Sutura laparoscópica frente a sutura por laparotomía en úlceras gastroduodenales perforadas / Laparoscopic suture facing laparotomy suture in perforated gastroduodenal ulcers

Resumen Introducción La perforación gastroduodenal continúa siendo una urgencia quirúrgica relativamente frecuente, a pesar de los avances realizados en el tratamiento médico de la enfermedad ulcerosa. Su abordaje laparoscópico ha ido aumentando en los últimos años, aunque no se ha generalizado. Nuestro objetivo es analizar los resultados postoperatorios en pacientes con úlcera perforada tratados mediante sutura laparoscópica, y compararlos con un grupo similar con sutura por laparotomía. Mantenemos la hipótesis de que la sutura laparoscópica es una opción segura y con menor morbilidad que el abordaje por laparotomía. Material y Métodos Análisis retrospectivo comparativo de dos cohortes de pacientes: una tratada mediante sutura laparoscópica durante los años 2014 y 2015, período en el que este abordaje estaba plenamente implantado en la Urgencia en nuestro hospital, y otro grupo comparable tratado mediante sutura por cirugía abierta durante el período 2001-2003. Se analizaron las complicaciones según la clasificación de Clavien-Dindo, tasa de conversión, estancia media y mortalidad. Resultados Los grupos eran comparables en edad, sexo, comorbilidades y riesgo anestésico. Se observó una tendencia a la superioridad a favor del abordaje laparoscópico en ciertas variables analizadas, con una tasa de conversión de un 3%. La presencia de complicaciones postoperatorias precoces fue mayor en el grupo con sutura por laparotomía: shock séptico postquirúrgico (15,2 % vs 6%) e infección de herida (15,2 % vs 3%), así como las complicaciones médicas, aunque de forma no significativa. El grupo tratado con sutura laparoscópica tuvo un mayor tiempo quirúrgico, menor estancia media y menor mortalidad. Conclusión La sutura laparoscópica de la úlcera gastroduodenal en nuestro centro ha tenido una baja tasa de conversión y una morbilidad algo menor a la sutura por laparotomía, con una menor tasa de reintervenciones y menor estancia media, a pesar de un mayor tiempo quirúrgico.

Introduction Gastroduodenal perforation continues to be a relatively frequent surgical emergency, despite advances in the medical treatment of ulcer disease. Its laparoscopic approach has been increasing in the last years, although it has not been generalized. Objective Was to analyze the postoperative results in patients with perforated ulcer treated with laparoscopic suture, and to compare them with a similar group with laparotomy suture. Our hypothesis was that laparoscopic suture is a safe option and with less morbidity than the laparotomy approach. Material and Methods Comparative retrospective analysis of two patient cohorts: one treated with laparoscopic suture during 2014 and 2015, a period in which this approach was fully implanted in the emergency room in our hospital, and another comparable group treated by suture for open surgery during the period 2001-2003. Complications were analyzed according to Clavien-Dindo classification, conversion rate, mean stay and mortality. Results The groups were comparable in age, sex, comorbidities and anesthetic risk. There was a trend towards superiority in favor of the laparoscopic approach in certain variables analyzed, with a conversion rate of 3%. The presence of early postoperative complications was greater in the laparotomy suture group: post-surgical septic shock (15.2% vs 6%) and wound infection (15.2% vs 3%), as well as medical complications, although not significantly. The group with laparoscopic suture had a longer surgical time, lower mean stay and lower mortality. Conclusion The laparoscopic suture of the gastroduodenal ulcer in our center has had a very low conversion rate and a somewhat lower morbidity to the laparotomy suture, with a lower rate of reinterventions and a mean stay, despite a longer surgical time.

Acute bleeding from pseudoaneurysms following liver and pancreatobiliary surgery.

