Complicaciones de cirugía de Whipple en un paciente pediátrico con tumor pseudopapilar de páncreas / Complications of Whipple procedure in a pediatric patient with pseudopapillary tumor of the pancreas

Las neoplasias de páncreas son una entidad poco frecuente en pediatría; el tumor pseudopapilar de páncreas (TSP) es el más comúnmente diagnosticado. Habitualmente, se localizan en la cabeza del páncreas. La cirugía de Whipple o pancreatoduodenectomía es la técnica elegida para el tratamiento de los tumores benignos o malignos de páncreas. Si bien la mortalidad conocida ha descendido en los últimos años, debido a la mayor experiencia de los cirujanos y al mejor cuidado pre- y posoperatorio, la morbilidad se ha mantenido elevada secundaria a las complicaciones asociadas. Dentro de estas se destacan retardo en el vaciamiento gástrico, colecciones intraabdominales, fístula pancreática, reestenosis del sitio quirúrgico y hemorragia pospancreatectomía. Se presenta el caso clínico de una niña de 13 años con diagnóstico de TSP que recibió tratamiento quirúrgico efectivo desde el punto de vista oncológico, pero que requirió una internación prolongada secundaria a las complicaciones quirúrgicas.

Pancreatic neoplasms are rare in pediatrics; the pseudopapillary tumor (PPT) of the pancreas is the most common. PPTs of the pancreas are usually located in the head of the pancreas. A pancreaticoduodenectomy or Whipple procedure is the technique of choice for the treatment of benign or malignant pancreatic tumors. Although mortality for this cause has decreased in recent years, due to the greater experience of surgeons and improved pre- and postoperative care, morbidity has remained high secondary to associated complications. These include delayed gastric emptying, intra-abdominal collections, pancreatic fistula, surgical site restenosis, and post-pancreatectomy hemorrhage. Here we describe the clinical case of a 13-year-old girl diagnosed with PPT of the pancreas who underwent an effective surgery in terms of cancer treatment, but who required a prolonged hospitalization secondary to surgical complications.

C-reactive protein as a marker of postoperative complication of emergency colorectal surgery

Introduction: The literature converges regarding the use of C-reactive protein (CRP) tests between postoperative days (PODs) 3 and 5 of elective procedures. In this period, they have great sensitivity and negative predictive value (NPV) for severe and anastomotic complications about two days before the first clinical sign. The few studies on colorectal urgency suggest that, despite the different initial values according to the surgical indication, following POD 3, the level of CRP is similar to that of elective procedures. However, given the heterogeneity of the studies, there is no consensus on the cutoff values for this use. Objective: To validate the use and propose a PO CRP cut-off value in urgent colorectal procedures as an exclusion criterion for complications of anastomosis or the abdominal cavity. Method: Retrospective analysis of the medical records of 308 patients who underwent urgent colorectal surgical procedures between January 2017 and December 2019. The following data were considered: age, gender, surgical indication, type of procedure performed, complications, CRP levels preoperatively and from POD 1 to 4, and the severity of the complications. We compared the CRP levels and the percentage variations between the preoperative period and PODs 1 to 4 as markers of severe complications using the receiver operating characteristic (ROC) curve. Results: The levels of CRP on POD4, and their percentage drops between PODs 2 to 4 and PODs 3 to 4, were better to predict severe complications. A cutoff of 7.45mg/dL on POD 4 had 91.7% of sensitivity and NPV. A 50% drop between PODs 3 and 4 had 100% of sensitivity and NPV. Conclusion: Determining the level of CRP is useful to exclude severe complications, and it could be a criterion for hospital discharge in POD 4 of emergency colorectal surgery. (AU)

Abdominal drain amylase on the first day after pancreatectomy: a predictive factor for pancreatic fistula

SUMMARY OBJECTIVE: To analyze abdominal drain on the first postoperative day and evaluate its predictive nature for the diagnosis of Pancreatic Fistula exclusion, seeking to establish a cutoff point from which lower values demonstrate safety in excluding the possibility of this complication. METHODS: From August 2017 to June 2020, data from 48 patients undergoing pancreatic resection were collected and analyzed from a prospective cohort. The patients were divided into two groups, one group consisting of patients who did not develop PF (Group A), and the other composed of patients who developed PF (Group B). The receiver operation characteristic curve was constructed, and cutoff points were evaluated by calculating sensitivity and specificity. RESULTS: Group A brought 30 patients together (62.5%) and Group B brought 18 patients together (37.5%). The 444 U/L value was the most satisfactory cutoff point for the receiver operation characteristic curve (CI 0.690-0.941), with a sensitivity of 94.4% and a specificity of 60%, thus being able to select 18 of 30 patients who did not succumb to PF. CONCLUSIONS: Abdominal drain on the first postoperative day can be used as a predictive factor in the diagnosis of PF exclusion (CI 0.690-0.941), with the value of 444 U/L being the best performance cutoff point.

