Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital.

BACKGROUND: Up to 25% of patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with a high death rate. To improve outcomes, patients may require interventional measures including surgical procedures. Multidisciplinary approach and best practice guidelines are important to decrease mortality. METHODS: We have conducted a retrospective analysis from a prospectively maintained database in a low-volume hospital. A total of 1075 patients were attended for acute pancreatitis over a ten-year period. We have analysed 44 patients meeting the criteria for severe acute pancreatitis and for intensive care unit (ICU) admittance. Demographics and clinical data were analysed. Patients were treated according to international guidelines and a multidisciplinary flowchart for acute pancreatitis and a step-up approach for pancreatic necrosis. RESULTS: Forty-four patients were admitted to the ICU due to severe acute pancreatitis. Twenty-five patients needed percutaneous drainage of peri-pancreatic or abdominal fluid collections or cholecystitis. Eight patients underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and biliary sepsis or pancreatic leakage, and one patient received endoscopic trans-gastric endoscopic prosthesis for pancreatic necrosis. Sixteen patients underwent surgery: six patients for septic abdomen, four patients for pancreatic necrosis and two patients due to abdominal compartment syndrome. Four patients had a combination of surgical procedures for pancreatic necrosis and for abdominal compartment syndrome. Overall mortality was 9.1%. CONCLUSION: Severe acute pancreatitis represents a complex pathology that requires a multidisciplinary approach. Establishing best practice treatments and evidence-based guidelines for severe acute pancreatitis may improve outcomes in low-volume hospitals.

How we do it: down to up posterior components separation.

BACKGROUND: Posterior component separation with transversus abdominis release technique is increasingly being used for abdominal wall reconstruction in complex abdominal wall repair. The main purpose of this study is to present a modification of the surgical technique originally described that facilitates the surgical procedure and offers additional advantages. METHODS: Based on the knowledge of the anatomy of the retromuscular space and the preperitoneal aerolar tissue distribution, we start the incision on the posterior rectus sheath from the arcuate line in a down to up direction. The posterior rectus sheath is incised 0,5-1 cm medial to the linea semilunaris and cut longitudinally as far as the fibers of transversus abdominis muscle that are divided in the superior part of the abdomen. It is also possible to avoid cutting the fibers of this muscle if we incise the posterior rectus sheath in an oblique direction to the midline from the umbilical area. Since 2012 to 2016, 69 consecutive patients with down to up TAR have been prospectively followed. Main outcome measures included demographics, perioperative details, wound complications, and recurrences. RESULTS: Between 2012 and 2016, we have operated 69 patients with down to up TAR technique. Mean operative time was 251 (range 65-566) minutes. Mean hospital stay was 9,8 (2-98) days. 10 patients presented surgical site events (14,5%): 6 patients had superficial site infection, 3 deep and 1 organ space. During follow-up, 3 patients (4,3%) presented incisional hernia recurrence. CONCLUSIONS: This novel modification allows a simpler dissection of the preperitoneal retromuscular space and makes the TAR technique easier to perform. It also enables to incise only the insertion of the transversalis fascia cranially.

Incremento de la densidad mineral ósea en pacientes con hiperparatiroidismo terciario tras paratiroidectomía total y autotrasplante de glándula paratiroides / Increased bone mineral density in patients with tertiary hyperparathyroidism after total parathyroidectomy and autotransplantation of the parathyroid gland

