Optimización de neumoperitoneo preoperatorio en hernia ventral: Uso de un dispositivo de compresión externa

La hernia incisional compleja es un desafío para el cirujano. Son ampliamente conocidos los factores que han permitido mejorar los resultados de la reparación herniaria, entre ellos el neumoperitoneo preoperatorio. Durante la insuflación preoperatoria, el aire difunde tanto en la cavidad abdominal como en el saco herniario. Sin embargo, gran porcentaje del contenido administrado, se distribuye mayormente en el saco herniario y no en la cavidad abdominal. En Latinoamérica, diversos equipos de cirujanos de pared abdominal han compartido experiencias en lo que respecta a la optimización de esta técnica como adyuvancia para el manejo de las hernias complejas. En este contexto, y para optimizar la distribución del aire insuflado hacia la cavidad abdominal, se comenzó a utilizar un dispositivo externo de compresión. Este trabajo busca estandarizar por primera vez esta técnica durante el neumoperitoneo preoperatorio buscando disminuir el volumen de aire insuflado, los días de neumoperitoneo y, por lo tanto, los días de hospitalización previo a la cirugía.

Complicated incisional hernia is challenging for surgeons. The factors that have improved the results of hernia repair are widely known, including preoperative pneumoperitoneum. During preoperative insufflation, air diffuses into both the abdominal cavity and the hernia sac. However, a large percentage of the administered content is distributed mainly in the hernia sac and not in the abdominal cavity. Latin-American teams of abdominal wall surgeons have shared experiences regarding the optimization of this technique as an adjuvant for the management of complicated hernias. In this context and to optimize the distribution of the insufflated air into the abdominal cavity, an external compression device began to be used. This article aims to standardize this technique for the first time during preoperative pneumoperitoneum. The target is to reduce the volume of air insufflated, the days of pneumoperitoneum and, therefore, the days of hospitalization prior to surgery.

Mortalidad quirúrgica durante pandemia de coronavirus en un centro universitario / Surgical mortality during a coronavirus pandemic in a university center

Resumen Introducción: La pandemia de coronavirus, iniciada en Wuhan el año 2019, ha trastocado al mundo y afectado profundamente a la actividad quirúrgica al restringir el número de intervenciones en forma dramática, después de los reportes iniciales de mortalidad posoperatoria sobre el 20% en pacientes operados portadores de COVID. El objetivo del presente estudio fue evaluar las cifras de mortalidad quirúrgica, en pacientes intervenidos quirúrgicamente durante la pandemia del COVID-19. Materiales y Método: Cohorte retrospectiva de pacientes operados entre el 15 de marzo de 2020 y el 31 de julio de 2020 en un centro universitario. Se evaluó variables clínicas asociadas a la intervención quirúrgica y coinfección por SARS-CoV-2. Resultados: Se analizaron 344 pacientes quienes presentaron una mortalidad global de 6,1%. Se realizó examen de PCR para COVID a 153 pacientes. Presentaron un riesgo de mortalidad significativo los pacientes: PCR COVID(+) (22,7%), p = 0,01, portadores de hipertensión arterial (11,6%) p = 0,03 y mayores de 60 años (12,4%) p < 0,001. No fueron factores estadísticamente significativos de mayor riesgo de mortalidad, las siguientes variables: género, obesidad, diabetes mellitus, patología oncológica, cirugía de urgencia y clasificación de ASA. Al analizar dos subgrupos se observó que los pacientes menores de 60 años COVID negativo presentaron una cifra de mortalidad de 1,26% versus 36,3% en los mayores de 60 años, COVID positivos (p = 0,01). Discusión: Los resultados del presente estudio sugieren que se deben realizar los mayores esfuerzos para descartar la infección por SARS-CoV-2 en la evaluación preoperatoria para disminuir los riesgos de mortalidad posoperatoria.

Background: The coronavirus pandemic, started in the city of Wuhan in 2019, has disrupted the world and deeply affected surgical activity. Restricting the number of interventions dramatically, after initial reports of postoperative mortality over 20% in patients with COVID. The purpose of this study is to evaluate the figures for surgical mortality, during the coronavirus pandemic. Materials and Method: Retrospective cohort of patients operated between March 15, 2020 and July 31, 2020 at a university center. Clinical variables associated with surgical intervention and coinfection by SARS-CoV-2 were evaluated. Results: 344 patients with an overall mortality of 6.1% were analyzed. PCR testing for COVID was performed on 153 patients. Only from the ninth week of the pandemic did routine preoperative testing begin. Patients who presented a higher risk of mortality were: PCR COVID(+) (22.7%), arterial hypertension (11.6%) and age over 60 years (12.4%). In the present series, the following variables were not statistically significant risk factors for mortality: gender, obesity, diabetes mellitus, oncological pathology, emergency surgery and ASA classification. When analyzing two subgroups, we observed that COVID negative patients under 60 had a mortality rate of 1.26%, versus 36.36% in those over 60 years of age, COVID positive. Discussion: The results of the present study lead us to make every effort to rule out COVID infection preoperatively to reduce the risks of postoperative mortality. Although this is a series of cases and the extrapolation of its results should be cautious, having national figures can be a useful element to make decisions in this stage of reactivation of surgical activity.