Diagnosis and treatment of anastomotic leak after low anterior resection for rectal cancer: current status and future prospect / 中华胃肠外科杂志

Anastomotic leak is one of inevitable postoperative complications of rectal cancer. With the improvement of surgical techniques, the enhancement of the cognization of rectal cancer, and the development of surgical instruments, surgical procedures of rectal cancer are getting more sophisticated. The anastomosis is performed lower and lower, however the incidence of anastomotic leak is not significantly decreased. In addition, different from intraperitoneal anastomotic leak, the low rectal anastomotic leak after low anterior resection has many special issues in the diagnosis and treatment in clinic. The incidence of peritonitis caused by low anastomotic leak is low, the onset time is late, and symptoms of peritonitis are mild. So most low anastomotic leak is treated conservatively, second surgical repair or resection of anastomotic site is rarely performed, and proximal intestinal diversion is commonly performed. In the prevention of low anastomotic leak, some techniques and precautions during the perioperative period and identification of high risk factors might play important roles. Combined our clinical experiences, we introduced the diagnosis, treatment, prevention and research progression of low anastomotic leak after anterior resection of low rectal cancer, we hope it would be helpful.

Procedimiento de Whipple: experiencia de un centro en fase de crecimiento en cirugía hepato-bilio-pancreática / Whipple procedure: hepatic-bilio-pancreatic single center experience

La operación de Whipple es el procedimiento quirúrgico de mayor complejidad en cirugía abdominal, este se realiza en pacientes con tumores de la encrucijada pancreatoduodenal, es la única alternativa para tratamiento curativo en fases tempranas de la enfermedad. Objetivo: Determinar los resultados del procedimiento Whipple, en pacientes intervenidos con tumores de la encrucijada pancreatoduodenal en el Hospital General de Enfermedades del Instituto Guatemalteco de Seguridad Social, en el periodo de enero 2,015 a enero 2,020. Método: Descriptivo, observacional, retrospectivo. Resultados: Se incluyeron 42 procedimientos de Whipple, 29 (69%) casos del género masculino y 13 (31%) para el género femenino. La edad media fue de 61.5 años, el 54% presentaban comorbilidad asociada. El 24% utilizo transfusión transoperatoria de hemoderivados, el tiempo quirúrgico de 5.5 horas. La reintervención fue del 4.7%. Complicaciones postoperatorias tempranas 18%. La histología más común fue el carcinoma de cabeza de páncreas en el 43%. La mortalidad postoperatoria temprana fue del 4.7%. El OR de complicaciones asociadas a comorbilidades fue de 1.7 con un IC 0.3046-7.20 y un valor de P: 0.9251 que no es estadísticamente significativo. Conclusiones: Los tumores pancreatoduodenales en nuestra población se presentan en edades más tempranas a lo reportado. La morbimortalidad es similar a lo reportado en otros estudios a nivel latinoamericano, sin embargo las complicaciones están más elevadas que las mejores series internacionales. No existe asociación entre el riesgo de complicaciones con comorbilidades del paciente. (AU)

Whipple operation is the most complex surgical procedure in abdominal surgery, it's performed in patients with tumors of the pancreaticoduodenal crossroads, it is the only alternative for curative treatment in early stages of the disease. Objective: To determine the results of the Whipple procedure in patients operated on with tumors of the ancreaticoduodenal crossroads at the Hospital General de Enfermedades del IGSS in the period from January 2015 to January 2020. Method: Descriptive, observational, retrospective. Results: fourtytwo Whipple procedures were included, 29 (69%) cases of the male gender and 13 (31%) for the female gender. The mean age was 61.5 years, 54% had associated comorbidity. Twentyfour percent used intraoperative transfusion of blood products and surgical time of 5.5 hours. Reoperation was 4.7% with early postoperative complications of 18%. The most common histology was carcinoma of the head of the pancreas in 43%. Early postoperative mortality was 4.7%. The OR of complications associated with comorbidities was 1.7 with a CI 0.3046-7.20 and a P value: 0.9251, which is not statistically significant. Conclusions: Pancreaticoduodenal tumors in our population present at an earlier age than reported. Morbidity and mortality is similar to that reported in other studies. There is no association between the risk of complications with patient comorbidities. (AU)

The routine use of the methylene blue test in sleeve gastrectomy: why not? / Uso rotineiro do teste do azul de metileno na gastrectomia vertical: por que não?

ABSTRACT Background: Although considered a safe procedure, sleeve gastrectomy (SG) has a non-negligible risk of major postoperative complications related to it, with special attention to gastric leaks. Aim: Evaluate the clinical value of the methylene blue test (MBT) in predicting the occurrence of post-SG leaks. Methods: Retrospective study that included 1136 patients who underwent SG with intraoperative MBT between 2012 and 2016. Sensitivity, specificity, positive predictive value (PPV) and negative predicted value (NPV) were calculated to determine the clinical correlation between the MBT and the occurrence of postoperative leaks. Staple line oversewing was performed in all patients who presented positive MBT. Results: Laparoscopic SG was performed in 97.0% of cases; open in 2.3%, and robotic in 0.7%. MBT was positive in 19 cases (1.67%). One positive MBT occurred during an open SG and the other 18 at laparoscopy. Moreover, there were nine cases (0.8%) of postoperative leaks, among which, only two presented positive MBT. MBT diagnostic value was evaluated through the calculation of sensitivity (22.0%), specificity (98.0%), PPV (11.0%) and NPV (99.0%). There were no cases of allergic reaction or any other side effect with the use of the methylene blue solution. Conclusion: MBT showed high specificity and negative predictive value, thus presenting an important value to rule out the occurrence of postoperative leaks.

