Case Studies in Physiology: Physiological and clinical effects of temporary diaphragm pacing in two patients with ventilator-induced diaphragm dysfunction.

Ventilator-induced diaphragm dysfunction (VIDD) is increasingly recognized as an important side-effect of invasive ventilation in critically ill patients and is associated with poor outcomes. Whether patients with VIDD benefit from temporary diaphragm pacing is uncertain. Intramuscular diaphragmatic electrodes were implanted for temporary stimulation with a pacing device (TransAeris System) in two patients with VIDD. The electrodes were implanted via laparoscopy (first patient) or via bilateral thoracoscopy (second patient). Stimulation parameters were titrated according to tolerance. Diaphragm thickening fraction by ultrasound, maximum inspiratory pressure (Pimax) and diaphragm electromyography (EMGdi) signal analysis were used to monitor the response to diaphragm pacing. Both patients tolerated diaphragm pacing. In the first patient, improvements in diaphragm excursions were noted once pacing was initiated and diaphragm thickening fraction did not further deteriorate over time. The diaphragm thickening fraction improved in the second patient, and Pimax as well as EMGdi analysis suggested improved muscle function. This patient could be fully weaned from the ventilator. These case reports present the first experience with temporary diaphragm pacing in critically ill patients with VIDD. Our results should be taken cautiously given the reduced sample size, but provide the proof of concept to put forward the hypothesis that a course of diaphragm pacing may be associated with improved diaphragmatic function. Our findings of the tolerance to the procedure and the beneficial physiological effects are not prove of safety and efficacy, but may set the ground to design and conduct larger studies.NEW & NOTEWORTHY Diaphragmatic electrode implantation and temporary diaphragm pacing have not been previously used in ICU patients with VIDD. Patients were monitored using a multimodal monitoring approach including ultrasound of the diaphragm, measurement of maximum inspiratory pressure and EMG signal analysis. Our results suggest that diaphragm pacing may improve diaphragmatic function, with the potential to prevent and treat VIDD in critically ill patients. Safety and efficacy of this intervention is yet to be proven in larger studies.

Necrosis intestinal asociada a la nutrición enteral por yeyunostomía / Intestinal necrosis associated with enteral nutrition by jejunostomy

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Neumatosis coli segmentaria en paciente con abdomen agudo / Segmentary pneumatosis coli in a patient with acute abdomen

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Cirugía laparoscópica intragástrica: una opción en lesiones gástricas no resecables endoscópicamente / Intragastric laparoscopic surgery: An option for gastric lesions not resectable by endoscopy

Las lesiones mucosas y submucosas gástricas pueden abordarse por vía endoscópica, laparoscópica o por cirugía abierta. El tamaño, la localización y el tipo de crecimiento son determinantes a la hora de la elección de la técnica. El interés en la cirugía mínimamente invasiva ha llevado a desarrollar nuevos abordajes para suplir las dificultades de la laparoscopia tradicional, como puede ser el caso de la resección de lesiones próximas a la unión esofagogástrica no resecables endoscópicamente, donde la cirugía convencional puede producir estenosis o deformidades posoperatorias y aumento de la morbimortalidad. Presentamos nuestra experiencia en el abordaje de este tipo de lesiones mediante cirugía laparoscópica intragástrica en 3 pacientes consecutivos, con resultado satisfactorio. Este tipo de intervención supone un abordaje más en el arsenal de la cirugía mínimamente invasiva, que puede proporcionar ventajas frente a la cirugía tradicional

Gastric mucosal and submucosal lesions can be resected by endoscopy, laparoscopy or open surgery. Operative methods have varied depending on the location, endophytic growth and size of the lesion. Interest in minimally invasive surgery has increased and many surgeons are attempting laparoscopic approaches, especially in lesions of the stomach near the esophagogastric junction not amendable to endoscopic removal, because conventional surgery can produce stenosis and distort the postoperative anatomy, and increase morbimortality. We report our experience with laparoscopic intragastric surgery in 3 consecutive patients, with no complications. Laparoscopic intragastric surgery extends the surgeons’ armamentarium to resect complex gastric lesions, while offering patients the benefits of minimal access surgery

Intragastric laparoscopic surgery: An option for gastric lesions not resectable by endoscopy.

Gastric mucosal and submucosal lesions can be resected by endoscopy, laparoscopy or open surgery. Operative methods have varied depending on the location, endophytic growth and size of the lesion. Interest in minimally invasive surgery has increased and many surgeons are attempting laparoscopic approaches, especially in lesions of the stomach near the esophagogastric junction not amendable to endoscopic removal, because conventional surgery can produce stenosis and distort the postoperative anatomy, and increase morbimortality. We report our experience with laparoscopic intragastric surgery in 3 consecutive patients, with no complications. Laparoscopic intragastric surgery extends the surgeons' armamentarium to resect complex gastric lesions, while offering patients the benefits of minimal access surgery.

