Sequential closure of the abdominal wall for the management of open abdomen. A new surgical technique.

BACKGROUND: The open abdomen is a surgical technique used in the treatment of patients with abdominal sepsis, abdominal trauma and abdominal hypertension syndrome. OBJECTIVE: The aim was to demonstrate the effectiveness of a new surgical technique designed for the management and closure of the abdominal wall in patients with open abdomen. METHOD: Study of all patients treated with open abdomen in our Hospital over a five-year period. RESULTS: It were included 24 patients, 18 men and 6 women. The average age was 41.5 ± 15.9 years. Operative diagnosis was abdominal compartment syndrome in 7 (29%) cases, abdominal sepsis in 9 (38%), and abdominal trauma in 8 (33%). The median of APACHE II score was 8 points (range: 5-21) while the assessment of SIRS score had a median of 2 points (range: 1-4). The median of surgical procedures performed in operating room was two per patient. The median of fascial surgical closures performed in the patient bed was four. A successful closure of the abdominal wall was performed in 21 of 22 live patients (95%). CONCLUSIONS: The sequential closure of the abdominal wall is an effective technique that offers an alternative to the management of the open abdomen.

ANTECEDENTES: El abdomen abierto es un método quirúrgico utilizado en el tratamiento de pacientes con sepsis abdominal, en trauma abdominal en casos de cirugía de control de daños y en casos de síndrome de hipertensión abdominal. OBJETIVO: Demostrar la efectividad de una nueva técnica quirúrgica en pacientes con abdomen abierto. MÉTODO: Estudio de todos los pacientes manejados con abdomen abierto en nuestro hospital en un periodo de 5 años. RESULTADOS: Se incluyeron 24 pacientes, 18 hombres y 6 mujeres, con una edad promedio de 41.5 ± 15.9 años. El diagnóstico operatorio fue síndrome compartimental abdominal en 7 (29%) casos, sepsis abdominal en 9 (38%) y trauma abdominal en 8 (33%). La puntuación APACHE II tuvo una mediana de 8 (rango: 5-21) y el SIRS una mediana de 2 (rango: 1-4). La mediana de ingresos a quirófano por paciente fue de dos. La mediana de las aproximaciones aponeuróticas fuera de quirófano fue de cuatro. Se realizó un cierre definitivo de la pared abdominal en 21 de 22 pacientes vivos, considerando cierre exitoso en el 95%. CONCLUSIONES: El cierre secuencial es una técnica efectiva que ofrece una alternativa en pacientes que requieren manejo con abdomen abierto.

Multicentric Study to Evaluate Mexican Medical Students' Knowledge of Transplants and Organ Donation.

INTRODUCTION: Transplants and organ donation are greatly aided by future medical professionals having adequate knowledge of this topic. This study aimed to elucidate the level of Mexican medical students' knowledge in the field of transplants and organ donation. MATERIALS AND METHODS: The evaluation instrument was designed and validated. The design used simple sampling with replacement, selecting a random sample of 5 universities from among the institutional members of the Mexican Association of Departments and Schools of Medicine (Asociación Mexicana de Facultades y Escuelas de Medicina [AMFEM]). The sample was composed of 3214 medical students. Measures of central tendency were determined, and the mean scores obtained across the different universities were compared using a Kruskal-Wallis test. The odds ratio was calculated for the students whose school or department included instruction on transplants and donation within their curriculum. Kendall correlation was used for the students' academic grade level and score. All analyses considered a threshold of P < .05. RESULTS: A questionnaire was administered to a sample of 2563 students to evaluate their knowledge of transplants and organ donation. The average score was 4.02 on a scale of 0 to 10 (standard deviation 0.03), with a 95% confidence interval (3.96-4.08). Students whose school or department taught the subject of transplants and donations within their curriculum obtained an odds ratio of 1.44 (P = .0000822). CONCLUSIONS: The findings of this study suggest that medical students in Mexico do not have sufficient knowledge of transplants and organ donation.

Prevention of intestinal adhesions as a result of intraperitoneal mesh with the addition of hyaluronic acid/carboxymethylcellulose gel. Experimental model in rats.

