Manejo de Cáncer de Vesícula Biliar T2 en EEUU

Management of T2 gallbladder cancer: are practice patterns consistent with national recommendations?
Byron E. Wright, Chris Lee, Douglas Iddings, Maihgan Kavanagh and Anton Bilchik.
American Journal of Surgery 2007;194(6):820-6

Background
The national recommendation for the management of localized T2 gallbladder cancer (GBCA) is radical cholecystectomy. Although reported survival for localized T2 disease has been poor, groups have documented improvement with radical resection. We hypothesized that a discrepancy exists between national recommendations and current practice patterns.

Methods
Patients diagnosed with localized T2 GBCA between 1988 and 2002 were identified from the Surveillance, Epidemiology, and End Results registry. Age, sex, race, ethnicity, extent of surgery, and overall survival were assessed. Surgical procedure was categorized as cholecystectomy alone (CS), cholecystectomy plus lymph node dissection (CS+LN), radical cholecystectomy (RCS), or other. Survival calculations were made using the Kaplan-Meier method and compared with the log-rank test.

Results
Of 382 patients with pathologically confirmed T2 GBCA, 280 were women. The median patient age was 75 years. A total of 238 patients underwent CS, 76 underwent CS+LN, and 14 underwent RCS. The remaining 54 patients underwent a lesser or no procedure and were excluded from comparative analysis. The median survival was 14 months for all patients and 14, 14, and 8 months for subgroups treated with CS, CS+LN, and RCS, respectively. Rates of 5-year survival were 23%, 24%, and 36% for CS, CS+LN, and RCS subgroups, respectively. There was no significant difference in survival rates between RCS and CS+LN, or between RCS and CS.

Conclusions
The majority of patients with T2 GBCA in the United States are not managed according to current national recommendations.

Manejo de la Enfermedad de Chagas en EEUU: Revisión Sistemática

Evaluation and Treatment of Chagas Disease in the United States: A Systematic Review
Caryn Bern; Susan Montgomery; Barbara Herwaldt; Anis Rassi Jr; Jose Antonio Marin-Neto; Roberto Dantas; James Maguire; Harry Acquatella; Carlos Morillo; Louis Kirchhoff; Robert Gilman; Pedro Reyes; Roberto Salvatella; Anne Moore.
JAMA. 2007;298(18):2171-81.


Context Because of population migration from endemic areas and newly instituted blood bank screening, US clinicians are likely to see an increasing number of patients with suspected or confirmed chronic Trypanosoma cruzi infection (Chagas disease).


Objective To examine the evidence base and provide practical recommendations for evaluation, counseling, and etiologic treatment of patients with chronic T cruzi infection.


Evidence Acquisition Literature review conducted based on a systematic MEDLINE search for all available years through 2007; review of additional articles, reports, and book chapters; and input from experts in the field.


Evidence Synthesis The patient newly diagnosed with Chagas disease should undergo a medical history, physical examination, and resting 12-lead electrocardiogram (ECG) with a 30-second lead II rhythm strip. If this evaluation is normal, no further testing is indicated; history, physical examination, and ECG should be repeated annually. If findings suggest Chagas heart disease, a comprehensive cardiac evaluation, including 24-hour ambulatory ECG monitoring, echocardiography, and exercise testing, is recommended. If gastrointestinal tract symptoms are present, barium contrast studies should be performed. Antitrypanosomal treatment is recommended for all cases of acute and congenital Chagas disease, reactivated infection, and chronic T cruzi infection in individuals 18 years or younger. In adults aged 19 to 50 years without advanced heart disease, etiologic treatment may slow development and progression of cardiomyopathy and should generally be offered; treatment is considered optional for those older than 50 years. Individualized treatment decisions for adults should balance the potential benefit, prolonged course, and frequent adverse effects of the drugs. Strong consideration should be given to treatment of previously untreated patients with human immunodeficiency virus infection or those expecting to undergo organ transplantation.


Conclusions Chagas disease presents an increasing challenge for clinicians in the United States. Despite gaps in the evidence base, current knowledge is sufficient to make practical recommendations to guide appropriate evaluation, management, and etiologic treatment of Chagas disease.

