[Septic thrombophlebitis of the portal vein associated with reversible portal hypertension]. / Tromboflebitis séptica de la vena porta asociada a hipertension portal reversible.

Septic thrombophlebitis of the portal vein is an unusual and serious complication of abdominal infection. We present a patient with thrombophlebitis of the portal vein of unknown origin, suffering from fever, abdominal pain, jaundice, abnormal liver test function and bacteremia related to Bacteroides fragilis. Ultrasonography, with doppler of the portal vein, was performed which showed thrombosis of the portal vein together with signs of portal hypertension. The patient underwent six weeks of antibiotic treatment. The evolution was favourable, the infection was overcome and the portal vein was de-obstructed as a consequence of which the signs of portal hypertension disappeared.

Tromboflebitis séptica de la vena porta asociada a hipertension portal reversible. / [Septic thrombophlebitis of the portal vein associated with reversible portal hypertension]

Septic thrombophlebitis of the portal vein is an unusual and serious complication of abdominal infection. We present a patient with thrombophlebitis of the portal vein of unknown origin, suffering from fever, abdominal pain, jaundice, abnormal liver test function and bacteremia related to Bacteroides fragilis. Ultrasonography, with doppler of the portal vein, was performed which showed thrombosis of the portal vein together with signs of portal hypertension. The patient underwent six weeks of antibiotic treatment. The evolution was favourable, the infection was overcome and the portal vein was de-obstructed as a consequence of which the signs of portal hypertension disappeared.

[Intra-abdominal infection and new quinolones]. / Infección intraabdominal y nuevas quinolonas.

Intra-abdominal infection is defined as the presence of an infectious process within the peritoneal cavity. It may be local or have a systemic consequence generating multiple organic disfunction. Most of the studies report a mortality of 30% in severe intra-abdominal infection. Secondary peritonitis is caused by the loss of integrity of the gastrointestinal apparatus, which contaminates with pathogens the peritoneal cavity. Invariably they are polymicrobial infections, mostly due to facultative anaerobic and anaerobic Gram negative bacilli. Prognosis of peritonitis depends on the struggle between two forces: local and systemic immunity of the host and the volume, nature and length of the contamination. Microorganisms and their products estimulate cellular defenses in the host and activate numerous inflammatory mediators responsible for sepsis. Antibiotic treatment of secondary peritonitis must act mainly against Escherichia coli and Bacteroides fragilis. The adequate and early empirical administration of antibiotics against these bacteria is well established. It is necessary to consider if the infection is localized or generalized and if it is accompanied or not by organic disfunction. It also has to be taken into account if peritonitis is community or hospital-acquired when choosing the antibiotic scheme. In community-acquired peritonitis with low to moderate infections a combination of metronidazole-ceftriaxone, metronidazole-gentamycin or a monodrug like ampicillin-sulbactam may be used. In severe hospital-acquired peritonitis imipenem or the combination piperacillin-tazobactam are effective. New quinolones such as trovafloxacin or clinafloxacin, with excellent activity against aerobes and anaerobes producing intra-abdominal infections, may be effective. Future clinical trials are needed to determine their utility. Tertiary peritonitis represent a systemic inflammatory response with multiorganic failure due to the uncontrolled activation of the inflammatory cascade. It is considered a persistent, systemic peritoneal inflammation. Antibiotics and new surgery do not seem to be useful in this situation.

Infección intraabdominal y nuevas quinolonas. / [Intra-abdominal infection and new quinolones]

Intra-abdominal infection is defined as the presence of an infectious process within the peritoneal cavity. It may be local or have a systemic consequence generating multiple organic disfunction. Most of the studies report a mortality of 30

in severe intra-abdominal infection. Secondary peritonitis is caused by the loss of integrity of the gastrointestinal apparatus, which contaminates with pathogens the peritoneal cavity. Invariably they are polymicrobial infections, mostly due to facultative anaerobic and anaerobic Gram negative bacilli. Prognosis of peritonitis depends on the struggle between two forces: local and systemic immunity of the host and the volume, nature and length of the contamination. Microorganisms and their products estimulate cellular defenses in the host and activate numerous inflammatory mediators responsible for sepsis. Antibiotic treatment of secondary peritonitis must act mainly against Escherichia coli and Bacteroides fragilis. The adequate and early empirical administration of antibiotics against these bacteria is well established. It is necessary to consider if the infection is localized or generalized and if it is accompanied or not by organic disfunction. It also has to be taken into account if peritonitis is community or hospital-acquired when choosing the antibiotic scheme. In community-acquired peritonitis with low to moderate infections a combination of metronidazole-ceftriaxone, metronidazole-gentamycin or a monodrug like ampicillin-sulbactam may be used. In severe hospital-acquired peritonitis imipenem or the combination piperacillin-tazobactam are effective. New quinolones such as trovafloxacin or clinafloxacin, with excellent activity against aerobes and anaerobes producing intra-abdominal infections, may be effective. Future clinical trials are needed to determine their utility. Tertiary peritonitis represent a systemic inflammatory response with multiorganic failure due to the uncontrolled activation of the inflammatory cascade. It is considered a persistent, systemic peritoneal inflammation. Antibiotics and new surgery do not seem to be useful in this situation.

