Resultados a Largo Plazo en Reparación de Vía Biliar Tras Lesión en Colecistectomía Laparoscópica

Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies
Matthew Walsh, Michael Henderson, David Vogt and Nancy Brown.Department of General Surgery, Cleveland Clinic.
Surgery 2007; 142(4):450-7.

Background
Major bile duct injuries remain a potentially devastating complication after laparoscopic cholecystectomy. A retrospective review was conducted of patients who underwent a biliary-enteric reconstruction of a biliary injury to assess their long-term outcome.

Methods
Retrospective review of bile duct injury database from January 1990 to December 2005.

Results
A total of 144 patients were treated for bile duct injury, and 84 (58%) required a biliary-enteric reconstruction. Stratification by Bismuth-Strasberg injury level revealed E1 or E2 in 23, E3 in 33, E4 in 17, E5 in 1, and B+C in 10. Forty-four (52%) were operated within 7 days of laparoscopic cholecystectomy, the remainder operated at a median of 79 days after referral. Early or late mortality occurred in 3 (4%). At a mean follow-up of 67 months, 9 patients (11%) developed a biliary stricture presented at a median of 13 months after bile duct repair. Level of injury was very important in predicting a postoperative biliary stricture: E4 (35%) versus E3 (9%; P = .023), and E4 versus E1, E2 B+C (0%; P = .001). More strictures occurred in patients operated within 7 days of laparoscopic cholecystectomy (19%) versus delayed repair (8%; P = .053). Overall, 90% of patients are alive and nonstented; 5 patients have chronic liver disease (1 on the waiting list for liver transplant). Nonbiliary complications occurred in 15 patients; the total morbidity was 40%.

Conclusions
Bile duct injuries that require a biliary-enteric repair are commonly associated with long-term complications. Level of injury and likely timing of repair predict risk of postoperative stricture.

Factores Preoperatorios Predictivos de Conversión en Colecistectomía Laparoscópica

Preoperative findings predict conversion from laparoscopic to open cholecystectomy
Jeremy Lipman, Jeffrey Claridge, Manjunath Haridas, Matthew Martin, David Yao, Kevin Grimes and Mark Malangoni.
Surgery 2007; 142(4):556-65.

Previous studies evaluating predictive factors for conversion from laparoscopic to open cholecystectomy have drawn conflicting conclusions. We evaluated objective preoperative variables to create an accurate, accessible risk score to predict conversion.

Methods
A retrospective review was performed of laparoscopic cholecystectomy patients at an urban tertiary care center. Seventy characteristics were subjected to bivariate and multivariate logistic regression analysis to identify parameters that independently predict conversion to open cholecystectomy. A model was created based on this analysis.

Results
Laparoscopic cholecystectomy was performed on 1377 patients for benign gallbladder disease over a 71-month period. There were 112 (8.1%) conversions to open cholecystectomy. The correlation between the preoperative clinical diagnosis and pathologic diagnosis for acute and chronic cholecystitis was 48.6% and 94.6%, respectively. Multivariate analysis identified male gender, elevated white blood cell count, low serum albumin, ultrasound finding of pericholecystic fluid, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. These 6 factors were also associated with the pathologic diagnosis of acute cholecystitis. A model to calculate the risk for conversion was created with an area under the receiver operator curve of 0.83. The risk for conversion also can be estimated based on the number of factors identified present and ranged from 2% when 1 factor was present to 89% with 6 factors.

Conclusions
These results demonstrate that conversion to open cholecystectomy can be predicted based on parameters available preoperatively. Conversion is more likely in patients who have acute cholecystitis; however, the correlation between its clinical and pathologic diagnosis is poor. Improvements in the ability to determine the risk for conversion have important implications for surgical care.

Cirugía de Displasia de Alto Grado en Esofago de Barrett

Tratamiento quirúrgico de la displasia de alto grado en el esófago de Barrett
Vicente Munítiza Luisa F Martínez de Haroa M Ángeles Ortiza David Ruiz de Anguloa Joaquín Molinab Juan Bermejoc Andrés Serranod Pascual Parrillae
Cir Esp 2007;82:214-8.