Quemaduras en Pies

Foot burns: Epidemiology and management
S. Hemington-Gorse, S. Pellard, Wilson-Jones and Potokara. The Welsh Regional Burns and Plastic Surgical Unit, Morriston Hospital. United Kingdom.
Burns 2007; 33(8):1041-5

This is a retrospective study of the epidemiology and management of isolated foot burns presenting to the Welsh Centre for Burns from January 1998 to December 2002. A total of 289 were treated of which 233 were included in this study.
Approximately 40% were in the paediatric age group and the gender distribution varied dramatically for adults and children.
In the adult group the male:female ratio was 3.5:1, however in the paediatric group the male:female ratio was more equal (1.6:1). Scald burns (65%) formed the largest group in children and scald (35%) and chemical burns (32%) in adults.
Foot burns have a complication rate of 18% and prolonged hospital stay.
Complications include hypertrophic scarring, graft loss/delayed healing and wound infection. Although isolated foot burns represent a small body surface area, over half require treatment as in patients to allow for initial aggressive conservative management of elevation and regular wound cleansing to avoid complications.
This study suggests a protocol for the initial acute management of foot burns. This protocol states immediate referral of all foot burns to a burn centre, admission of these burns for 24–48 h for elevation, regular wound cleansing with change of dressings and prophylactic antibiotics.

Dolor Crónico tras Hernioplastía Primaria vs Con Malla

Randomized clinical trial of mesh versus non-mesh primary inguinal hernia repair: Long-term chronic pain at 10 years
Ruben van Veen, Arthur Wijsmuller, Wietske Vrijland, Wim Hop, Johan Lange and Johannus Jeekel. University Medical Center, Rotterdam, The Netherlands
Surgery 2007;142(5):695-8.

Background
Open mesh or non-mesh inguinal hernia repair may influence the incidence of chronic postoperative pain differently.

Methods
A total of 300 patients scheduled for repair of a primary unilateral inguinal hernia were randomized to non-mesh or mesh repair. The primary outcome measure was clinical outcome including persistent pain and discomfort interfering with daily activity. Long-term results at 3 years of follow-up have been published. Included here are 10-year follow-up results with respect to pain.

Results
Of the 300 patients, 87 patients (30%) died and 49 patients (17%) were lost to follow-up. A total of 153 were physically examined in the outpatient clinic after a median long-term follow-up of 129 months (range, 109 to 148 months). None of the patients in the non-mesh or mesh group suffered from persistent pain and discomfort interfering with daily activity.

Conclusions
Our 10-year follow-up study provides evidence that mesh repair of inguinal hernia is equal to non-mesh repair with respect to long-term persistent pain and discomfort interfering with daily activity. An important new finding from the patient’s perspective is that chronic postoperative pain seems to dissipate over time.

Sarcomas

Sarcoma
KEITH SKUBITZ; DAVID D’ADAMO.
Mayo Clin Proc 2007;82(11):1409-32.

Sarcomas comprise a heterogeneous group of mesenchymal neoplasms.
They can be grouped into 2 general categories, soft tissue sarcoma and primary bone sarcoma, which have different staging and treatment approaches.
This review includes a discussion of both soft tissue sarcomas (malignant fibrous histiocytoma, liposarcoma, leiomyosarcoma, synovial sarcoma, dermatofibrosarcoma protuberans, angiosarcoma, Kaposi sarcoma, gastrointestinal stromal tumor, aggressive fibromatosis or desmoid tumor, rhabdomyosarcoma, and primary alveolar soft-part sarcoma) and primary bone sarcomas (osteosarcoma, Ewing sarcoma, giant cell tumor, and chondrosarcoma).
The 3 most important prognostic variables are grade, size, and location of the primary tumor. The approach to a patient with a sarcoma begins with a biopsy that obtains adequate tissue for diagnosis without interfering with subsequent optimal definitive surgery. Subsequent treatment depends on the specific type of sarcoma. Because sarcomas are relatively uncommon yet comprise a wide variety of different entities, evaluation by oncology teams who have expertise in the field is recommended. Treatment and follow-up guidelines have been published by the National Comprehensive Cancer Network

Papel del Trasplante en el Manejo del Cáncer Hepático

Role of transplantation in the management of hepatic malignancy.
British Journal of Surgery 2007 94(11):1319-30
S. R. Knight, P. J. Friend, P. J. Morris.

