Ascitis masiva secundaria a preeclampsia severa: reporte de caso / Massive ascitis secondary to severe preeclampsia: case report

RESUMEN La preeclampsia es una patología con múltiples implicaciones y causa de morbimortalidad materno perinatal. Aunque su frecuencia es baja, la ascitis es un signo clínico a tener en cuenta. Reportamos el caso de un embarazo de 33,1 semanas con preeclampsia severa, en quien durante la cesárea se observó ascitis que evolucionó a ascitis masiva al segundo día postoperatorio, y requirió manejo invasivo (drenaje por pig tail) y traslado a UCI por 6 días. Necesitó nitroprusiato durante 2 días por persistencia de la crisis hipertensiva, con mejoría progresiva y egreso de la clínica a los 12 días.

ABSTRACT Preeclampsia is a pathology with multiple implications and a cause of maternal and perinatal morbidity and mortality. Although its frequency is low, ascites is a clinical sign to be taken into account. We report the case of a 33.1-week pregnant woman with severe preeclampsia, in whom ascites was observed during cesarean section and evolved to massive ascites on the second postoperative day, requiring invasive management (pig tail drainage) and transfer to the ICU for 6 days. She needed nitroprusside for 2 days due to persistent hypertensive crisis, with progressive improvement and discharge from the clinic after 12 days.

[Venous thromboembolism prophylaxis in Colombian surgical and medical patients: results for Colombia of the ENDORSE study]. / Profilaxis de la tromboembolia venosa en pacientes colombianos de tratamiento médico o quirúrgico: resultados para Colombia del estudio ENDORSE.

INTRODUCTION: More information is needed on the risk of venous thromboembolism in the hospital setting, and on patterns of use of thromboprophylaxis, as advocated in consensus guidelines. ENDORSE was an international study aimed at evaluating hospital venous thromboembolism prevention practices in medical and surgical patients. OBJECTIVES: The risk of venous thromboembolism was evaluated along with the use of thromboprophylaxis in hospitalized medical and surgical subjects; these data were compared with the international sample from the ENDORSE study. MATERIALS AND METHODS: Participating institutions in Colombia were selected arbitrarily. The medical charts for medical and surgical patients were evaluated randomly. The 2004 American College of Chest Physician guidelines were used to evaluate risk of venous thromboembolism and adherence to recommended thromboprophylaxis regimens. RESULTS: The study included 761 subjects (218 surgical, 543 medical) located in five acute care hospitals; 49% of these subjects were considered at risk of venous thromboembolism (40% medical, 72% surgical), compared with 52% in the international sample. Prophylaxis use was higher in medical patients at risk (63.7%, n=137) than in surgical patients (48.4%, n=76; p=0.01). Compared with the international sample, the use of prophylaxis in Colombia was greater in medical patients (63.7% vs. 39.5%, p=0.003), but lower in surgical patients (48.4% vs. 58.5%, p=0.02). CONCLUSIONS: Participating Colombian centers treat patients at risk of venous thromboembolism similarly to other participant countries, but appropriate prophylaxis was prescribed more frequently to medical patients. Greater efforts are needed, both in Colombia and around the world, to improve rates of appropriate venous thromboembolism prophylaxis in at-risk subjects.

Profilaxis de la tromboembolia venosa en pacientes colombianos de tratamiento médico o quirúrgico: resultados para Colombia del estudio ENDORSEA / Venous thromboembolism prophylaxis in Colombian surgical and medical patients: Results for Colombia of the ENDORSE study

Introducción. La profilaxis en pacientes de tratamiento médico o quirúrgico con riesgo de tromboembolia venosa, requiere ser evaluada para obtener suficiente información que contribuya a mejorar estas prácticas, para que sean efectivas y eficaces, y ayudar con las medidas necesarias de prevención hospitalaria de la tromboembolia venosa. Objetivo. Evaluar el riesgo de tromboembolia venosa y de los hábitos de profilaxis en pacientes de tratamiento médico o quirúrgico hospitalizados en Colombia y compararlos con los de los centros internacionales participantes en el estudio ENDORSE. Materiales y métodos. Las instituciones fueron escogidas al azar. Se evaluaron todas las historias clínicas de pacientes de tratamiento médico o quirúrgico. Se utilizaron las guías del 2004 del American College of Chest Physicians para evaluar el riesgo de tromboembolia venosa y lo apropiado de la profilaxis. Resultados. Se evaluaron 761 pacientes: 218 de tratamiento quirúrgico y 543 de tratamiento médico, de cinco centros hospitalarios de Colombia. De esta población, 49 % se encontraba en riesgo de tromboembolia venosa (40 % de los de tratamiento médico y 72% de los de tratamiento quirúrgico), en comparación con 52 % de la muestra internacional. La profilaxis fue significativamente mayor en los pacientes de tratamiento médico en riesgo (63,7 %, n=137), que en los de tratamiento quirúrgico (48,4 %, n=76, P=0,01). En comparación con la muestra internacional, la profilaxis en los de tratamiento médico fue significativamente superior (63,7 % Vs. 39,5 %, P=0,003), a diferencia de los de tratamiento quirúrgico (48,4 % Vs. 58,5 %, P=0,02). Conclusiones. Los resultados muestran que en los centros hospitalarios de Colombia se trataron pacientes con riesgo de tromboembolia venosa en forma similar al resto de los países participantes en el estudio ENDORSE, y que se hizo más profilaxis apropiada en pacientes de tratamiento médico. Sin embargo, se requiere mejorar la utilización de profilaxis en pacientes hospitalizados.