Acceso a documento completo en pdf al hacer doble click en título de este entry

Introducción. El esófago de Barrett tiene capacidad de malignización en el 0,5-1% de los pacientes por año por la secuencia displasia de bajo grado, displasia de alto grado y adenocarcinoma. El objetivo de este trabajo es presentar nuestra experiencia en el tratamiento quirúrgico del esófago de Barrett que ha evolucionado a displasia de alto grado.

Pacientes y método. De un grupo de 128 pacientes diagnosticados de esófago de Barrett, 8 (6,2%) desarrollaron una displasia de alto grado tras una mediana de seguimiento de 7 (intervalo, 2-25) años. Además, otros 5 pacientes diagnosticados de displasia de alto grado fuera de este estudio fueron remitidos para valoración y tratamiento quirúrgico. En 8 casos los pacientes estaban en tratamiento médico con 40 mg diarios de omeprazol y a los otros 5 se los había intervenido mediante funduplicatura de Nissen por vía abierta, y se les diagnosticó la displasia de alto grado tras una mediana de 5 (1-16) años una vez instaurado el tratamiento. Tras la confirmación del diagnóstico por otro patólogo y estudio de estadificación, se realizó una esofagectomía transtorácica con anastomosis en el vértice del tórax en todos los casos.

Resultados. No hubo mortalidad postoperatoria. La morbilidad fue del 36% (5 pacientes). El estudio histológico definitivo de la pieza informó de displasia de alto grado en 7 (54%) pacientes y adenocarcinoma en 6 (46%). Todos los pacientes están vivos tras una mediana de seguimiento de 4,7 (1-14) años.

Conclusiones. Ante un paciente con esófago de Barrett y displasia de alto grado, la mejor opción terapéutica es la resección quirúrgica, que puede resultar con mortalidad cero en centros experimentados. En casi la mitad de los casos intervenidos hay un adenocarcinoma diagnosticado en la pieza de resección. La supervivencia a los 5 años es superior al 90%.

Hallazgos Endoscópicos en Estómagos "in-situ" Excluidos en Bypass Gástrico

Endoscopic Findings in the Excluded Stomach After Roux-en-Y Gastric Bypass Surgery
Rogerio Kuga; Adriana Safatle-Ribeiro; Joel Faintuch; Robson Ishida; Carlos Furuya Jr; Arthur Garrido Jr; Ivan Cecconello; Shinichi Ishioka; Paulo Sakai.
Arch Surg. 2007;142:942-946.

Hypothesis After gastric bypass surgery performed because of morbid obesity, the excluded stomach can rarely be endoscopically examined. With the advent of a new apparatus and technique, possible mucosal changes can be routinely accessed and monitored, thus preventing potential benign and malignant complications.

Design Prospective observational study in a homogeneous population with nonspecific symptoms.

Setting Outpatient clinic of a large public academic hospital.

Patients Forty consecutive patients (mean ± SD age, 44.5 ± 10.0 y ears; 85.0% women) were seen at a mean ± SD of 77.3 ± 19.4 months after Roux-en-Y gastric bypass surgery.

Intervention Elective double-balloon enteroscopy of the excluded stomach was performed.

Main Outcome Measures Rate of successful intubation, endoscopic findings, and complications.

Results The excluded stomach was reached in 35 of 40 patients (87.5%). Mean ± SD time to enter the organ was 24.9 ± 14.3 minutes (range, 5-75 minutes). Endoscopic findings were normal in 9 patients (25.7%), whereas in 26 (74.3%), various types of gastritis (erythematous, erosive, hemorrhagic erosive, and atrophic) were identified, primarily in the gastric body and antrum. No cancer was documented in the present series. Tolerance was good, and no complications were recorded during or after the intervention.

Conclusions The double-balloon method is useful and practical for access to the excluded stomach. Although cancer was not noted, most of the studied population had gastritis, including moderate and severe forms. Surveillance of the excluded stomach is recommended after Roux-en-Y gastric bypass surgery performed because of morbid obesity.