Laparoscopic hand-sewn gastrojejunal anastomoses.

BACKGROUND: Reconstruction of the digestive tract during gastric bypass (RYGBP) or biliopancreatic diversion (BPD) involves a mechanical or a hand-sewn gastrojejunal anastomosis. The object of this paper is to assess laparoscopic hand-sewn gastrojejunal anastomoses. METHODS: A series of morbidly obese patients was treated with RYGBP or BPD with a laparoscopic hand-sewn gastrojejunal anastomosis at the Hospital Universitario de Getafe-Madrid (Spain) between March 2001 and November 2007. RESULTS: The series comprised 250 patients, with 232 RYGBPs and 18 BPDs performed. The mean BMI was 46 +/- 4. Only a single case of gastrointestinal hemorrhage (0.4%) was recorded, caused by a marginal ulcer in the early postoperative period (day 6). In the late postoperative period, there were two cases of ulcer (0.8%), one complicated by hemorrhage, the other by perforation. There was no anastomotic leak. One patient (0.4%) required reintervention after 48 h because of thermal perforation of the gastric pouch. There were 11 cases of stenosis (4.4%) requiring radiologically or endoscopically guided dilatation, none in the BPD patients. Mean anastomosis time was 40 +/- 15 min. No cases of mortality or abscess, abdominal sepsis, or thromboembolism were recorded. Mean hospital stay was 5.1 +/- 2.4 days. CONCLUSIONS: Laparoscopic hand-sewn anastomoses are safe and reproducible by surgeons experienced in internal suturing and knot-tying. The technique lengthens operating time, but constant training develops the surgeon's skills, significantly shortening operating time.

Biopsia guiada por laparoscopia de tumoraciones intraabdominales no digestivas / Laparoscopic biopsy of non-digestive intra-abdominal masses

Introducción. La laparoscopia es un recurso diagnóstico de múltiples enfermedades que requieren biopsia de masas intraabdominales no abordables mediante punciones guiadas por imagen. Evita la morbimortalidad asociada a la laparotomía favoreciendo el tratamiento precoz de los procesos malignos. Pacientes y método. Análisis descriptivo, retrospectivo de los resultados de una serie de pacientes de nuestro hospital, que presentan nódulo intraabdominal de etiología desconocida biopsiados mediante cirugía laparoscópica desde enero de 2001 hasta mayo de 2006. Ninguno de los pacientes es candidato a punción percutánea guiada por imagen. Resultados. Realizamos 23 biopsias: 8 retroperitoneales (34,7%), 5 mesentéricas (21,7%), 5 en hilio hepático, 4 pelvianas y 1 en cadena de vena ilíaca y asociamos 5 biopsias complementarias. Se obtuvo un 100% de material suficiente para diagnóstico anatomopatológico. La duración media de la intervención fue de 71 min. El 61% tuvo un ingreso menor de 24 h. La estancia hospitalaria (mediana) fue de 1,5 días. Conclusiones. El abordaje laparoscópico permite una exposición y una revisión completa de la cavidad peritoneal. La biopsia laparoscópica es segura y efectiva con excelente recuperación del paciente permitiendo iniciar precozmente el tratamiento definitivo (AU)

Introduction. Laparoscopic surgery offers an alternative diagnostic technique in multiple diseases requiring biopsy of non-digestive intra-abdominal masses in which image-guided biopsy cannot be performed. Laparoscopic biopsy aims to reduce the surgical aggression and complications associated with laparotomy and favors the early treatment of malignancies. Patients and method. We performed a retrospective descriptive study of our results in a series of patients in our hospital with intra-abdominal masses of unknown etiology who underwent laparoscopic surgery between January 2001 and April 2006. None of the patients were candidates for image-guided percutaneous biopsy. Results. We carried out 23 biopsies: 8 retroperitoneal (34.7%), 5 mesenteric (21.7%), 5 hepatic, 4 pelvic, and 1 in the iliac chain, as well as 5 complementary biopsies. In all patients, sufficient material for histologic diagnosis was obtained. The mean operating time was 71 minutes. Length of hospital stay was less than 24 hours in 61% of the patients. The median length of hospital stay was 1.5 days. Conclusions. The laparoscopic approach allows complete visualization and examination of the entire peritoneal cavity. Laparoscopic biopsy is a safe and effective procedure with excellent patient recovery and allows early definitive treatment (AU)