PURPOSE: We report 12 patients with visceral PA following pancreato-biliary and hepatic surgery. RESULTS: Seven patients (7/11, 63 %) had developed postoperative complications from their original procedure; that information was missing in one patient. Bleeding occurred in eight (three with hemoperitoneum two with haemobilia, and three with GI bleeding through a biliary-enteric anastomosis), three were asymptomatic, and the other one presented with abdominal pain. Eleven patients had an interventional radiology procedure performed (Five underwent angioembolization, a stent was placed in four, and two patients underwent both procedures). Complications related to the procedure developed in 6 (54.5 %) patients, and surgery was required in four of them. CONCLUSION: Postoperative pseudoaneurysms (PA) of visceral arteries are rare and usually secondary to vascular injury after pancreato-biliary and liver surgery. They usually present with bleeding and nowadays most are amenable to initial control by interventional radiology.

Anatomy-based surgical strategy of gastrointestinal fistula treatment.

Anatomic delineation of a gastrointestinal fistula is essential in assessing the likelihood of spontaneous closure or to plan the surgical management. Computed tomography (CT) enterography and/or fistulograms provide invaluable information. The surgical strategy should carefully consider the when and how, as well as the special clinical situations that may arise following radiotherapy, the inaccessible or "frozen abdomen", and enteroatmospheric fistulas (EAFs). New operations like those performed in bariatric surgery, and the wide acceptance of the damage-control philosophy in severe trauma, have given rise to new types of fistulas and increased the occurrence of others. When confronted with this difficult complication, the surgeon must always exercise patience and restraint, and be open-minded about the different surgical alternatives to solve the problem.

Endoprótesis recubierta en el manejo de la fístula cervical tras esofaguectomía / Covered stent in the management of cervical anastomotic leaks after esophaguectomy

Small cervical esophageal anastomotic leaks are usually treated conservatively, with considerable delays to oral feeding and a prolonged hospital stay. Self-expanding covered stents endoscopically placed are suggested as an alternative treatment. We report our hospital experience with covered stents, with good functional results but also potential morbidity.

La fístula anastomótica esofágica cervical suele manejarse de forma conservadora, lo que retrasa el inicio de la alimentación oral y prolonga la estancia hospitalaria. El uso de endoprótesis recubiertas colocadas vía endoscópica se utiliza como una alternativa para evitar esta situación. Presentamos dos casos manejados con endoprótesis recubierta, con adecuado funcionamiento pero no exenta de morbilidad.

Gradual thawing improves the preservation of cryopreserved arteries.

This study was designed to test a slow, controlled, automated process for the thawing of cryopreserved arteries, whereby specimen warming is synchronized with the warming of its environment. Segments of minipig iliac artery, 4-5 cm in length, were subjected to controlled, automated cryopreservation in a biological freezer at a cooling rate of 1 degrees C/min to -120 degrees C, followed by storage in liquid nitrogen at -196 degrees C for 30 days. Following storage, the arterial segments were subjected to rapid (warming rate of approximately 100 degrees C/min) or gradual (1 degrees C/min) thawing. Thawed specimens were processed for light microscopy and for scanning and transmission electron microscopy, Cell death was determined by the TUNEL method. Metalloproteinase (MMP) expression was estimated by immunohistochemical analysis. Most of the cryopreserved vessels subjected to rapid thawing showed spontaneous fractures, mainly microfractures, whereas these were absent in slowly thawed specimens. In rapidly thawed vessels, the proportion of damaged cells was double that observed in those thawed more gradually. Increased intensity and extent of MMP-2 expression was shown by rapidly thawed specimens. The slow-thawing protocol tested avoids the formation of spontaneous fractures and microfractures and the accumulation of fluid within the arterial wall tissue. This results in improved tissue preservation.