RESUMO Racional: Embora considerada procedimento seguro, a gastrectomia vertical (GV) apresenta risco não desprezível de complicações pós-operatórias importantes relacionadas a ela, com atenção especial para fístulas gástricas Objetivo: Avaliar a aplicabilidade clínica do teste do azul de metileno (TAM) na predição da ocorrência de fístulas após a GV. Método: Estudo retrospectivo que incluiu 1136 pacientes operados entre 2012 e 2016 com aplicação do TAM intraoperatório. Sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) foram calculados na tentativa de determinar a correlação clínica entre os resultados do TAM e a ocorrência de fístulas pós-operatórias. Sobressutura da linha de grampos foi realizada em todos os pacientes que apresentaram TAM positivo. Resultados: GV laparoscópica foi realizada em 97,0% dos casos; por laparotomia em 2,3% e roboticamente em 0,7%. TAM foi positivo em 19 casos (1,67%). Um dos casos positivos ocorreu na laparotomia e os outros 18 na laparoscopia. Ainda, houve nove casos (0,8%) de fístulas pós-operatórias, dentre os quais, apenas dois apresentaram TAM positivo. O valor diagnóstico do TAM foi avaliado através dos cálculos de sensibilidade (22,0%), especificidade (98,0%), VPP (11,0%) e VPN (99,0%). Não houve casos de reação alérgica ou qualquer outro efeito colateral advindo do uso da solução de azul de metileno. Conclusão: TAM mostrou alta especificidade e VPN, apresentando importância em descartar a ocorrência de fístulas pós-operatórias.

S100B level and cognitive dysfunction after robotic-assisted laparoscopic radical prostatectomy procedures: a prospective observational study / Nível de S100B e disfunção cognitiva após prostatectomia radical laparoscópica assistida por robô: estudo observacional prospectivo

Abstract Background: The present study investigated the association between Postoperative Cognitive Dysfunction (POCD) and increased serum S100B level after Robotic-Assisted Laparoscopic Radical Prostatectomy (RALRP). Methods: The study included 82 consecutive patients who underwent RALRP. Serum S100B levels were determined preoperatively, after anesthesia induction, and at 30 minutes and 24 hours postoperatively. Cognitive function was assessed using neuropsychological testing preoperatively, and at 7 days and 3 months postoperatively. Results: Twenty four patients (29%) exhibited POCD 7 days after surgery, and 9 (11%) at 3 months after surgery. Serum S100B levels were significantly increased at postoperative 30 minutes and 24 hours in patients displaying POCD at postoperative 7 days (p = 0.0001 for both) and 3 months (p = 0.001 for both) compared to patients without POCD. Duration of anesthesia was also significantly longer in patients with POCD at 7 days and 3 months after surgery compared with patients without POCD (p = 0.012, p = 0.001, respectively), as was duration of Trendelenburg (p = 0.025, p = 0.002, respectively). Composite Z score in tests performed on day 7 were significantly correlated with duration of Trendelenburg and duration of anesthesia (p = 0.0001 for both). Conclusions: S100B increases after RALRP and this increase is associated with POCD development. Duration of Trendelenburg position and anesthesia contribute to the development of POCD. Trial Registry Number: Clinicaltrials.gov (N° NCT03018522).

Resumo Introdução: O presente estudo investigou a associação entre Disfunção Cognitiva Pós-Operatória (DCPO) e aumento do nível sérico de S100B após Prostatectomia Radical Laparoscópica Assistida por Robô (PRLAR). Métodos: O estudo incluiu 82 pacientes consecutivos submetidos à PRLAR. Os níveis séricos de S100B foram determinados: no pré-operatório, após indução anestésica, e aos 30 minutos e 24 horas do pós-operatório. A função cognitiva foi avaliada com testes neuropsicológicos no pré-operatório, no 7° dia pós-operatório (7 DPO) e aos 3 meses após a cirurgia (3 MPO). Resultados: Observamos 24 pacientes (29%) com DCPO no 7 DPO e 9 pacientes com DCPO (11%) após 3 meses da cirurgia. Quando comparados com os pacientes sem DCPO, os níveis séricos de S100B estavam significantemente aumentados aos 30 minutos e às 24 horas do pós-operatório nos pacientes que apresentaram DCPO no 7 DPO (p= 0,0001 para os dois momentos) e 3 meses após a cirurgia (p= 0,001 para os dois momentos) A duração anestésica também foi significantemente maior em pacientes com DCPO no 7 DPO e 3 MPO em comparação com pacientes sem DCPO (p= 0,012, p= 0,001, respectivamente), assim como a duração da posição de Trendelenburg (p= 0,025, p= 0,002, respectivamente). O escore Z composto nos testes realizados no 7 DPO foi significantemente correlacionado com a duração da posição de Trendelenburg e a duração da anestesia (p= 0,0001 para ambos). Conclusão: S100B aumenta após PRLAR e o aumento está associado ao desenvolvimento de DCPO. A duração anestésica e o tempo decorrido em posição de Trendelenburg contribuem para o desenvolvimento de DCPO. Número de registro do estudo: Clinicaltrials.gov (n° NCT03018522)

Embolization in patient with hypovolemic shock after transobturator sling procedure / Embolização após sling transobturatório em paciente com choque hipovolêmico

Abstract The placement of a suburethral sling is standard treatment for stress urinary incontinence. The transobturator technique (TOT) emerged as an alternative to minimize the risks of the blind insertion of needles, leading to a lower rate of perforation complications compared with the retropubic approach. We present a case of injury to a branch of the left obturator artery following the placement of a urethral sling using TOT, followed by intense bleeding and hemodynamic instability, which was treated with embolization.

