutional review board approval, 30 consecutive patients scheduled to undergo elective upper extremity surgery by the same surgeon were included. For each patient, surgical marking according to Joint Commission on Accreditation of Healthcare Organizations guidelines were placed on more than half of the planned incision site, and the other half was left unmarked. The patients then underwent routine surgical preparation. The skin was incised, starting from the unmarked side and continuing to the marked aspect. Cultures were obtained by swabbing the skin edges: one from the unmarked side and one from the marked side. After blood agar plating, cultures were incubated for 72 hours and analyzed by a blinded observer.

Results
All cultures were negative, regardless of swab site (unmarked or marked location).

Conclusions
The practice of surgical site marking does not increase the risk of operative field contamination.

Apendicectomía Incidental

Incidental Appendectomy: 18-Year Pathologic Survey and Cost Effectiveness in the Nonmanaged-Care Setting
Jeffrey B. Albright, G. Peter Fakhre, William W. Nields and Philip P. Metzger. Department of Surgery, Mayo Clinic Jacksonville
Journal of the American College of Surgeons 2007; 205 (2): 298-306

Incidental appendectomy (IA) remains a controversial issue. The role of IA in the nonmanaged-care setting has not been evaluated recently. This study evaluates the cost-benefit of IA based on current third-party reimbursements and reports the incidence of pathology from routine IA during an 18-year period.

Study Design
A retrospective review was performed for all patients who underwent open intestinal operations for nonappendiceal pathology by a single colon and rectal surgeon between 1988 and 2006. Patient records were reviewed for surgical indication, procedure, pathology reports, and complications. A cost-benefit analysis for IA versus laparoscopic appendectomy was performed using previously published epidemiologic data for risk of appendectomy.

Results
During this period, 341 patients (mean age 62.9 years) underwent IA during open intestinal operation. Malignancy was the indication for operation in 61.6%. Pathologic findings of clinical significance in the appendix were present in 2.6% of specimens. Combined reimbursements for laparoscopic appendectomy for nonruptured and ruptured appendicitis are $8,500.95 and $15,870.37, respectively. For patients with a benign surgical indication, there was cost-benefit for IA during open operation for men younger than 55 years and women younger than 50 years of age. For patients with malignant disease, there was cost-benefit for men and women younger than 45 years of age.

Conclusions
IA can be performed safely during open operation for other bowel pathology. Rate of clinically significant appendiceal pathology is low but not negligible. For patients with third-party payor status, IA can be more broadly performed during open gastrointestinal operation when no additional surgeon reimbursement is obtained

Reparación Laparoscópica de Hernias de Pared Abdominal

Artículo publicado en Contemporary Surgery que demuestra algunos trucos durante la realización de hernioplastía laparoscópica para reparar hernias ventrales (eventraciones).

http://www.contemporarysurgery.com/pdf/6308/6308CS_Review.pdf