Venous thromboembolism prophylaxis in Colombian surgical and medical patients: Results for Colombia of the ENDORSE study Introduction. More information is needed on the risk of venous thromboembolism in the hospital setting, and on patterns of use of thromboprophylaxis, as advocated in consensus guidelines. ENDORSE was an international study aimed at evaluating hospital venous thromboembolism prevention practices in medical and surgical patientes. Objectives. The risk of venous thromboembolism was evaluated along with the use of thromboprophylaxis in hospitalized medical and surgical subjects; these data were compared with the international sample from the ENDORSE study. Materials and methods. Participating institutions in Colombia were selected arbitrarily. The medical charts for medical and surgical patients were evaluated randomly. The 2004 American College of Chest Physician guidelines were used to evaluate risk of venous thromboembolism and adherence to recommended thromboprophylaxis regimens. Results. The study included 761 subjects (218 surgical, 543 medical) located in five acute care hospitals; 49% of these subjects were considered at risk of venous thromboembolism (40% medical, 72% surgical), compared with 52% in the international sample. Prophylaxis use was higher in medical patients at risk (63.7%, n=137) than in surgical patients (48.4%, n=76; p=0.01). Compared with the international sample, the use of prophylaxis in Colombia was greater in medical patients (63.7% vs. 39.5%, p=0.003), but lower in surgical patients (48.4% vs. 58.5%, p=0.02). Conclusions. Participating Colombian centers treat patients at risk of venous thromboembolism similarly to other participant countries, but appropriate prophylaxis was prescribed more frequently to medical patients. Greater efforts are needed, both in Colombia and around the world, to improve rates of appropriate venous thromboembolism prophylaxis in at-risk subjects.

Does prolonged pneumoperitoneum affect oxidative stress compared with open surgical procedures?

BACKGROUND AND PURPOSE: As laparoscopic surgery has evolved, it has become part of the urologic surgical armamentarium and is now used to perform more complex procedures. Carbon dioxide, used to create pneumoperitoneum, produces physiologic changes in various organs, including the kidneys. Such changes are associated with altered redox status because of the release of free radicals and changes in oxidative stress signals. It is unknown whether prolonged pneumoperitoneum is associated with an increase in oxidative stress compared with open surgery. The objective of this study was to compare oxidative stress in patients undergoing urologic laparoscopic and open operations. PATIENTS AND METHODS: Urine samples were obtained immediately preoperatively, immediately postoperatively, and at 6 and 18 hours after surgery from 10 patients who underwent urologic laparoscopic surgery and 10 patients who underwent open surgery. Concentrations of the oxidative stress marker isoprostane (8- iso-prostaglandin F2a) were measured, and the results were analyzed with respect to clinical factors associated with the type of surgery. RESULTS: Urinary isoprostane concentrations (mean +/- SEM) in the laparoscopic and open groups showed an increase immediately after surgery to 189.0 +/- 64.2% and 141.1 +/- 45.8% of the preoperative values, respectively. A decrease in isoprostane was subsequently observed in both groups at 6 hours postoperatively, with preoperative values restored at 18 hours postoperatively (126.3 +/- 19.7% and 89.5 +/- 55.9% at 6 and 18 hours, respectively, in the laparoscopic group and 130.7 +/- 41.6% and 88.7 +/- 20.4% at 6 and 18 hours, respectively, in the open-surgery group). Although in both groups the peak PGF 2a concentration was observed immediately (0 hours) postoperatively, no significant differences were observed between the groups at 0, 6, and 18 hours. In the laparoscopic-surgery group, the mean increase tended to be higher and the decrease to be less prolonged than in the open-surgery group. CONCLUSION: Oxidative stress, as measured by urinary 8-iso-prostaglandin F2a, is produced by both laparoscopic and open urologic surgery. The findings of our nonrandomized study suggest a pattern of increased oxidative stress postoperatively with either type of surgery, with subsequent return almost to preoperative levels. Prolonged laparoscopic operative time did not affect oxidative stress levels.