Resumo Sling de uretra média é o tratamento padrão para a incontinência urinária de esforço. A abordagem transobturatória (TOT) surgiu como alternativa para minimizar os riscos da inserção às cegas das agulhas com taxa de complicações perfurativas menores quando comparadas à abordagem retropúbica. Apresentamos um caso de lesão em ramo da artéria obturatória esquerda após sling TOT que evoluiu com sangramento intenso e instabilidade hemodinâmica, sendo tratado com embolização.

Desempenho dos Índices de Gravidade na Predição de Complicações Pós-Operatórias de Revascularização Miocárdica / Performance of Severity Indices to Estimate Postoperative Complications of Myocardial Revascularization

Resumo Fundamento Os pacientes em pós-operatório (PO) de cirurgia de revascularização miocárdica (CRM) internados em unidade de terapia intensiva (UTI) apresentam risco de complicações que aumentam o tempo de permanência e a morbimortalidade. Portanto, é fundamental o reconhecimento precoce desses riscos para otimizar estratégias de prevenção e desfecho clínico satisfatório. Objetivo Analisar o desempenho de índices de gravidade na predição de complicações em pacientes no PO de CRM durante a permanência na UTI. Métodos Estudo transversal, com análise retrospectiva de prontuários eletrônicos de pacientes com idade ≥ 18 anos submetidos à CRM isolada e admitidos na UTI de um hospital cardiológico, em São Paulo, Brasil. As áreas sob as curvas receiver operating characteristic (AUC) com intervalo de confiança de 95% foram analisadas para verificar a acurácia dos índices European System for Cardiac Operative Risk Evaluation (EuroScore), Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS II) e Sequential Organ Failure Assessment (SOFA) na predição de complicações. Resultados A casuística foi composta por 366 pacientes (64,58±9,42 anos; 75,96% sexo masculino). As complicações identificadas foram respiratórias (24,32%), cardiológicas (19,95%), neurológicas (10,38%), hematológicas (10,38%), infecciosas (6,56%) e renais (3,55%). O APACHE II apresentou satisfatório desempenho para a predição de complicações neurológicas (AUC 0,72) e renais (AUC 0,78). Conclusão O APACHE II se destacou na previsão das complicações neurológicas e renais. Nenhum dos índices teve bom desempenho na predição das outras complicações analisadas. Portanto, os índices de gravidade não devem ser utilizados indiscriminadamente com o objetivo de predizer todas as complicações frequentemente apresentadas por pacientes após CRM. (Arq Bras Cardiol. 2020; 115(3):452-459)

Abstract Background Patients in the postoperative period of myocardial revascularization (Coronary Artery Bypass Grafting - CABG) surgery admitted to the intensive care unit (ICU) are at risk of complications which increase the length of stay and morbidity and mortality. Therefore, early recognition of these risks is essential to optimize prevention strategies and a satisfactory clinical outcome. Objective To analyze the performance of severity indices in predicting complications in patients in the postoperative of CABG during the ICU stay. Methods A cross-sectional study with retrospective analysis of electronic medical records of patients aged ≥ 18 years who underwent isolated CABG and were admitted to the ICU of a cardiology hospital in São Paulo, Brazil. The areas under the receiver operating characteristic curves (AUC) with a 95% confidence interval were analyzed to verify the accuracy of the European System for Cardiac Operative Risk Evaluation (EuroScore), Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) indices in predicting complications. Results The sample consisted of 366 patients (64.58 ± 9.42 years; 75.96% male). The complications identified were: respiratory (24.32%), cardiovascular (19.95%), neurological (10.38%), hematological (10.38%), infectious (6.56%) and renal (3.55%). APACHE II showed satisfactory performance for predicting neurological (AUC 0.72) and renal (AUC 0.78) complications. Conclusion APACHE II excelled in predicting neurological and renal complications. None of the indices performed well in predicting the other analyzed complications. Therefore, severity indices should not be used indiscriminately in order to predict all complications frequently presented by patients after CABG. (Arq Bras Cardiol. 2020; 115(3):452-459)

Cirugía bariátrica en adolescentes con obesidad severa: recomendaciones de la Rama de Nutrición, Sociedad Chilena de Pediatría / Bariatric surgery in adolescents with severe obesity: recommendations of the Nutrition Branch, Chilean Pediatric Society

