Early versus late necrosectomy in severe necrotizing pancreatitis.

BACKGROUND: Debate as to whether surgery in severe necrotizing pancreatitis (SNP) should be done early or late has been present ever since the disease was described. There are no prospective, randomized studies addressing this specific issue. METHODS: Patients with SNP, documented clinically, with Ranson's criteria, and dynamic pancreatography (DP) findings were randomly allocated in two groups for treatment. Group A included early necrosectomy (within 48 to 72 hours of onset) and group B, late necrosectomy (at least 12 days after onset). Both groups continued with open packing and staged necrosectomies. Cultures were obtained at each laparotomy and necrosis was verified histologically in all instances. RESULTS: During a 36-month study period, 150 patients with unequivocal acute pancreatitis were admitted for treatment. Forty-one with SNP initially entered the study; there were 5 drop outs. Patients in group A (25) and group B (11) had no difference in distribution by gender or mean age, etiology, mean Ranson's signs (4 versus 3.8), DP findings, rate of infected necrosis, or necrosectomies required per patient. Although the mortality rate (58% versus 27%) did not reach statistical significance, the odds ratio for mortality was 3.4 times higher in group A, which made us finish the study. CONCLUSION: This prospective, randomized study from a single institution clearly demonstrates that early intensive conservative treatment with late necrosectomy for selected cases is the current rationale approach for SNP.

[Surveillance of the clinical course of 6,030 surgical wounds]. / Vigilancia de la evolución de 6.030 heridas quirúrgicas.

This report describes a 4 year prospective study of postoperative wound infections, utilizing a program of wound surveillance. Surgical wounds after 6030 operations of a general surgery service were surveyed by the authors and a specialist nurse, daily and in the follow up clinic for 30 days. Results were reported to all the surgeons monthly. The rates of infections demonstrated a decline over the years of surveillance. In the first year there was a 6.37 percent incidence of infection and the fourth year 4.7 percent. This represents an improvement in hospitalization days and expenses.

[Surgical treatment of acute pancreatitis. The Mexican experience]. / Tratamiento quirúrgico de la pancreatitis aguda. La experiencia mexicana.

Acute Pancreatitis is a complex clinical problem. The mexican experience in the Acute Pancreatitis treatment was analyzed, from the papers published between 1970-1990. During the first decades of the 20th century. Acute Pancreatitis was usually diagnosed at operation or at autopsy. Because a significant proportion of those diagnosed at surgery survived, early intervention was recommended. With the introduction of laboratory test, surgical diagnosis was regarded as unnecessary. In the past 30 years in has become clear that patients with severe forms of Pancreatitis do not survive without surgery and interest in the value of surgical measures has been renewed. We reviewed the papers of the surgical treatment of Acute Pancreatitis and its complications, only articles with documented surgical treatment were selected for analysis. From 1970 through 1990, 41 articles were published by Mexican Journals, only 10, fulfill the criteria, 632 patients with operative management. Patients with gall-stone associated Pancreatitis were the most frequent, 70-72%, and alcoholic Pancreatitis the second 20%; significant hospital morbidity occurred, recurrent sepsis was frequently identified; mortality rate was 52.6%. Available data do not provide any reasonable approach, therefore, we urge to develop clinical trials, with control groups for better results.

[Surveillance of the course of 6030 surgical wounds]. / Vigilancia de la evolución de 6030 heridas quirúrgicas.

This report describes a 4-year prospective study of post-operative wound infections, utilizing a program of wound surveillance. Surgical wounds after 6030 operations of a general surgery service were surveyed by the authors and a specialist nurse, daily, and in the follow-up clinic for 30 days. The rates of infections showed a decline over the years of surveillance. On the first year there was a 6.37 per cent incidence of infections, and the fourth year, of 4.7 per cent. This represented an improvement in hospitalization days and expenses.

[Acute pancreatitis. The classification of its severity by dynamic pancreatography and the results of surgical treatment]. / Pancreatitis aguda. Clasificación de la severidad con pancreatografía dinámica y resultados del tratamiento quirúrgico.

In acute pancreatitis determination of glandular necrosis has been difficult because of the lack of an objective method; with dynamic enhanced tomography (bolus injection of contrast media) we have reasonably classify 28 patients with acute pancreatitis. With this technique 5 grades of sequelae of acute pancreatitis are identified: I. Non complicated acute pancreatitis; II. pancreatic abscess: III. peripancreatic necrosis; IV. less than 50% pancreatic necrosis and V. more than 50% pancreatic necrosis. A 100% correlation was found between tomography and surgical findings. This is the first report in Mexico of this method to identify pancreatic or peripancreatic necrosis; we also present the surgical results with a programmed pancreatic debridation; mortality has decreased form 80 to 31.9% in our hospital in recent years.

El cateterismo subclavio para nutricion parenteral. Experiencia con 500 cateteres consecutivos. / The subclavian catheterization for parenteral Ize L L nutrition. Experience with 500 consecutive catheters

El cateterismo subclavio para la nutricion parenteral es un procedimiento utilizado para satisfacer, por via venosa central, las demandas de un organismo imposibilitado para nutrirse por via oral. El cateterismo se realiza habitualmente por via subclavia mediante puncion infraclavicular. El metodo tiene riesgos debido a complicaciones inherentes a la tecnica o como posible punto de partida de infeccion. En un lapso de 6 anos se colocaron 500 cateteres subclavios de dos materiales: polivinilo (263) y de silicon (237), con la misma tecnica, para ser utilizados en nutricion parenteral. Los cateteres permanecieron colocados, en su gran mayoria, por un lapso menor de 32 dias y las complicaciones relacionadas con la tecnica de puncion se presentaron en un 3.6%. Estas complicaciones no afectaron la evolucion del paciente. La punta del cateter subclavio desarrollo algun germen en el 15.7% de los casos pero sin relacion directa con la presencia de septicemia en el paciente.Los cateteres de silicon tuvieron un menor numero de complicaciones en la puncion, pero se ocluyeron con mayor frecuencia que los de polivinilo