[Digoxin: continuous or discontinuous treatment?]. / Digoxina: tratamiento continuo o discontinuo?

In our country, patients with congestive heart failure who are treated chronically with digoxin are usually advised by their physicians to stop taking the medication two days a week. This is probably aimed at decreasing digitalis toxicity. Based on digoxin pharmacokinetics we assumed that the drug plasmatic level should diminish by 40 to 50%, below the therapeutic concentration of 0.8 to 2 milligrams, after two days of suspension. The objectives of this study were: a) to analyze the reduction of the plasmatic concentration of digoxin after a two day interruption of treatment, b) to compare the plasmatic levels of the drug between patients who received continuous and discontinuous treatment. A prospective, randomized and simple blind trial was designed. A total of 36 patients with congestive heart failure and systolic dysfunction with atrial fibrillation or sinus rythm were included. Group 1 (19 patients) received continuous treatment and Group 2 (17 patients) took the drug from Monday to Friday. In the continuous treatment group there was no significant difference between the Monday (1.06 +/- 0.55 milligrams) and the Friday (1.1 +/- 0.57 milligrams) digoxin concentrations. In the discontinuous treatment group the Monday digoxin concentration (0.611 +/- 0.396 milligrams) was lower than the Friday one (1.04 +/- 0.58 milligrams). The difference was statistically significant with a p = 0.000002. In conclusion, the two days a week suspension schedule reduces the plasmatic concentration of digoxin to subtherapeutic levels while the continuous regime maintains stable concentrations within the therapeutic range. Adjusting the dose to the creatinine clearance, average concentrations of 1 milligram are obtained. These results suggest that digitalis intoxication could be prevented by adjusting the dose according to renal function rather than interrupting the treatment as it is usually done in our country.

[Preoperative clinical evaluation]. / Evaluación clínica preoperatoria.

The purpose of preoperative evaluation is to reduce the morbidity and mortality of surgical interventions. The operative risk is related to: the nosocomial environment, the anesthetic procedure, the surgical team, the magnitude of the intervention and the patient's psychological, physical and pathological conditions. An adequate history and physical examination are essential to evaluate the patient's clinical situation. In our country, an electrocardiogram (EKG) with an estimation of the "surgical risk" and a number of laboratory tests are usually done. This article discusses the evidence and recommendations on the usefulness and indications of the EKG, the laboratory test, the coagulation tests and the chest X-ray. The decision to order preoperative tests should be based on positive clinical findings, the need to obtain basal values before major interventions and the existence of risk factors for certain diseases. The ambulatory preoperative clinical evaluation is the best method for the detection of diseases that could modify the surgical risk. It is also the opportunity to consult specialists if needed and to indicate necessary prophylactic measures.

[Renal vascular lesion and microangiopathic hemolytic anemia in systemic lupus erythematosus]. / Lesión vascular renal y anemia hemolítica microangiopática en lupus eritematoso sistémico.

A 22 year-old woman with a seven year history of (SLE) was readmitted because of oliguria, edema, dyspnea and arterial hypertension. She had a previous biopsy diagnosis of focal glomerulonephritis, (WHO III b), and had been treated with immunosuppressors and steroids. Laboratory data showed lupus activity, AHM with thrombocytopenia, nephrotic-range proteinuria and renal failure. A second renal biopsy was performed showing diffuse proliferative nephritis, (WHO IV), in association with noninflammatory necrotizing vasculopathy with luminal obliteration. She started with hemodialysis and was subsequently treated with methylprednisolone pulses, plasmapheresis, cyclophosphamide and oral steroids. During the inpatient period, she had generalized seizures, acute lung injury and pulmonary hemorrhage. These complications, the AHM and the thrombocytopenia receded totally. Renal function was never resumed. We emphasize that this association of diffuse proliferative nephritis with noninflammatory necrotizing vasculopathy is not infrequent and has a poor renal prognosis. The AHM with thrombocytopenia was interpreted as secondary to endothelial cell damage due to vasculopathy.