Resumen: En los últimos años, la obesidad severa en adolescentes ha aumentado a nivel mundial y Chile no es la excepción a este fenómeno. Es conocido que esta condición aumenta exponencialmente los riesgos para la salud y se asocia a mortalidad prematura. Desde el año 2008, diversas guías de tratamiento de obesidad pediátrica han incluido a la cirugía bariátrica como una estrategia de tratamiento para adolescentes obesos severos seleccionados. Estos procedimientos han mostrado ser seguros y eficaces en adultos. Un cuerpo emergente de evidencia demuestra que, en centros especializados, en el corto y mediano plazo se obtendrían resultados similares en adolescentes. Sin embargo, en este grupo de pacientes, la cirugía bariátrica tiene implícitos otros riesgos inherentes a la etapa de desarrollo en que se encuentran, y los resultados y complicaciones especialmente de largo plazo en gran medida son aún desconocidos. Por lo anterior y para el logro de los resultados esperados, es muy importante que la selección de pacientes, la cirugía y el seguimiento, sean realizados por equipos multidisciplinarios calificados, en centros hospitalarios que cuenten con la infraestructura adecuada, siendo imprescin dible la adherencia de por vida al seguimiento médico y nutricional. El objetivo de este documento es presentar la postura de la Rama de Nutrición de la Sociedad Chilena de Pediatría (SOCHIPE) frente a las diversas aristas a considerar para la adecuada indicación de estos procedimientos en adolescentes obesos severos.

Abstract: In recent years, severe obesity in adolescents has been rising worldwide, and Chile is no exception to this phenomenon. This condition exponentially increases health risks and it is associated with prema ture mortality. Since 2008, several guidelines on pediatric obesity treatment have included bariatric surgery as a treatment strategy for certain severely obese adolescents. These procedures have proven to be safe and efficient in adults. Recent evidence shows that, when done in specialized centers, the re sults would be similar in adolescents in the short and medium term. Nonetheless, in this group of pa tients, bariatric surgery has risks related to their stage of development, and data on long-term results and complications are still lacking. Therefore, to achieve the expected results, the patient selection, surgery, and follow-up must be carried out by qualified multidisciplinary teams, in hospitals centers that have the appropriate infrastructure, It is essential for the patients a life-long adherence to medi cal and nutritional monitoring. The objective of this document is to present the position statement of the Nutrition Branch of the Chilean Society of Pediatrics on the different issues to be considered for the adequate indication of these procedures in severely obese adolescents.

Significación del lactato sérico como biomarcador de infección del neonato intervenido quirúrgicamente / Significance of serum lactate as a biomarker of infection of the newborn undergoing surgery

Introducción: El neonato que se interviene quirúrgicamente está expuesto al desarrollo de infecciones. El lactato sérico ha sido recomendado como criterio diagnóstico de sepsis. Objetivo: Determinar la magnitud de asociación del valor del lactato sérico con la sepsis en el neonato intervenido quirúrgicamente. Métodos: Estudio entre 2013 y 2016, en el Hospital Pediátrico Universitario William Soler, en 307 neonatos intervenidos quirúrgicamente. Las variables se agruparon en: clínicas (edad gestacional, peso al nacer, causa de la intervención quirúrgica, localización de la infección) y paraclínicas (microorganismo causal, lactato sérico). Se aplicó la prueba de correlación lineal de Pearson parcial y se estimó odds ratio con el control de la variable infección (sí y no) para identificar la correlación entre los valores de lactato sérico en el preoperatorio y en el posoperatorio. Resultados: De los neonatos 63 tenían bajo peso (20,52 por ciento) y 55 eran pretérminos (17,92 por ciento). En los neonatos infectados 20,83 por ciento fueron operados por afecciones digestivas (n= 35); las infecciones sistémicas alcanzaron 67,74 por ciento (n= 42), ocasionadas en 45,24 por ciento por Cándida sp. La velocidad de cambio de los valores del lactato sérico en los infectados (p= 0,001) significó que por cada unidad en mmol/L que ascendió el lactato preoperatorio, en el posoperatorio se incrementó 0,489 mmol/L y estos cambios fueron debidos en 16,9 por ciento a los valores del lactato preoperatorio. Conclusiones: El lactato sérico está asociado a la infección en los neonatos intervenidos quirúrgicamente y es un biomarcador de sepsis útil en los cuidados intensivos neonatales(AU)

Introduction: The newborn undergoing a surgery is exposed to the development of infections. The serum lactate has been recommended as a diagnostic criterion of sepsis. Objective: To determine the magnitude of association of the value of serum lactate with sepsis in the newborn undergoing a surgery. Methods: Study conducted from 2013 to 2016 in William Soler Pediatric Teaching Hospital, to 307 newborns whom underwent surgery. The variables were grouped in: clinical (gestational age, birth weight, cause of surgical intervention, location of the infection) and paraclinical (causative microorganisms, serum lactate). The partial Pearson's test of linear correlation was applied and it was estimated the odds ratio with the control of the variable infection (yes and no) to identify correlation between serum lactate values in the preoperative and postoperative results. Results: Of the newborns, 63 were under weight (20.52 percent) and 55 were preterm infants (17.92 percent). In the infected newborns, 20.83 percent were operated due to digestive conditions (n= 35); systemic infections reached 67.74 percent (n= 42), caused in 45.24 percent by Candida sp. The rate of change of the values of serum lactate in infected subjects (p= 0.001) meant that for each unit in mmol/L in which increased the preoperative lactate, the postoperative increased 0.489 mmol/L; and these changes were due in a 16.9 percent to the values of preoperative lactate. Conclusions: The serum lactate is associated to the infection in newborns that underwent surgery and is a useful biomarker of sepsis in neonatal intensive care(AU)