The acceptance of liver transplantation in the management of hepatic malignancy declined after early poor outcomes.

Despite recent developments, including stricter selection criteria and improved adjuvant therapies, the role of liver transplantation in the management of cancer remains controversial.

This review explores the evidence for the current role of liver transplantation in the management of hepatic malignancy in the context of recent advances in surgical resection and non-surgical treatments.A literature search was conducted using the Cochrane Library and Ovid MEDLINE and EMBASE, using terms for hepatic malignancy and interventions that included liver transplantation, percutaneous interventions, chemotherapy and surgical resection.

In patients with primary hepatocellular carcinoma, improved selection has led to outcomes equivalent to those from surgical resection and comparable to those in patients transplanted for non-malignant indications.

Recent studies suggest that selection criteria may be refined further. Surgical resection or percutaneous therapies may reduce the risk of progression while waiting for a transplant. Recent improvements have occurred in neoadjuvant therapies for cholangiocarcinoma.

Nevertheless, a number of questions regarding the role of liver transplantation for hepatic malignancy remain.

Manejo del Absceso (Flegmón) Apendicular: Metaanálisis

Nonsurgical Treatment of Appendiceal Abscess or Phlegmon: A Systematic Review and Meta-analysis.
Annals of Surgery. 246(5):741-748, November 2007.
Andersson, Roland; Petzold, Max G.

Objective: A systematic review of the nonsurgical treatment of patients with appendiceal abscess or phlegmon, with emphasis on the success rate, need for drainage of abscesses, risk of undetected serious disease, and need for interval appendectomy to prevent recurrence.

Summary Background Data: Patients with appendiceal abscess or phlegmon are traditionally managed by nonsurgical treatment and interval appendectomy. This practice is controversial with proponents of immediate surgery and others questioning the need for interval appendectomy.

Methods: A Medline search identified 61 studies published between January 1964 and December 2005 reporting on the results of nonsurgical treatment of appendiceal abscess or phlegmon. The results were pooled taking the potential clustering on the study-level into account. A meta-analysis of the morbidity after immediate surgery compared with that after nonsurgical treatment was performed.

Results: Appendiceal abscess or phlegmon is found in 3.8% (95% confidence interval (CI), 2.6-4.9) of patients with appendicitis. Nonsurgical treatment fails in 7.2% (CI: 4.0-10.5). The need for drainage of an abscess is 19.7% (CI: 11.0-28.3). Immediate surgery is associated with a higher morbidity compared with nonsurgical treatment (odds ratio, 3.3; CI: 1.9-5.6; P < 0.001). After successful nonsurgical treatment, a malignant disease is detected in 1.2% (CI: 0.6-1.7) and an important benign disease in 0.7% (CI: 0.2-11.9) during follow-up. The risk of recurrence is 7.4% (CI: 3.7-11.1).

Conclusions: The results of this review of mainly retrospective studies support the practice of nonsurgical treatment without interval appendectomy in patients with appendiceal abscess or phlegmon.

Congreso Chileno/FELAC de Cirugía 2007

A continuación encuentran el programa completo del congreso que empieza mañana en Santiago.

http://www.cirujanosdechile.cl/Congresos/Detalle2007/ProgramaDefinitivo.pdf

Grupo de Consenso: Definición de Vaciamiento Gástrico Enlentecido tras Cirugía Pancréatica

Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)
Surgery Volume 142, Issue 5, November 2007, Pages 761-768
Moritz Wente, Claudio Bassi, Christos Dervenis, Abe Fingerhut, Dirk Gouma, Jakob Izbicki, John Neoptolemos, Robert Padbury, Michael Sarr, William Traverso, Charles Yeo and Markus Büchler.

Background
Delayed gastric emptying (DGE) is one of the most common complications after pancreatic resection. In the literature, the reported incidence of DGE after pancreatic surgery varies considerably between different surgical centers, primarily because an internationally accepted consensus definition of DGE is not available. Several surgical centers use a different definition of DGE. Hence, a valid comparison of different study reports and operative techniques is not possible.

Methods
After a literature review on DGE after pancreatic resection, the International Study Group of Pancreatic Surgery (ISGPS) developed an objective and generally applicable definition with grades of DGE based primarily on severity and clinical impact.