Anastomosis mecánicas circulares colónicas y rectales / Mechanical circular colonic and rectal anastomoses

Se realizaron 536 anastomosis mecánicas, en distintos niveles del aparato digestivo. Los instrumentos de sutura utilizados fueron los conocidos con las siglas: TA, GIA y EEA. Las 404 anastomosis circulares colónicas y rectales se discriminan en 85 ileotransversas, 4 ileosigmoideas, 10 ileorrectales, 42 colocolónicas y 263 colorrectales. El ileo posoperatorio se resolvió en el 88 % de los casos en las primeras 96 horas. Se hicieron presentes 7 fístulas latentes, 5 fístulas piostercoráceas 9 peritonitis, 4 hemorragias y 3 estrecheces, en todas de ellas se había afectuado reparación manual y 7 recidivas. La mortalidad por dehiscencia de peritonitis, inherente al método, fue del 1,23 %. La facilidad que otorga el EEA para realizar las anastomosis con la porción baja del recto, no debe hacer variar los principios oncológicos que rigen la táctica quirúrgica en los cánceres de esta localización. Se concluye que el empleo de estos instrumentos incorporados a la práctica diaria constituyen un notable progreso en el campo de la cirugía digestiva

Restablecimiento de la continuidad intestinal luego de la operacion de Hartmann con el aparato E.E.A. de sutura mecanica. / Restoration of intestinal continuity after Hartmann's operation with EEA stapler

Se presentan 12 casos de reconstruccion de operacion de Hartmann con sutura mecanica E.E.A. Se describen la tactica y tecnica operatorias, preferindo los autores la anastomosis terminolateral. En 6 casos se efectuo colostomia transversa contemporanea. No se observaron dehiscencias anastomoticas, ni se registro mortalidad

Restablecimiento de la continuidad intestinal luego de la operacion de Hartmann con el aparato E.E.A. de sutura mecanica. / Restoration of intestinal continuity after Hartmanns operation with EEA stapler

Se presentan 12 casos de reconstruccion de operacion de Hartmann con sutura mecanica E.E.A. Se describen la tactica y tecnica operatorias, preferindo los autores la anastomosis terminolateral. En 6 casos se efectuo colostomia transversa contemporanea. No se observaron dehiscencias anastomoticas, ni se registro mortalidad

Profilaxis antimicrobiana sistemica y oral en cirugia colorrectal electiva.Comparacion. / Antimicrobial systemic and oral prophylaxis in elective colorectal surgery

En el presente estudio se ha evaluado la incidencia de infeccion postoperatoria en 68 pacientes sometidos a cirugia colorrectal electiva, comparando en forma prospectiva y al azar dos tipos diferentes de antibioticos profilacticos. Un regimen incluia neomicina-eritromicina por via oral y el otro clindamicina fosfato-lobramicina por via parenteral.Los 2 grupos de pacientes fueron similares en terminos de sexo, edad, enfermedad y tipos de operaciones.Se realizaron cultivos de la flora colonica o de los sitios de infeccion postoperatoria. Los niveles sericos de clindamicina fosfato y tobramicina fueron determinados por metodos microbiologicos. La incidencia de infeccion postoperatoria significativas entre los 2 regimenes con respecto a la frecuencia e importancia de infecciones parietales, peritoneales, septicemia y mortalidad y promedio de dias de internacion. Complicaciones toxicas significativas no se observaron. Se concluye que cualquiera de estas dos preparaciones pueden ser recomendadas indistintamente para la prevencion de infecciones post-operatorias en la cirugia colorrectal electiva

Profilaxis antimicrobiana sistemica y oral en cirugia colorrectal electiva.Comparacion. / Antimicrobial systemic and oral prophylaxis in elective colorectal surgery

En el presente estudio se ha evaluado la incidencia de infeccion postoperatoria en 68 pacientes sometidos a cirugia colorrectal electiva, comparando en forma prospectiva y al azar dos tipos diferentes de antibioticos profilacticos. Un regimen incluia neomicina-eritromicina por via oral y el otro clindamicina fosfato-lobramicina por via parenteral.Los 2 grupos de pacientes fueron similares en terminos de sexo, edad, enfermedad y tipos de operaciones.Se realizaron cultivos de la flora colonica o de los sitios de infeccion postoperatoria. Los niveles sericos de clindamicina fosfato y tobramicina fueron determinados por metodos microbiologicos. La incidencia de infeccion postoperatoria significativas entre los 2 regimenes con respecto a la frecuencia e importancia de infecciones parietales, peritoneales, septicemia y mortalidad y promedio de dias de internacion. Complicaciones toxicas significativas no se observaron. Se concluye que cualquiera de estas dos preparaciones pueden ser recomendadas indistintamente para la prevencion de infecciones post-operatorias en la cirugia colorrectal electiva