Ascitis quilosa en el posoperatorio de hepatectomía derecha / Chylous ascites after right liver resection

La ascitis quilosa posoperatoria (AQP) se debe a acumulación de líquido rico en triglicéridos en la cavidad peritoneal tras una lesión en la cisterna del quilo o en sus afluentes. Es infrecuente verla después de una hepatectomía. Se presenta el caso de un varón de 44 años con adenocarcinoma a 16 cm del margen anal T3N1, con metástasis que ocupaba casi la totalidad del lóbulo hepático derecho. Luego de quimioterapia se realizó hepatectomía derecha, observándose al cuarto día postoperatorio líquido del drenaje endotorácico de aspecto lechoso, con triglicéridos 223 mg/dL y 77 mg/dL de triglicéridos séricos. Se inició dieta sin grasas, hiperproteica, con ácidos grasos de cadena media y octreótide (100 microgramos subcutáneos cada 8 horas), con resolución del cuadro. En conclusión, la complicación quilosa puede tratarse exitosamente con un abordaje menos agresivo, sin suprimir la ingesta oral, utilizando octreótide subcutáneo, dieta exenta de grasas, suplementada con proteínas y ácidos grasos de cadena media.

Postoperative chylous ascites is an intraperitoneal collection of lymphatic fluid enriched with long-chain triglycerides that results from injury of the cisterna chyli or its main tributaries. This complication is rare after liver resections. Here, we report on the case of a 44 year-old man with a T3N1 rectal adenocarcinoma 16 cm above the anal margin, with metastatic compromise of almost the entire right liver lobe. Following chemotherapy, he underwent right liver resection. On postoperative day four, the thoracic drain evidenced milky fluid containing triglyceride 223 mg/dL with serum triglycerides 77 mg/dL. A fat-free diet was indicated with fat-free protein supplements, medium chain triglycerides and octreotide (100 μg subcutaneously every 8 hours), with complete resolution. In conclusion, postoperative chylous complications may be treated successfully by a less aggressive approach, with oral diet, subcutaneous octreotide, fat-free diet supplemented with proteins and medium chain fatty acids.

Urine microscopy as a biomarker of Acute Kidney Injury following cardiac surgery with cardiopulmonary bypass / Microscopia urinária como biomarcador de lesão renal aguda após cirurgia cardíaca com circulação extracorpórea

Abstract Introduction: Acute kidney injury (AKI) occurs in about 22% of the patients undergoing cardiac surgery and 2.3% requires renal replacement therapy (RRT). The current diagnostic criteria for AKI by increased serum creatinine levels have limitations and new biomarkers are being tested. Urine sediment may be considered a biomarker and it can help to differentiate pre-renal (functional) from renal (intrinsic) AKI. Aims: To investigate the microscopic urinalysis in the AKI diagnosis in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: One hundred and fourteen patients, mean age 62.3 years, 67.5 % male, with creatinine 0.91 mg/dL (SD 0.22) had a urine sample examined in the first 24 h after the surgery. We looked for renal tubular epithelial cells (RTEC) and granular casts (GC) and associated the results with AKI development as defined by KDIGO criteria. Results: Twenty three patients (20.17 %) developed AKI according to the serum creatinine criterion and 76 (66.67 %) by the urine output criterion. Four patients required RRT. Mortality was 3.51 %. The use of urine creatinine criterion to predict AKI showed a sensitivity of 34.78 % and specificity of 86.81 %, positive likelihood ratio of 2.64 and negative likelihood ratio of 0.75, AUC-ROC of 0.584 (95%CI: 0.445-0.723). For the urine output criterion sensitivity was 23.68 % and specificity 92.11 %, AUC-ROC was 0.573 (95%CI: 0.465-0.680). Conclusion: RTEC and GC in urine sample detected by microscopy is a highly specific biomarker for early AKI diagnosis after cardiac surgery.

Resumo Introdução: Lesão renal aguda (LRA) ocorre em cerca de 22% dos pacientes submetidos a cirurgia cardíaca e 2,3% necessitam de terapia renal substitutiva (TRS). Os atuais critérios diagnósticos para LRA fundamentados no aumento dos níveis de creatinina sérica apresentam limitações e novos biomarcadores estão sendo testados. O sedimento urinário é um biomarcador que pode ajudar a diferenciar a LRA pré-renal (funcional) da LRA renal (intrínseca). Objetivos: Investigar a urinálise microscópica no diagnóstico de LRA em pacientes submetidos a cirurgia cardíaca com circulação extracorpórea. Métodos: Um total de 114 pacientes com idade média de 62,3 anos, 67,5% do sexo masculino e níveis médios de creatinina de 0,91 mg/dL (DP 0,22) tiveram amostras de urina examinadas nas primeiras 24 horas após a cirurgia. A identificação de células epiteliais tubulares renais (CETR) e cilindros granulares (CG) foi associada a desfechos de desenvolvimento de LRA conforme os critérios do KDIGO. Resultados: Vinte e três pacientes (20,17%) desenvolveram LRA pelo critério de creatinina sérica e 76 (66,67%) pelo critério de diurese. Quatro pacientes necessitaram de TRS. A mortalidade foi de 3,51%. O uso da creatinina urinária como critério preditivo para LRA mostrou sensibilidade de 34,78% e especificidade de 86,81%; razão de verossimilhança positiva de 2,64 e razão de verossimilhança negativa de 0,75; e ASC-COR de 0,584 (IC 95%: 0,445-0,723). Para o critério de diurese, a sensibilidade foi de 23,68% e a especificidade 92,11%; a ASC-COR foi 0,573 (IC 95%: 0,465-0,680). Conclusão: A identificação de CETR e CG em amostras de urina por microscopia representa um biomarcador altamente específico para o diagnóstico precoce de LRA após cirurgia cardíaca.