Results
DGE represents the inability to return to a standard diet by the end of the first postoperative week and includes prolonged nasogastric intubation of the patient. Three different grades (A, B, and C) were defined based on the impact on the clinical course and on postoperative management.

Conclusion
The proposed definition, which includes a clinical grading of DGE, should allow objective and accurate comparison of the results of future clinical trials and will facilitate the objective evaluation of novel interventions and surgical modalities in the field of pancreatic surgery.

Inutilidad de Sonda Nasogastrica en Apendicitis Aguda Perforada en Niños

Does Routine Nasogastric Tube Placement After an Operation for Perforated Appendicitis Make a Difference?
Journal of Surgical Research 2007;143(1):88-93
Shawn Peter, Patricia Valusek, Danny Little, Charles Snyder, George Holcomb and Daniel Ostlie. Department of Pediatric Surgery, The Children’s Mercy Hospital, Kansas City, Missouri.

Background
Divergent opinions exist regarding the routine use of nasogastric (NG) tubes in the postoperative management of patients undergoing abdominal surgery. Empiric use of an NG tube after abdominal surgery is presumed to prevent abdominal distension, vomiting, and ileus, which may complicate the postoperative course. To investigate the validity of this assumption, we compared the postoperative course of patients who underwent appendectomy for perforated appendicitis who subsequently either had or did not have an NG tube placed postoperatively.

Methods
A retrospective chart review of all children operated for perforated appendicitis between 1999 and 2004 was performed. Patients with prolonged hospitalizations were excluded to eliminate bias created by patients with multiple operations and opportunities for NG placement. The use of an NG tube, time to first and to full oral feeds, length of hospitalization, and complications were compared between groups.

Results
Patients with NG tubes left in place (N = 105) were compared with those who did not receive an NG tube (N = 54) following appendectomy for perforated appendicitis. Mean time to first oral intake was 3.8 d in those with NG tubes compared with 2.2 d in those without NG tubes (P < 0.001). Similarly, mean time to full feeds was 4.9 d when an NG tube was left compared with 3.4 d in those without tubes (P < 0.001). Mean length of stay was 6.0 d in those with NG tubes compared to 5.6 d in those without (P = 0.002).

Conclusions
The use of NG decompression after an operation for perforated appendicitis does not appear to improve the postoperative course and we recommend that it is not routinely used in this patient population.

Manejo de Tromboflebitis

Artículo publicado en el número de este mes de Contemporary Surgery.
Para acceder a texto completo en pdf hacer click en el título.

http://www.contemporarysurgery.com/pdf/6311/6311CS_Review.pdf

Riesgos en Reconstitución de Tránsito tras Operación de Hartmann

Reversal of Hartmann’s procedure: A high-risk operation?
Thomas Schmelzer, Gamal Mostafa, James Norton, William Newcomb, William Hope, Amy Lincourt, Kent Kercher, Timothy Kuwada, Keith Gersin and Todd Heniford. Department of Surgery, Carolinas Medical Center, Charlotte, NC.

Background
Patients who undergo Hartmann’s procedure often do not have their colostomy closed based on the perceived risk of the operation. This study evaluated the outcome of reversal of Hartmann’s procedure based on preoperative risk factors.

Methods
We retrospectively reviewed adult patients who underwent reversal of Hartmann’s procedure at our tertiary referral institution. Patient outcomes were compared based on identified risk factors (age >60 years, American Society of Anesthesiologists [ASA] score >2, and >2 preoperative comorbidities).

Results
One-hundred thirteen patients were included. Forty-four patients (39%) had an ASA score of ≥3. The mean hospital duration of stay was 6.8 days. There were 28 (25%) postoperative complications and no mortality. Patients >60 years old had significantly longer LOS compared with the rest of the group (P = .02). There were no differences in outcomes between groups based on ASA score or the presence of multiple preoperative comorbidities. An albumin level of <3.5 was the only significant predictor of postoperative complications (P = .04).

Conclusions
The reversal of Hartmann’s operation appears to be a safe operation with acceptable morbidity rates and can be considered in patients, including those with significant operative risk factors.

Autonomía del Paciente: Cuando es Díficil de Determinar (¿y aceptar?)

Articulo publicado en New Englnd Journal of Medicine sobre un tema que no toca enfrentar más frecuente de lo que quisieramos.

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