Utilidad de la tonometría por aire en el diagnóstico de la isquemia intestinal experimental / Utility of air tonometry in the diagnosis of experimental intestinal ischemia

Introducción. La utilidad del tonómetro por aire en el estudio de la isquemia del tubo digestivo está siendo evaluada en los últimos años. Su principio básico consiste en medir la PCO2 del aire que hay en una sonda colocada en el interior de una víscera hueca, asumiendo que dicho valor equivale a la presión regional de CO2 (PrCO2). Con ella se puede calcular el pH intramucoso (pHi) del órgano estudiado. El objetivo de este trabajo es comprobar la fiabilidad del tonómetro aéreo en diversas situaciones de isquemia intestinal. Material y métodos. Se ha desarrollado un modelo experimental con cerdos "mini-pig" entre 40 y 60 kg de peso distribuidos en 3 grupos diferentes: grupo A, (n = 4) pinzamiento total de la arteria mesentérica superior (AMS) durante 1 h con tonometría gástrica e intestinal realizada al mismo tiempo; grupo B (n = 4), pinzamiento total de la AMS durante 2 h con tonometría intestinal exclusivamente, y grupo C (n = 5), pinzamiento parcial (30 por ciento de flujo residual) de la AMS durante 3 h con tonometría intestinal. La reducción parcial del flujo en la AMS se cuantificó mediante una sonda perivascular conectada a un medidor de flujo por ultrasonidos. En el análisis estadístico de los resultados se aplicó el test de Friedman. Resultados. En el grupo A no hubo cambios significativos de los parámetros gástricos analizados a lo largo del tiempo (p > 0,1); sin embargo, el tonómetro intestinal sí detectó cambios casi significativos (p = 0,05) con respecto al pHi, PrCO2 y GAP. En el grupo B se observaron resultados similares con el tonómetro intestinal alcanzando en la mayoría de los cerdos el valor máximo detectable de PrCO2 al final de la primera hora. En el grupo C las diferencias fueron casi significativas (p = 0,07) y el pHi intestinal se estabilizó durante la última hora Conclusiones. La utilidad de la tonometría gástrica por aire en el diagnóstico precoz de la isquemia intestinal resulta significativamente inferior si se compara con la tonometría intestinal. La tonometría por aire es capaz de medir sensiblemente los cambios en la PrCO2 del tubo digestivo hasta alcanzar los valores máximos cuantificables por este aparato. La tonometría aérea puede ser aplicada clínicamente para detectar de forma temprana condiciones de bajo flujo en vísceras huecas (AU)

Mortalidad hospitalaria en pacientes con traumatismos graves: análisis de la mortalidad evitable / In-hospital mortality among patients with major trauma: analysis of preventable mortality

Introducción. Los programas de mejora y control de calidad que analizan la provisión de cuidados a los pacientes traumatizados tienden, fundamentalmente, a utilizar la mortalidad como marcador de esa calidad. El concepto de mortalidad evitable en politraumatizados surge de la evaluación de esa calidad asistencial, y se basa en la información obtenida de registros que incluyen muchos miles de pacientes. Métodos. Hemos analizado la mortalidad hospitalaria en un registro de pacientes traumatizados graves (n = 593) recogido desde junio de 1993 hasta diciembre de 1999. El análisis de la mortalidad evitable se ha basado fundamentalmente en el modelo TRISS de cálculo de probabilidad de supervivencia (Ps) y en los criterios de mortalidad evitable del Comité de Trauma del Colegio Americano de Cirujanos. Se ha puesto especial énfasis en la revisión detallada de aquellos pacientes fallecidos cuando la probabilidad de supervivencia era superior al 50 por ciento. Resultados. La mortalidad de la serie ha sido del 22,5 por ciento (134 pacientes), para una mortalidad esperada del 26 por ciento. El principal mecanismo lesional en pacientes fallecidos ha sido la precipitación al vacío (29,8 por ciento), y el traumatismo craneoencefálico ha sido la principal causa fundamental de muerte (42,5 por ciento). El traumatismo cerrado ha revestido una gravedad doble de la del penetrante (ISS de 30 ñ 18 frente a 15 ñ 12, respectivamente), siendo el Injury Severity Score (ISS) global de la serie de 26 ñ 18. El estadístico Z para el traumatismo cerrado y penetrante fue de -0,28 y -0,19, respectivamente. El estadístico M fue de 0,59 y 0,93, respectivamente. El 26 por ciento de los pacientes fallecidos tenían una Ps superior a 0,50. El 86,5 por ciento de las muertes se juzgaron como inevitables, el 11,9 por ciento como potencialmente evitables y el 1,6 por ciento como claramente evitables, para una mortalidad evitable global del 13,5 por ciento. Conclusiones. Las cifras de mortalidad evitable obtenidas parecen aceptables, aun asumiendo las dificultades de su cálculo, la variabilidad y la ausencia de referencias en nuestro entorno sanitario. El análisis de esta mortalidad evitable en traumatizados, basado fundamentalmente en métodos objetivos de análisis estadístico de sistemas de puntuación de la gravedad, se considera, a pesar de sus dificultades, el estándar para la evaluación de la calidad asistencial (AU)