Angioplastia Coronaria Primaria: Una Cuestión de Tiempo

Time to Treatment in Primary Percutaneous Coronary Intervention
Brahmajee Nallamothu, Elizabeth Bradley, and Harlan Krumholz.
N Engl J Med 2007;357(16):1631-8.

Acceso a documento completo en pdf al hacer doble click en título de este entry.

Early administration of reperfusion therapy improves survival in patients with ST-elevation myocardial infarction by reestablishing coronary blood flow within the occluded infarct-related artery. Primary percutaneous coronary intervention (PCI) is superior to fibrinolytic therapy when performed rapidly by expert teams, but its effectiveness may be limited by delays in delivery.

Recent national efforts are drawing attention to the importance of door-to-balloon time as a key indicator of quality of care for patients with ST-elevation myocardial infarction who are treated with primary PCI. The American College of Cardiology (ACC), in collaboration with the American Heart Association (AHA), the American College of Emergency Physicians (ACEP), the National Heart, Lung, and Blood Institute (NHLBI), and other partners, has implemented a national quality-improvement campaign to decrease door-to-balloon time in primary PCI. The convergence of clinical and policy interest in door-to-balloon time makes this an opportune occasion to review current knowledge on this topic.

Ganglio Centinela en Patología Digestiva

Utilización del ganglio centinela en patología digestiva
Carmen Balaguéa Sandra Velaa aServicio de Cirugía General y Digestiva. Hospital de la Santa Creu i de Sant Pau. Barcelona. España.
Cir Esp 2007;82:195-203.

Acceso al texto completo PDF al hacer doble click en título de este entry.

El concepto de ganglio centinela (GC) surge a partir de la consideración de que la diseminación linfática de las células tumorales se produce en un foco ganglionar inicial (GC) antes de afectar al resto de los territorios linfáticos.

Aunque este concepto ha sido validado en melanoma maligno y en cáncer de mama, su aplicación a otros tumores sólidos, incluidos los gastrointestinales, es todavía controvertida.

Con el objetivo de evitar la realización de una cirugía muy invasiva de forma uniforme, la detección del ganglio centinela puede desempeñar un importante papel para obtener información individualizada y, de esta forma, modificar el procedimiento quirúrgico u otras alternativas terapéuticas.

Recientemente, se ha realizado la determinación de los GC mediante abordaje laparoscópico, y puede convertirse en un componente importante del tratamiento mínimamente invasivo de tumores gastrointestinales en estadios iniciales.

El sentido del GC varía en función de la localización del tumor, así, en el caso del cáncer gástrico el objetivo principal es ampliar la indicación de cirugía mínimamente invasiva en casos con ganglios negativos, mientras en el cancer colorrectal forma parte de la búsqueda de métodos que ayuden a evitar una posible infraestadificación del paciente, con posible trascendencia en el tratamiento adyuvante requerido.

Porque Utilizar Y de Roux en Cirugía Bariatrica

Why Roux-en-Y? A Review of Experimental Data
Brendan Collins; Tomoharu Miyashita; Michael Schweitzer; Thomas Magnuson; John Harmon.
Arch Surg. 2007;142:1000-3.

Objective To highlight the clinical and experimental rationales that support why the Roux-en-Y limb is an important surgical principle for bariatric gastric bypass.

Data Sources We reviewed PubMed citations for open Roux-en-Y gastric bypass (RYGBP), laparoscopic RYGBP, loop gastric bypass, chronic alkaline reflux gastritis, and duodenoesophageal reflux.

Study Selection We reviewed clinical and experimental articles. Clinical articles included prospective, retrospective, and case series of patients undergoing RYGBP, laparoscopic RYGBP, or loop gastric bypass. Experimental articles that were reviewed included in vivo and in vitro models of chronic duodenoesophageal reflux and its effect on carcinogenesis.