The very elderly surgical population in a critically ill scenario: clinical characteristics and outcomes / A população cirúrgica muito idosa em cuidados intensivos: características clínicas e desfechos

Abstract Background: The elderly population is an especially heterogeneous group of patients with a rising number of surgical interventions being performed in the very elderly patient. The aim of this study was to evaluate the correlation between different age strata and functional status with the surgical outcome of the elderly patient. Methods: Retrospective cohort study conducted in a Surgical Intensive Care Unit (SICU), between 2006 and 2013. A total of 2331 surgical patients' ≥ 65 years old were included. Patients were grouped according to age: Older Elderly Group (OEG: 65‒85 years old); Very Elderly Group (VEG > 85 years old). Demographic and perioperative data were recorded. Revised Cardiac Risk Index, APACHE II and SAPS II scores were calculated and postoperative complications were documented. Variables were compared on univariate analysis. Results: The incidence of the VEG was 5.4%. This group had a higher proportion of non-elective surgery (22.4% vs. 11.2%, p < 0.001), higher APACHE II (12.0 vs. 10.0, p < 0.001) and SAPS II (26.6 vs. 22.2, p < 0.001) scores, higher incidence of organ failure (24.6% vs. 17.6%, p = 0.048) and a higher mortality rate during SICU (14.0% vs. 5.2%, p = 0.026) and hospital stay (9.3% vs. 5.0%, p = 0.012). Conclusion: We found that very elderly patients represented a significant proportion of patients admitted to the SICU. They had higher severity scores with a higher prevalence of organ failure and were more likely to undergo non-elective surgery. They had worse outcomes in regarding mortality during SICU and hospital stay.

Resumo Introdução: A população idosa envolve um grupo muito heterogêneo de doentes, com um crescente número de doentes muito idosos a serem propostos para cirurgia. O objetivo do presente estudo foi avaliar a relação entre diferentes grupos etários e estados funcionais com os resultados cirúrgicos do doente idoso. Métodos: Estudo retrospectivo de coorte realizado em uma Unidade de Cuidados Intensivos Cirúrgica (UCIC) que incluiu um total de 2331 doentes cirúrgicos com idade ≥ 65 anos, entre 2006 e 2013. Os doentes foram agrupados de acordo com a idade: doentes idosos (65-85 anos); doentes muito idosos (DMI > 85 anos). Dados demográficos e perioperatórios foram registrados. Índice de Risco Cardíaco Revisto, scores de APACHE e SAPS II foram calculados e complicações pós-operatórias, documentadas. As variáveis foram comparadas em análise univariada. Resultados: A incidência de DMI foi de 5,4%. Este grupo foi mais frequentemente submetido à cirurgia não eletiva (22,4%vs.11,2%; p< 0,001), apresentou scores maiores de APACHE II (12,0vs.10,0; p< 0,001) e SAPS II (26,6 vs. 22,2; p< 0,001), maior incidência de insuficiência do órgão (24,6%vs.17,6%; p= 0,048) e uma mortalidade superior na UCIC (14,0%vs.5,2%; p= 0,026) e no hospital (9,3% vs.5,0%; p= 0,012). Discussão: Os piores resultados nos DMI podem refletir uma maior vulnerabilidade a complicações pós-operatórias, possivelmente relacionadas com múltiplas comorbilidades e uma reserva fisiológica diminuídas. Conclusão: Os doentes muito idosos representaram uma porção importante dos doentes admitidos na UCIC, tinham scores de gravidade mais elevados e maior prevalência de falência orgânica e foram mais frequentemente submetidos a cirurgias não eletivas. Tinham piores resultados relativamente à mortalidade durante a permanência na UCIC e no hospital.

Lesión quirúrgica del conducto hepático derecho: tratamiento combinado laparoscópico-endoscópico / Right hepatic bile duct injury: a single stage combined laparoscopic-endoscopic treatment

RESUMEN El tratamiento de las lesiones quirúrgicas de las vías biliares (LQVB), empleando procedimientos quirúrgicos de mínimo acceso en forma conjunta, a pesar de sus beneficios, ha sido escasamente reportado. Describimos el tratamiento combinado láparoendoscópico, en una paciente con fístula biliar y estenosis postoperatoria del conducto hepático derecho (CHD). Con base en la descripción de un caso clínico, ilustramos la técnica quirúrgica y evaluamos su aplicabilidad y resultados. Empleando colangiografía laparoscópica, identificamos la fistula biliar y demostramos la oclusión del CHD por un clip metálico, el cual fue retirado mediante guía fluoroscópica. Realizamos maniobra de "rendezvous" biliar y colocamos de prótesis plástica endoscópica. La fístula biliar resolvió en 12 días y a 40 meses de seguimiento, la paciente permanece sin alteraciones. El abordaje láparo-endoscópico, aunque técnicamente demandante, resultó efectivo para el tratamiento de esta paciente. Su seguimiento es fundamental y de especial interés, a fin de evaluar los resultados a largo plazo.

