Descompresión con Aguja en Neumotórax a Tensión: ¿Qué Longitud de Aguja Usar?

Needle Thoracostomy in the Treatment of a Tension Pneumothorax in Trauma Patients: What Size Needle?
Journal of Trauma-Injury Infection & Critical Care. 64(1):111-114, January 2008.
Zengerink, Imme; Brink, Peter; Laupland, Kevin; Raber, Earl; Zygun, Dave; Kortbeek, John.

Background: A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle.

Objectives: To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces.

Methods: Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40>=40 years of age was defined a priori. CWT was measured to the nearest 0.01 cm at the second ICS in the MCL.

Results: The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50 cm at the left second ICS MCL and 3.51 cm on the right. The mean CWT was significantly higher for women than men (p <>4.5 cm and 24.1% to 35.4% of the women studied.

Conclusions: A catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy

Resumen Consenso Cáncer de Vesícula Biliar.

El 26 de Agosto del año 2004, se realizó en Santiago una reunión de consenso sobre el manejo del cáncer de la vesícula biliar, que incluyó un importante número de profesionales médicos relacionados con el tema.

Al hacer click en título de este entry se puede acceder a los puntos más importantes de este consenso resumidos y que fueron publicados en la Revista Chilena de Cirugía en su número de diciembre 2007.

Toracotomia de Emergencia en el Manejo del Trauma Abdominal Exsanguinante

Emergency Department Thoracotomy: Still Useful After Abdominal Exsanguination?
Journal of Trauma-Injury Infection & Critical Care. 64(1):1-8, January 2008.
Seamon, Mark; Pathak, Abhijit; Bradley, Kevin; Fisher, Carol; Gaughan, John; Kulp, Heather; Pieri, Paola; Santora, Thomas; Goldberg, Amy.

Background:
Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage.

Methods:
A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival.

Results:
The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days).

Conclusions:
Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.

Divertículo de Meckel Incidental: ¿Resecar o No?

Incidentally Detected Meckel Diverticulum: To Resect or Not to Resect?
Annals of Surgery. 247(2):276-281, February 2008.
Zani, Augusto; Eaton, Simon; Rees, Clare; Pierro, Agostino.

Background:
Management of incidentally detected Meckel diverticulum (MD) remains controversial. Our aims were to establish: (1) the prevalence of MD; (2) the morbidity and (3) mortality due to MD.
Methods:
Systematic review: A total of 244 papers meeting defined criteria were included; there were no prospective or randomized studies. MD prevalence and mortality from autopsy studies, postoperative complications, and outcome of incidentally detected MD were extracted. Population-based data: Data were obtained from national databases on MD as cause of death, and on number of MD resections per year.

Results:
The prevalence of MD is 1.2% and historical mortality of MD was 0.01%. The current mortality from MD is 0.001%. The number of MD resections per year per 100,000 population decreased significantly after the pediatric age range (P < 0.001). Resection of incidentally detected MD has a significantly higher postoperative complication rate than leaving it in situ (P < 0.0001). The long-term outcome of patients with incidentally detected MD left in situ showed no complications. Seven-hundred fifty-eight patients would require incidentally detected MD resection to prevent 1 death from MD.

Conclusions:
MD is present in 1.2% of the population, it is a very rare cause of mortality, and it is primarily a disease of the young. Leaving an incidentally detected MD in situ reduces the risk of postoperative complications without increasing late complications. A large number of MD resections would need to be performed to prevent 1 death from MD. The above evidence does not support the resection of incidentally detected MD.

CPRE Precoz en el Manejo de Pancreatitis Aguda Sin Colangitis: Metaanálisis

Early Endoscopic Retrograde Cholangiopancreatography Versus Conservative Management in Acute Biliary Pancreatitis Without Cholangitis: A Meta-Analysis of Randomized Trials.
Annals of Surgery. 247(2):250-257, February 2008.
Petrov, Maxim; van Santvoort, Hjalmar; Besselink, Marc; van der Heijden, Geert; van Erpecum, Karel; Gooszen, Hein.