Data Extraction and Synthesis No formal data extraction was performed. We reviewed published operative times, lengths of stay, and anastomotic leak rates for laparoscopic RYGBP and loop gastric bypass. For in vivo and in vitro experimental models of duodenoesophageal reflux, we reviewed the kinetics and potential molecular mechanisms of carcinogenesis.

Conclusions Recent data suggest that laparoscopic loop gastric bypass, performed without the creation of a Roux-en-Y gastroenterostomy, is a faster surgical technique that confers similarly robust weight loss compared with RYGBP or laparoscopic RYGBP. In the absence of a Roux limb, the long-term effects of chronic alkaline reflux are unknown. Animal models and in vitro analyses of chronic alkaline reflux suggest a carcinogenic effect.

Hemofiltración Continua en Pacientes con Shock Séptico Hipertérmico

Continuous Hemofiltration in Hyperthermic Septic Shock Patients.
Journal of Trauma-Injury Infection & Critical Care. 63(4):751-756, October 2007.
Pestana, David;Casanova, Elena; Villagran, Maria; Tormo, Carolina; Perez-Chrzanowska, Hanna; Redondo, Javier; Caldera, Maria; Royo, Concepcion.

Background: Severe hyperthermia commonly accompanies septic shock. High body temperature in absence of infection activates the inflammatory response and is associated with a high mortality. Three years ago, our hypothesis that sustained fever is harmful in septic shock led us to the development of a protocol aiming at decreasing hyperthermia (>=39.5[degrees]C) by means of hemofiltration when the patients did not respond to antipyretics. We present a report of temperature and hemodynamic changes and the outcome of 19 consecutive hyperthermic septic shock patients with multiorgan system failure and compare them with a historical similar group of patients in whom hyperthermia was not treated with hemofiltration.

Methods: Depending on renal function, patients were treated with continuous low-flow hemofiltration (n = 8) or hemodiafiltration, (n = 11). Core temperature was registered every hour. A hemodynamic index (HI) was defined (mean arterial pressure to noradrenaline dose) and used during the first 24 hours to describe the patients' hemodynamic profile by means of its percent variation starting 6 hours before instituting the hemofiltration.

Results: The patients' temperature decreased linearly from 39.8[degrees]C +/- 0.5[degrees]C before hemofiltration to 37[degrees]C +/- 1.2[degrees]C after 24 hours of treatment (p < 0.001). The HI decreased significantly from -6 hours to the onset of hemofiltration (p = 0.002) and increased significantly after 24 hours (p = 0.008). Twenty-eight-day mortality was 32% (6 of 19) when compared with 100% (11 of 11) in the historical group (p < 0.001).

Conclusions: Continuous low-flow hemofiltration decreased body temperature and vasopressor requirements in hyperthermic septic shock patients. The mortality was unexpectedly low.

Stents Colorectales: Cuando Utilizarlos

Revisión publicada en el tomo de este mes de Contemporary Surgery. Analiza el tema de los stent colorrectales y su indicación en la obstrucción intestinal baja como alternativa a la cirugía de urgencia.

http://www.contemporarysurgery.com/pdf/6310/6310CS_Review.pdf

"¿Hay un Médico Abordo?": Emergencias Médicas en Vuelos Comerciales

Les presento los accesos directos a 2 textos muy interesantes.

El primero es una editorial de Contemporary Surgery que toca el tema de que se le pasa por la mente a un médico ante una emergencia médica en vuelo, contando un notable caso de manejo de un neumotórax a tensión con una sonda Foley, un lápiz pasta y una botella de whisky.

El segundo artículo es una guía de manejo de este tipo de emergencias.

http://www.contemporarysurgery.com/pdf/6310/6310CS_Editorial.pdf

http://www.asma.org/publications/medguid.pdf

Breve Historia del Desarrollo de Válvulas Cardiacas Protésicas

Breve compilado respecto al desarrollo de las valvulas cardiacas artificiales. Publicado en N Engl J Med. Se puede acceder al texto completo PDF.

http://content.nejm.org/cgi/reprint/357/14/1368.pdf