BACKGROUND: Intraperitoneal meshes produce adhesions and intestinal fistula. Composite materials with an antiadherent barrier prevent that complication. There are no studies using gel products in intraperitoneal meshes to keep in contact with viscera. METHODS: Two groups of 20 rats each were used. Polypropylene mesh was placed intraperitoneally in both groups adding hyaluronic acid/carboxymethylcellulose gel to the mesh in the study group. At 28 days, rats were sacrificed and evaluated using the Diamond adhesions scale. RESULTS: There were 20 rats in the study group and 19 rats in the control group (one postoperative death). Control group all had adhesions: six (32%) >50% of the mesh surface. In the study group one rat (5%) showed no adhesions, and in 14 (70%) <25% of the mesh surface. Severity showed strong and cohesive adhesions in 11 (58%) control group rats and thin, avascular adhesions in 11 (55%) study group rats. For density, in the study group there were two rats (10%) where adhesions were released spontaneously by separating the flap. There was mild to moderate traction in 16 (80%) study group rats and six (32%) control group rats. Adhesiolysis with scissors was used in the study group (5%) and in 13 (68%) control group rats (p <0.05). CONCLUSIONS: Hyaluronic acid/carboxymethylcellulose gel appears to be effective in reducing the percentage of adhesions to segments of intraperitoneal mesh implants.

Peritoneal tuberculosis. Report of seven cases.

BACKGROUND: Peritoneal tuberculosis (TB) is a misdiagnosed clinical entity of low frequency. Due to its rarity, it requires a high index of suspicion in clinical practice. Its incidence has been increasing in recent years. CLINICAL CASES: We present and analyze seven cases of peritoneal TB diagnosed and treated at four hospitals in Aguascalientes, Mexico during a 5-year period. Mean age of the patients was 47.5 +/- 6.5 years. There were six females and one male. Two patients had a history of treated lung TB. The most frequent clinical data were abdominal pain (six patients), ascites (four patients), and abdominal tumor (three patients). Symptom duration prior to surgery was 5.0 +/- 1.7 months. Abdominopelvic CT examinations revealed unilateral ovarian tumor in four patients, bilateral ovarian tumor in two patients, ascites in four patients, and retroperitoneal adenopathy in one patient. All female patients had elevated serum CA-125 levels with a median of 419 U/ml (range: 286-512 U/ml). All patients had a preoperative diagnosis of malignant tumor. All surgical procedures were elective and consisted of laparotomy with biopsy in three patients, laparotomy with salpingo-oophorectomy in two patients, and laparoscopy with biopsy in two patients. Diagnosis of TB was suspected in all cases during surgery. Mean hospital stay was 2 +/- 0.5 days. There was no postoperative morbidity or mortality. CONCLUSIONS: Peritoneal TB is uncommon. Diagnoses should be considered in all patients with ascites, adnexal tumors and elevated serum CA-125 levels.

Tuberculosis peritoneal: informe de siete casos / Peritoneal tuberculosis: report of seven cases

Introducción: La tuberculosis peritoneal es una entidad clínica con baja frecuencia de presentación y por mucho tiempo casi olvidada de la práctica clínica. Casos clínicos: Presentación y análisis de siete casos con diagnóstico de tuberculosis peritoneal, tratados en cuatro hospitales de la ciudad de Aguascalientes, en un periodo de cinco años, que presentaron las siguientes características: edad promedio de 47.5 ± 6.5 años; seis de ellos del sexo femenino y uno del masculino. Dos pacientes tenían el antecedente de tuberculosis pulmonar. Los datos clínicos más relevantes fueron dolor abdominal en seis, ascitis en cuatro y dolor abdominal en tres. El tiempo de evolución promedio de los síntomas fue de 5 ± 1.7 meses. Los hallazgos tomográficos identificados fueron tumor ovárico unilateral en cuatro y bilateral en dos, ascitis en cuatro y adenopatía retroperitoneal en uno. A los seis pacientes del sexo femenino se les encontró niveles elevados de CA125, con mediana de 419 U/ml (286 a 512 U/ml). Se sospechó neoplasia maligna en el preoperatorio en todos los casos, por lo que fueron operados en forma electiva. Se realizó laparotomía con biopsia en tres, laparotomía con salpingo-ooforectomía en dos y laparoscopia con biopsia en dos. Se sospechó tuberculosis peritoneal al momento de la cirugía en todos. El promedio de estancia hospitalaria fue de 2 ± 0.5 días. No se presentaron complicaciones ni muertes hospitalarias. Conclusiones: La tuberculosis peritoneal es una enfermedad rara que se presenta cada vez con mayor frecuencia. Debe considerarse el diagnóstico en pacientes jóvenes con tumor anexial, ascitis y elevación de CA125.