Effect of the thawing process on cryopreserved arteries.

This study was designed to explore the changes that occur in cryopreserved pig arteries following different thawing procedures, before and after being placed in an in vitro flow circuit. Segments of minipig iliac artery were cryopreserved in complete minimal essential medium plus 10% dimethylsulphoxide and stored in liquid nitrogen at -196 degrees C for 30 days. Three study groups were established according to whether the arterial specimens were fresh (control, n = 20), cryopreserved and rapidly thawed (RT) at 37 degrees C (n = 22) or cryopreserved and subjected to controlled, automated slow thawing (ST) (n = 22). Half of the specimens of each group were subsequently placed in the flow circuit for 72 hr. Evaluation was made of morphological and ultrastructural changes. Cell damage was established using the TUNEL method. All cryopreserved specimens showed endothelial denudation that was most extensive in those subjected to rapid thawing. Slowly thawed specimens showed improved cell viability and organization of the vessel wall, compared to those thawed rapidly. Under conditions of flow, the damage induced by the freezing/thawing process was enhanced. These findings suggest that (a) slow thawing of cryopreserved arteries results in improved preservation of the structure and viability of vessels, and (b) the damage induced by freezing/thawing is enhanced when vessels are subjected to flow in an in vitro circuit.

Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation.

PURPOSE: To determine the effectiveness and safety of metallic stents in the treatment of malignant colorectal obstruction before surgery and for palliation. MATERIALS AND METHODS: Eighty patients with acute malignant colorectal obstruction presumed to be malignant were treated by means of implanting self-expanding metallic stents. RESULTS: Stent placement was successful in 70 of the 80 patients and resolved bowel obstruction in 67 patients (96%). Two patients had colonic perforation and developed peritonitis 18 and 24 hours after stent placement; one patient died as a consequence. Thirty-three patients underwent elective surgery after 7 days +/- 3 (SD; range, 4-10 days), and adequate tumoral coverage and cleansing of the colon were observed in all patients. Stent placement was used as final palliative treatment in another 35 patients. Patient follow-up lasted a mean of 138 days +/- 93 (range, 36-334 days). The survival rate for the palliative group was 55% at 3 months, 44% at 6 months, and 25% at 9 months. The estimated primary stent patency rate was 91% at 3 and 6 months. CONCLUSION: Management of colorectal obstruction by using metallic stents was effective and safe, although colonic perforation is a potential complication. In cases of palliation, the method may obviate palliative colostomy.

El proceso de descongelación lenta mantiene la viabilidad de la pared arterial criopreservada / Slow thawing maintain cryopreserved arterial wall viability