ABSTRACT Treatment of bile ducts injuries (BDI) treatment, combining minimally access surgical techniques, although their benefits, has been scarcely reported. We described a combined laparoscopic-endoscopic procedure, carried out in a patient with postoperative right hepatic duct (RHD) injury associated to laparoscopic cholecystectomy. Based on a clinical case description, we illustrate the surgical technique and assess their applicability and results. A biliary fistula was identified employing laparoscopic cholangiography and a metallic clip applied, producing RHD occlusion, was retrieved under fluoroscopic guidance. A biliary "rendezvous" maneuver was done for positioning an endoscopic biliary stent. The biliary fistula disappeared within two weeks and during 40-months of follow-up the patient remains asymptomatic. Laparoscopic-endoscopic approach, although technically demanding, resulted effective to treat this patient. A Continuous follow-up is essential for evaluating the long-term results.

Infecciones postneuroquiróºrgicas: Puesta al día y recomendaciones intersociedades / Post-neurosurgical infections. Update and intersociety recommendations

Las infecciones asociadas a procedimientos neuroquiró;ºrgicos son complicaciones graves que contribuyen a la morbimortalidad de los pacientes neurocríticos, así como tambín a la prolongació;n de la estancia en la UTI y/o en el hospital. El diagnó;stico es complejo ya que no se dispone de gold standard y se apoya en la sospecha clínica, las alteraciones físico-químicas del líquido cefalorraquídeo y el aislamiento microbiano. El tratamiento debe ser precoz y guiado por la epidemiología local. La duració;n dependerá del microorganismo causal, su sensibilidad y la disponibilidad de tratamientos antibió;ticos efectivos en el sitio de la infecció;n. La implementació;n de medidas de prevenció;n con evidencia demostrada minimiza el riesgo de infecció;n. Esta puesta al día intersociedades SADI-SATI presenta datos epidemioló;gicos (internacionales y locales), mó;©todos diagnó;sticos, tratamiento, y pautas de prevenció;n, considerando las publicaciones más relevantes de los ó;ºltimos aó;±os sobre el tema.

Infections associated with neurosurgical procedures are serious complications that contribute to the morbidity and mortality of neurocritical patients, as well as to the prolongation of the stay in the ICU and the hospital. The diagnosis is complex since there is no gold standard, so it is based on clinical suspicion, CSF physical-chemical examination, and microbial isolation. Treatment should be initiated early, guided by local epidemiology. The duration will depend on the causative microorganism, its sensitivity and the availability of antibiotic treatments that are effective at the site of infection. The implementation of preventive measures with proven efficacy minimizes the risk of infection. This SADI-SATI intersociety update reviews relevant data recently published on this area at the national at international level regarding epidemiology, diagnostic methodologies, therapeutic approaches, and prevention guidelines.

Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report / Sepse aguda pós-operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso

Abstract Background: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. Objective: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. Case report: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. Conclusions: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Resumo Justificativa: A sepse é uma disfunção orgânica fatal com características clínicas inespecíficas que podem imitar outras condições clínicas com quadro hipermetabólico, como a hipertermia maligna. Os cenários são extremamente desafiadores para a anestesia perioperatória e requerem intervenção urgente. Objetivo: Ilustrar a necessidade de intervenção e consulta precoces para uma assistência adicional na abordagem e exclusão de hipertermia maligna e outras possíveis causas durante tal cenário. Relato de caso: Paciente do sexo masculino, 63 anos, submetido à cistoscopia eletiva com cistoscópio flexível e biópsia transretal da próstata guiada por ultrassom sem intercorrências. No pós-operatório, o paciente desenvolveu sintomas que levantaram a suspeita de hipertermia maligna. O protocolo de hipertermia maligna foi imediatamente iniciado, inclusive a administração de dantrolene e uma consulta pela linha direta da associação de hipertermia maligna, juntamente com outros diagnósticos e manejos intervencionistas com vistas ao aprimoramento do paciente. Enquanto a administração precoce de dantrolene ajudou na estabilização hemodinâmica do paciente, a consulta com outros anestesistas e com a Associação de Hipertermia Maligna, juntamente com repetidos exames físicos e laboratoriais, ajudou a excluir a hipertermia maligna como o possível diagnóstico. O paciente recuperou-se mais tarde na unidade de terapia intensiva, onde recebeu tratamento para a bacteremia detectada em suas hemoculturas. Conclusões: A sepse compartilha sintomas clínicos que mimetizam a hipertermia maligna. Enquanto a sepse progride rapidamente para lesões secundárias, a hipertermia maligna é uma ameaça à vida. Proporcionar o tratamento ideal requer um bom julgamento clínico e um alto nível de suspeita quanto aos cuidados oportunos e apropriados, como a administração precoce de dantrolene e a consulta pela linha direta da Associação de Hipertermia Maligna para assistência adicional, que podem resultar em desfechos positivos.