BACKGROUND: Peritoneal tuberculosis (TB) is a misdiagnosed clinical entity of low frequency. Due to its rarity, it requires a high index of suspicion in clinical practice. Its incidence has been increasing in recent years. CLINICAL CASES: We present and analyze seven cases of peritoneal TB diagnosed and treated at four hospitals in Aguascalientes, Mexico during a 5-year period. Mean age of the patients was 47.5 +/- 6.5 years. There were six females and one male. Two patients had a history of treated lung TB. The most frequent clinical data were abdominal pain (six patients), ascites (four patients), and abdominal tumor (three patients). Symptom duration prior to surgery was 5.0 +/- 1.7 months. Abdominopelvic CT examinations revealed unilateral ovarian tumor in four patients, bilateral ovarian tumor in two patients, ascites in four patients, and retroperitoneal adenopathy in one patient. All female patients had elevated serum CA-125 levels with a median of 419 U/ml (range: 286-512 U/ml). All patients had a preoperative diagnosis of malignant tumor. All surgical procedures were elective and consisted of laparotomy with biopsy in three patients, laparotomy with salpingo-oophorectomy in two patients, and laparoscopy with biopsy in two patients. Diagnosis of TB was suspected in all cases during surgery. Mean hospital stay was 2 +/- 0.5 days. There was no postoperative morbidity or mortality. CONCLUSIONS: Peritoneal TB is uncommon. Diagnoses should be considered in all patients with ascites, adnexal tumors and elevated serum CA-125 levels.

[Early diagnosis and risk factors associated with abdominal compartment syndrome]. / Detección temprana y factores de riesgo asociados al síndrome compartimental abdominal.

INTRODUCTION: Abdominal compartment syndrome (ACS) is a clinical entity that develops after sustained and uncontrolled intraabdominal hypertension (IAHT). The ACS is clinically characterized by a massively distended abdomen and respiratory, cardiovascular, neurologic, and renal dysfunction. OBJECTIVE: The goal of this study was to demonstrate the benefit of early diagnosis of intra-abdominal hypertension and ACS and to identify risk factors associated with mortality. MATERIAL AND METHODS: We used a prospective study that included all patients admitted to Hospital de Especialidades Miguel Hidalgo with known ACS risk factors between January 2002 and December 2003. All patients were submitted to systematic measurements of intra-abdominal pressure (IAP). Those patients with grade III-IV IAHT were treated with decompressive laparotomy. RESULTS: Included in the study were 32 patients (23 males and 9 females). Mean age was 45.0 +/- 18.34 years. Twenty three patients developed IAHT grade I-II (group I) and nine developed grade IIIIV (group II). All group II patients were treated with abdominal decompression. The most common clinical entities associated were closed abdominal trauma (28%), hernias (15%), intestinal occlusions: (12.5%), acute pancreatitis (9.4%) and mesenteric ischemia (6.3%). Grade III-IV IAHT was statistically associated with reoperation (p = 0.038), acidosis (p = 0.003), anuria (p < 0.001) and sustained arterial hypotension (p = 0.004). The significant variables associated to mortality were anuria (p = 0.024) and grade III-IV IAHTA (0.017). CONCLUSIONS: It is possible to make an early diagnosis of IAHT and ACS with an indirect measurement of IAP. The most important factors related to mortality are anuria and IAHT.