Cirugía herniaria electiva en pacientes portadores de tratamiento anticoagulante / Elective hernia surgery in patients with anticoagulant treatment

Resumen Introducción: Diversas patologías requieren de tratamiento anticoagulante oral (TACO). Algunos de estos pacientes requieren resolución quirúrgica. El manejo perioperatorio de estos pacientes es variable dependiendo del centro. Objetivos: Evaluar la morbilidad y mortalidad del protocolo de manejo de patología herniaria en TACO, atendidos en nuestro hospital. Material y Métodos: Estudio descriptivo prospectivo de 37 pacientes sometidos a cirugía herniaria en TACO entre 2008-2016. Los datos fueron obtenidos de la base de datos computacional del Equipo de Hernias, con un seguimiento mínimo de 1 mes. Se evaluaron las características clínicas, quirúrgicas y la morbimortalidad postoperatoria. El traslape consistió en hospitalizar al paciente tres días previos a la cirugía, suspendiéndose el TACO e iniciando heparina de bajo peso molecular (HBPM) en dosis terapéuticas, que se suspende 24 h previas a la cirugía. Se reinicia la HPBM a las 12 a 24 h postoperatorias, y se inicia el traslape a TACO a las 24-48 h. Los datos fueron analizados con Stata v14. Resultados: De los 37 pacientes estudiados, veintiséis pacientes fueron hombres (70,2%), la media de edad fue de 67,3 años. El 48,7% tenían fibrilación auricular. El 100% consumía acenocumarol como TACO. La media en el inicio del traslape a la anticoagulación oral fue de 1,4 días. El promedio de INR al momento del alta fue de 2,04. Dos pacientes fueron dados de alta con dalteparina. Un paciente (2,7%), presentó dolor en el postoperatorio inmediato y uno (2,7%), equimosis del sitio quirúrgico. Conclusiones: El protocolo de trabajo utilizado, demostró ser seguro, con una mínima morbilidad postoperatoria.

Introduction: Various pathologies require oral anticoagulant treatment (TACO). Some of these patients present pathologies of surgical resolution. The perioperative management of these patients is variable depending on the center. Aim: To evaluate the morbidity and mortality of patients attended with hernia pathology and TACO, assisted in our hospital. Materials and Method: Prospective, descriptive study of 37 patients submmited to hernia surgery in TACO between 2008-2016. The data was obtained from the computer database of the Hernia Team, with a minimum follow-up of 1 month. Clinical, surgical characteristics and postoperative morbidity and mortality were evaluated. The treatment overlap from TACO to Low Molecular Weight Heparin (LMWH) in therapeutic doses, was initiated three days before surgery. LMWH was suspended 24 hours prior to surgery, and reinitiated 12 to 24 hours post operation. 48 to 72 hours TACO was resumed. The data was analyzed with Stata v14. Results: Twenty-six patients were men, the mean age was 67.3 years. 48.7% had atrial fibrillation. 100% consumed acenocoumarol as TACO. The mean time for resuming TACO after surgery was 1.4 days. The average INR at the time of discharge was 2.04. Two patients were discharged with dalteparin. One patient (2.7%) presented pain in the immediate postoperative period and one showed ecchymosis of the surgical site (2.7%). Conclusions: The work protocol used, proved to be safe, with minimal postoperative morbidity.

Obesidad mórbida asociada a quiste broncogénico y leiomioma subcardial que simula GIST: caso clínico / Morbid obesity, esophageal bronchogenic cyst and subcardial leiomioma: report of one case

Gastric wall diseases are found in approximately of 1 percent of the patients submitted to bariatric surgery. Half of these are leiomiomas. Esophageal bronchogenic cysts are exceptional We report a 57 years old female with morbid obesity, a bronchogenic esophageal cyst and subcardial leiomioma. The preoperative study and intraoperative biopsy, suggested the presence of a gastrointestinal stromal tumor (GIST), but the definitive pathological study did not confirm its presence. A total gastrectomy was performed, with an uneventful postoperative course.