Background:
Early endoscopic retrograde cholangiopancreatography (ERCP) should be performed in all patients with acute biliary pancreatitis (ABP) and coexisting acute cholangitis. In patients without cholangitis and predicted mild ABP it is generally accepted that early ERCP should not be performed. Nevertheless, there is a controversy regarding the role of early ERCP in the treatment of patients with predicted severe ABP without cholangitis. We reviewed randomized trials on early ERCP versus conservative management in patients with ABP without acute cholangitis.

Methods:
Relevant publications in 3 electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) were systematically reviewed and meta-analyzed.

Results:
Seven randomized trials on ERCP in acute pancreatitis were found, of which 3 including a total of 450 patients (230 in the invasive arm and 220 in the control arm) qualified for a meta-analysis according to predefined criteria. In all patients with ABP (predicted mild and severe), early ERCP was associated with a nonsignificant reduction in overall complications [risk ratio (RR) 0.76; 95% confidence interval (CI) 0.41-1.04; P = 0.38] and a nonsignificant increase in mortality (RR 1.13; 95% CI 0.23-5.63; P = 0.88). Subgroup analysis based on predicted severity did not affect these outcomes (overall complications: predicted mild: RR 0.86; 95% CI 0.62-1.19; P = 0.36; predicted severe: RR 0.82; 95% CI 0.32-2.10; P = 0.68; mortality: predicted mild: RR 1.90; 95% CI 0.25-14.55; P = 0.53; predicted severe: RR 1.28; 95% CI 0.20-8.06; P = 0.80).

Conclusion:
In this meta-analysis, early ERCP in patients with predicted mild and predicted severe ABP without acute cholangitis did not lead to a significant reduction in the risk of overall complications and mortality.

Consejos para Realizar Anastomosis en Forma Segura

Artículo publicado en Contemporary Surgery que abarca el tema de suturas intestinales. Se puede acceder al texto completo en PDF al hacer click en el título de este entry.

Recuento de Compresas: Utilidad

Managing the Prevention of Retained Surgical Instruments: What Is the Value of Counting?
Annals of Surgery. 247(1):13-18, January 2008.
Egorova, Natalia; Moskowitz, Alan; Gelijns, Annetine; Weinberg, Alan; Curty, James; Rabin-Fastman, Barbara; Kaplan, Harold; Cooper, Mary; Fowler, Dennis; Emond, Jean; Greco, Giampaolo.

Objective: Preventing retained foreign bodies is critical for patient safety. However, the value of counting surgical instruments and the reliability of the information provided have never been quantified. This study examines the diagnostic characteristics of counting and its impact on surgical costs.

Methods: We examined data from the Medical Event Reporting System-Total HealthSystem (MERS-TH), administrative hospital, and the New York State Cardiac Surgery Report databases (2000-2004). The cost per count discrepancy was examined by studying a cohort of patients undergoing coronary artery bypass graft (CABG) surgery. Linear and logistic multivariable regression models were used for statistical analysis.

Results: Of 153,263 operations, there were 1062 count discrepancies. The rate of retained items was 1 of 7000 surgeries or 1 of 70 discrepancy cases. Final count discrepancies identified 77% and prevented 54% of retained items. The sensitivity of counting was 77.2%, specificity was 99.2%, but the positive predictive value was only 1.6%. Count discrepancies increased with surgery duration, late time procedures, and number of nursing teams. Bypass time, intravenous nitroglycerin injections, or myocardial infarction in the previous 24 hours were independent predictors of count discrepancies in CABG surgery. The incremental OR cost for CABG because of a count discrepancy was $932. Nationally, this would amount to an additional $24 million/yr in OR CABG cost.

Conclusions: This study, for the first time, quantifies the diagnostic accuracy of counting and defines the parameters against which alternative strategies of prevention should be measured, before being adopted in standard practice.