Use of the LigaSure vessel sealing device in laparoscopic living-donor nephrectomy.

BACKGROUND: Laparoscopic living-donor nephrectomy has gained acceptance within the transplant community. The technique requires advanced laparoscopic techniques, and great care must be taken to ensure safety of the operation for the donor and transplantability of the donor kidney. Minimizing the risk of bleeding and trauma to the kidney are important features of a successful living-donor nephrectomy. Improved laparoscopic instrumentation has afforded greater safety and efficacy through technical advances. METHODS: The LigaSure device was used in 124 consecutive living-donor nephrectomies beginning in 1999. A transplant database was reviewed for operative statistics including intraoperative blood loss and operating time. RESULTS: The LigaSure device was used to dissect and seal all venous and arterial branches. Estimated blood loss was 90 +/- 53 mL. A suction device was required in only 40 (32%) of the cases. No patient experienced postoperative bleeding. There were two donor complications: one incisional hernia and one ileus. All kidneys functioned immediately upon reperfusion. CONCLUSIONS: The LigaSure device is an extremely effective tool for obtaining hemostasis by sealing both venous and arterial branches of the major renal vessels. This is also effective in sealing lymphatic tissues and thereby facilitating dissection. Avoiding the use of metallic clips simplified final division of the renal artery and vein. As with any laparoscopic instrument, the anatomic geometry of the operative field may limit use based upon port placement.

Laparoscopic partial nephrectomy of solid renal masses without hilar clamping using a monopolar radio frequency device.

PURPOSE: Partial nephrectomy is currently recommended for most amenable solid renal tumors, especially if they are exophytic and less than 4 cm. We reviewed our initial experience with laparoscopic partial nephrectomy for solid renal masses without clamping the renal vasculature using a monopolar device that uses radio frequency energy with low volume saline irrigation for simultaneous blunt dissection, hemostatic sealing and coagulation of the renal parenchyma (TissueLink, TissueLink Medical, Inc., Dover, New Hampshire). MATERIALS AND METHODS: From September 2002 to April 2003, 10 patients underwent transperitoneal laparoscopic partial nephrectomy, including 9 with solid renal masses and 1 with a complex cyst. In all cases the renal hilum was dissected and the renal vessels were isolated but none had renal vascular clamping. The TissueLink DS dissecting sealer or Floating Ball (TissueLink Medical, Inc.) was used to dissect the tumor free bluntly, while simultaneously sealing and coagulating bleeders. RESULTS: Mean patient age was 54.6 years (range 42 to 72). Mean American Society of Anesthesiologists score was 2.3 (range 2 to 4). Mean tumor size was 3.9 cm (range 2.1 to 8). The mass had a peripheral location in 7 cases and a central location in 3. Mean operative time was 232 minutes (range 144 to 280) and mean blood loss was 352 ml (range 20 to 1000). One patient received blood transfusion and all tumor margins were negative. Mean hospital stay was 1.7 days (range 1 to 5) and pain medication use was minimal. One patient had a brief period of urine leakage from the lower pole calix, which was managed successfully by ureteral stenting and Foley catheter drainage of the bladder. CONCLUSIONS: Laparoscopic partial nephrectomy can be performed without renal vascular clamping. TissueLink technology allows complete tumor resection and provides adequate parenchymal hemostasis of the tumor bed. Its scant tissue charring production does not interfere with the pathological assessment of the tumor margin status.

Extramedullary plasmacytoma invading the bladder: case report and review of the literature.

Multiple myeloma is characterized by neoplastic proliferation of a single clone of plasma cells engaged in the production of a monoclonal protein. This condition affects mainly the bone marrow, but extramedullary manifestations can be seen in any organ. Urinary bladder involvement is extremely rare, with only 14 cases reported in the literature to our knowledge. Herein, we report a large extramedullary bladder plasmacytoma arising in a patient with history of multiple myeloma. A 78-year-old woman with history of multiple myeloma, currently in remission, presented with a large intravesical tumor. Because the tumor was considered to have characteristics of anaplastic neoplasm from transitional cell origin with evidence of deep muscular invasion, a radical cystectomy was performed. A subsequent microscopic evaluation of the cystectomy specimen revealed round cells with an eccentric cartwheel-like nucleus suggestive of plasmacytoma. The diagnosis was further confirmed with immunohistochemical studies. It is difficult, according to the literature, to distinguish bladder plasmacytoma from anaplastic transitional cell tumors. It is important to provide the pathologist with an appropriate history and to have a high index of suspicion for bladder plasmacytoma in patients with previous diagnosis of multiple myeloma and bladder mass.