La patología intramural gástrica tiene una frecuencia menor al 1 por ciento, en cirugía gástrica. Alrededor del 50 por ciento corresponden a leiomiomas. Los quistes broncogénicos tienen origen embriológico y son excepcionales, y la mayor parte de los reportes corresponden a pacientes pediátricos. Se presenta un caso clínico de paciente portadora de Obesidad mórbida (IMC = 52), asociado a lesión subcardial que simula GIST, cuyo estudio histopatológico resultó ser un quiste esofágico de origen broncogénico de 40 mm, asociado a leiomioma subcardial de 10 mm. Fue sometida a gastrectomía total más anastomosis esófago-yeyunal en Y de Roux, con asa de 180 cm. No presentó morbi-mortalidad postoperatoria. Se discuten los métodos de estudio preoperatorio y las alternativas terapéuticas. No hemos encontrado en la literatura otro caso de asociación de estas raras patologías.

Mallas en la reparación de la pared abdominal / Mesh in the repair of abdominal wall

The modern concept about the aetiology of hernias, referred to deficiencies in the metabolism of the collagen, makes recommendable the use of a prosthetic material in the hernia repair. The material most widely spread is the polypropylene monofilament, macroporous, sheet with the exception of the intraperitoneal use. The long term follow - up of the patients and his results, allow us, to evaluate the results of a specific material.

Hernioplastia y orquidectomía / Hernioplasty and orchidectomy

Estudio prospectivo en pacientes con hernia inguinal irreductible crónica y portadores de patología médica severa, con el propósito de efectuar una intervención con menor riesgo quirúrgico, para lo cual se programó realizar una orquidectomía en forma concomitante con el procedimiento de hernioplastía,. De común acuerdo con cada paciente y debidamente avalado por un consentimiento informado legal específico para patología herniaria, entre Julio de 2000 a Junio de 2005 se operaron 8 pacientes, realizándose 9 orquidectomías. El promedio de edad fue de 66,6 años, con valores extremos de 41 y 85 años. Cinco pacientes tenían patología cardiovascular severa asociada, con un promedio de edad de 76 años, nueve más que en la serie general; dos tenían déficit mental significativo. En tres pacientes se asoció a cirugía herniaria previa; en cuatro un hidrocele de tamaño considerable, con bilateralidad en uno. El saco herniario contenía principalmente ileon y colon; elementos herniarios deslizados: colon derecho en tres, sigmoides en uno y vejiga y uréteres en uno. El tiempo operatorio promedio, fue de 105 minutos, haciendo excepción de dos pacientes. La estadía hospitalaria de fue de 84 horas, a excepción del paciente con sepsis renal. No hubo complicaciones intraoperatorias. La evolución postoperatoria fue satisfactoria en siete pacientes. Las complicaciones quirúrgicas fueron mínimas. No hubo mortalidad en la serie. Conclusión: en pacientes con edad avanzada con patología herniaria irreductible crónica y patología médica severa, el agregar la exéresis testicular a la hernioplastía, disminuye el tiempo quirúrgico, permite una estadía hospitalaria más breve y un escaso compromiso local.

[Melatonin: ulcer disease and seasons of the year]. / Melatonin: iazvennaia bolezn' i sezony.

Melatonin produces a great variety of effects in human organism and plays an essential role in normal function of the body. This explains growing interest of medical researchers to this substance. The paper provides the results of 3-year studies of seasonal rhythm of melatonin production in patients with duodenal ulcer. Acute disorders of circadian and seasonal melatonin production in summer and autumn were discovered in patients with duodenal ulcer. These findings suggest involvement of abnormal melatonin production in pathological mechanisms of autumn exacerbations of duodenal ulcer.

[Visceral neuroses: clinical approaches to the problem]. / Organnye nevrozy: klinicheskii podkhod k analizu problemy.

Visceral neuroses are regarded as psychosomatic pathology represented by functional symptom complexes common for both psychic (personality, psychopathologic disorders of anxietyphobic, affective, hypochondriac spectrum) and somatic pathology. Two hundreds fourteen patients: 67 with hyperventilation syndrome (HVS), 77 with Da Costa syndrome (DCS), 70 with irritable bowl syndrome (IBS) have been studied. The study suggest that visceral neuroses represent a group of independent diseases. In contrast to converse neuroses, a topical projection (respiratory, cardiovascular system, gastrointestinal tract, etc.) of visceral neuroses reflects not only a psychosomatic disorder's specificity but also the course and prognosis regularities inherent to them. HVS course is wavy with periodic exacerbations and incomplete remissions, DCS one is phased (remissive), IBS is chronic without distinct phases and intervals. HVS and DCS are comorbid to milder psychic (personality and anxiety phobic disorders) and somatic pathology. IBS is associated with not only more severe mental disorders (overvalued, hypochondriac, affective) but also with chronic somatic diseases (alimentary system).

Synchronous endometrioid tumors of the ovary and endometrium. A clinicopathologic study of 22 cases.