Investigaciones recientes han centrado su interés en los procesos de descongelación como posibles inductores de los daños que hacen fracasar los injertos realizados con arterias criopreservadas. El objetivo del presente trabajo es, conocer el efecto de la descongelación sobre la pared de vasos criopreservadas a -80 -'C. Arterias ilíacas de cerdo (Mini Pig) fueron criopreservadas en un congelador biológico a -80 ='C, en Medio Mínimo Esencial con el 10 por ciento de dimetilsulfóxido disminuyendo la temperatura 1 ºC/min. Los vasos fueron almacenados 30 días a -80 ='C y rara vez transcurrido este período de tiempo se sometieron a dos protocolos diferentes de descongelación: descongelación rápida, 5 minutos en un baño a 37 ='C o descongelación lenta, programada y automatizada, 2 horas; con un incremento de temperatura de 1 ºC/m. hasta alcanzar la temperatura ambiente. Arterias frescas fueron utilizadas como controles. Se realizaron estudios morfológicos; microscopía óptica y microscopía electrónica de transmisión 1l barrido, de los diferentes grupos y se valoró el daño celular mediante la técnica TUNEL. En los vasos sometidos tanto a deseorrgelación lenta como a deseorrgelación rápida, existían zonas donde el endotelio estaba bien conservado, alternando con zonas totalmente denudas. En la capa media, el grupo de descongelación rápida presentaba una mayor desorganización celular, con presencia de zonas edematosas distribuidas por todo el espesor de la capa. La rnicroscopía electrónica de barrido mostraba una superficie luminal cubierta de celulas endoteliales globulares t/ pequeñas áreas denudadas que dejaban al descubierto una densa matriz subendotelial. Tras el proceso de criopreservación, el número de células viables disminuye, produciéndose un incremento de célalas TUNEL-positivas. La viabilidad celular total resultó ser menor en aquellas arterias que habrán sido sometidas al protocolo de descongelación rápida. Por todo ello, podemos concluir que la descongelación rápida, en comparación con la descongelación lenta, provoca daños más acusados en la capa media de las arterias criopreservadas a -80 ='C y disminuye la viabilidad celular de las mismas (AU)

Superior mesenteric arterial embolism: local fibrinolytic treatment with urokinase.

PURPOSE: To evaluate the efficacy of intraarterial urokinase in the treatment of superior mesenteric arterial (SMA) embolism. MATERIALS AND METHODS: Within 3 years, 10 patients (six men, four women; aged 62-82 years) with angiographically proved SMA emboli were selected on the basis of absence of peritoneal signs of intestinal necrosis at physical examination and normal abdominal plain radiographs to undergo local lysis with urokinase. RESULTS: The procedure was performed without complications in all 10 patients. The embolus was successfully lysed in nine patients (90%). Clinical success was achieved in seven patients (70%); however, in one patient laparotomy was required to confirm the clinical finding. None of these patients had recurrent embolism or postischemic intestinal stenosis during follow-up (mean, 11.2 months). The three remaining patients (30%) underwent laparotomy subsequent to failure of intraarterial treatment with urokinase. CONCLUSION: Fibrinolytic treatment with urokinase may be an effective alternative to surgical embolectomy in patients with SMA embolism without clinical or radiologic signs of intestinal infarction. In this small series, abatement of abdominal pain in the 1st hour of fibrinolytic treatment was the best indicator of clinical success. Pain persisted in patients with intestinal infarction.

Hepatocellular carcinoma in a non-cirrhotic coal miner with secondary haemochromatosis.

We report a case of hepatocarcinoma in a non-cirrhotic patient with secondary haemochromatosis. A 61-year-old man, who had been a coal miner for 36 years, presented with a well differentiated hepatocarcinoma without cirrhosis. The patient had a haemochromatosis with no family history of liver disease and a normal genetic study. Right hepatectomy was performed and 15 months later there has been no recurrence. This case confirms the possibility of hepatocarcinoma occurring in haemochromatosis patients without cirrhosis. The recognition of populations at risk of haemochromatosis is a necessity, and this should include coal miners.

Lipoma-induced jejunojejunal intussusception: US and CT diagnosis.

A case study of a patient who presented with abdominal pain and a palpable mesogastric mass is discussed. Ultrasound and computed tomography (CT) demonstrated that the palpable mass was jejunojejunal intussusception of the small intestine. The lead point of the intussusception was a lipoma that appeared in the CT scan as a small intramural mass with an attenuation coefficient of fat.