OBJECTIVE: To analyze a group of 22 patients with synchronous endometrioid tumors of the ovary and endometrium. STUDY DESIGN: A retrospective chart review was undertaken and information collected on patient age, parity, tumor grade and stage, presence of coexisting endometriosis and survival. Flow cytometry was determined from archival samples of the endometrial and ovarian tumors. RESULTS: The mean age at diagnosis was 52.8 years (range 36-71); mean parity was 1.05. With regard to the endometrial component, 68.2% were grade 1, 63.6% were stage I and, by flow cytometry, 62.5% were aneuploid. With regard to the ovarian lesions, 68.2% were grade 1, 68.2% were stage I, and 71.4% were aneuploid by flow cytometry. Twelve (54.5%) of 22 patients had pathologic evidence of coexisting endometriosis. Overall, three-year survival was 75%. All 11 patients with stage I disease at both sites were alive, without disease, at a mean follow-up of 34.9 months. CONCLUSION: Patients with synchronous endometrioid tumors of the endometrium and ovary are generally younger than reported for either endometrial adenocarcinomas or ovarian epithelial adenocarcinomas. They tend to be low grade and early stage and are frequently associated with endometriosis. Our data suggest that the survival of patients with synchronous primaries correlates with the stage of the individual tumors and that a second, synchronous primary does not adversely affect prognosis.

Implicancias de la evaluación inmunológica en el paciente oncológico quirúrgico / Implicances of the inmunologic evaluation in the surgery oncologic patient

El propósito de esta comunicación preliminar es evaluar la respuesta inmunológica del pacinete oncológico candidato a cirugía y sus implicancias en la morbimortalidad postoperatoria. Se analizan en forma prospectiva 27 pacientes portadores de neoplasia maligna(17 hombres y 10 mujeres) con una edad promedio de 64,4 años. La respuesta a los test cutáneos fue: 0 respuestas posistivas en 8 pacientes(29,6 por ciento ); 1 respuesta positiva en 9 pacientes(33,4 por ciento ); 2 respuestas positivas en 8 pacientes(29,6) y 3 o más respuestas positivas en 2 pacientes(7,4 por ciento ). La morbimortalidad postoperatoria se presentó exclusivamente en los pacientes anérgicos 3/14(21,4 por ciento ); en cambio, los pacientes con dos o más respuestas positivas, no presentaron morbimortalidad postoperatoria(p< 0,05). En el grupo de pacientes anérgicos 11 de 14 pacientes (78,6 por ciento ) fueron resecados versus el 100 por ciento de los pacientes con dos o más respuestas positivas(p< 0,05). En esta serie no se observaron diferencias estadistícamente significativas al correlacionar la respuesta inmunológica con los otros parámetros de evaluación nutricional

Properties of trypsin and of acid phosphatase immobilized in sol-gel glass matrices.

Trypsin and acid phosphatase-containing silica sol-gel glasses were obtained by mixing a solution of an enzyme with polyethylene glycol (PEG) 6000 and tetramethoxy orthosilicate at room temperature, followed by gelation and drying. Activity of the immobilized trypsin toward small substrates, such as N-benzoyl-L-arginine-4-nitroanilide at its Km, for the best preparations equaled that of the soluble enzyme. Polylysine (M(r) less than or equal to 13,000) and aprotinin (M(r) = 6,500) inhibited this activity. Larger polylysines as well as soybean trypsin inhibitor (M(r) = 20,100) were ineffective. The sol-gel-entrapped trypsin activity was stable when sol-gel glasses were incubated at ambient temperature (pH 7.5) for several months. In comparison, trypsin, immobilized in sol-gel glass by surface adsorption and incubated under the same conditions overnight, was completely autodigested. The firm interaction between the protein molecules and the silica matrix stabilized the enzymes. Thus, the half-life of sol-gel-entrapped acid phosphatase at 70 degrees C (pH 8.0) was two orders of magnitude larger than that of the enzyme in solution. Transparent, mechanically and chemically stable bioactive sol-gel glasses may be used for the development of robust on-line biochemical photodetection sensors and for the purposes of chemical catalysis.

Widespread intradermal accumulation of mononuclear leukocytes in lepromatous leprosy patients treated systemically with recombinant interferon gamma.

Intradermal administration of recombinant interferon gamma (rIFN-gamma) to lepromatous leprosy patients has converted the local histology toward a tuberculoid pattern. However, such changes have been confined to the site of injection. In contrast, in the present study, marked, intradermal accumulation of CD3+, CD4+, CD8+, and CD1a+ T cells and Leu-M5+ mononuclear phagocytes was induced at a distance from the sites of administration, in a dose-dependent manner, by 10 daily intramuscular injections of 10-30 micrograms rIFN-gamma/m2. Mononuclear cell infiltration began within 3 d of onset of rIFN-gamma therapy and persisted at least 8 wk. Intramuscular administration of rIFN-gamma to lepromatous patients receiving concurrent chemotherapy can safely induce widespread histologic features of an upgrading reaction.