Introducción En los pacientes trasplantados renales con hiperparatiroidismo terciario se observan alteraciones del metabolismo óseo así como un descenso de la densidad mineral ósea. El objetivo de este trabajo fue analizar el incremento de la densidad mineral ósea, así como los resultados analíticos tras la paratiroidectomía total y autotrasplante en pacientes trasplantados renales con hiperparatiroidismo terciario. Material y métodos Estudio retrospectivo en el que se analizaron los valores de la densidad mineral ósea a nivel femoral y lumbar, así como los niveles séricos de calcio, fósforo, hormona paratiroidea (PTH) y fosfatasa alcalina en 13 pacientes trasplantados renales con hiperparatiroidismo terciario antes y después de la realización de paratiroidectomía total y autotrasplante de glándula paratiroides. Resultados La paratiroidectomía se asoció a un incremento de la densidad mineral ósea a nivel femoral y a nivel lumbar. El incremento de la densidad mineral ósea a nivel lumbar fue de 8,6±6,7% y de 4±16,1% a nivel femoral. El descenso de calcio tras la paratiroidectomía fue de 2,8mg/dl (IC 95%:1,9-4). El descenso de PTH fue de 172pg/mL (IC 95%:98-354) y el descenso de fosfatasa alcalina fue de 229 U/l (IC 95%:70-371).Conclusiones La paratiroidectomía total y el autotrasplante de glándula paratiroides en pacientes trasplantados renales con hiperparatiroidismo terciario incrementa la densidad mineral ósea. Asimismo, se observa una normalización de las cifras de calcio, PTH y fosfatasa alcalina a largo plazo (AU)

Introduction Changes in bone metabolism and bone mineral density are observed in renal transplant patients with tertiary hyperparathyroidism. The objective of this work was to analyse the increase in bone mineral density, as well the laboratory results, after total parathyroidectomy and autotransplantation in renal transplant patients with tertiary hyperparathyroidism. Material and methods A retrospective study was conducted in which the bone mineral density values at femoral and lumbar level were analysed, together with the serum levels of calcium, phosphorous, parathyroid hormone (PTH), and alkaline phosphatase in 13 renal transplant patients with tertiary hyperparathyroidism before and after total parathyroidectomy and autotransplantation of the parathyroid glands. Results Parathyroidectomy is associated with an increase in bone mineral density at femoral and lumbar level, with an increase of 8.6±6.7% at lumbar level, and 4±16.1% at femoral level. The decrease in calcium after the parathyroidectomy was 2.8mg/dL (95% CI; 1.9-4). The decrease in PTH was 172pg/mL (95% CI; 98-354) and the decrease in alkaline phosphatase was 229 U/L (95% CI; 70-371).Conclusions Total parathyroidectomy and autotransplantation of the parathyroid glands in renal transplant patients with tertiary hyperparathyroidism increases the bone mineral density. Furthermore, the calcium, PTH and alkaline phosphatase returned to normal in the long-term (AU)

[Increased bone mineral density in patients with tertiary hyperparathyroidism after total parathyroidectomy and autotransplantation of the parathyroid gland]. / Incremento de la densidad mineral ósea en pacientes con hiperparatiroidismo terciario tras paratiroidectomía total y autotrasplante de glándula paratiroides.

INTRODUCTION: Changes in bone metabolism and bone mineral density are observed in renal transplant patients with tertiary hyperparathyroidism. The objective of this work was to analyse the increase in bone mineral density, as well the laboratory results, after total parathyroidectomy and autotransplantation in renal transplant patients with tertiary hyperparathyroidism. MATERIAL AND METHODS: A retrospective study was conducted in which the bone mineral density values at femoral and lumbar level were analysed, together with the serum levels of calcium, phosphorous, parathyroid hormone (PTH), and alkaline phosphatase in 13 renal transplant patients with tertiary hyperparathyroidism before and after total parathyroidectomy and autotransplantation of the parathyroid glands. RESULTS: Parathyroidectomy is associated with an increase in bone mineral density at femoral and lumbar level, with an increase of 8.6 ± 6.7% at lumbar level, and 4 ± 16.1% at femoral level. The decrease in calcium after the parathyroidectomy was 2.8 mg/dL (95% CI; 1.9-4). The decrease in PTH was 172 pg/mL (95% CI; 98-354) and the decrease in alkaline phosphatase was 229 U/L (95% CI; 70-371). CONCLUSIONS: Total parathyroidectomy and autotransplantation of the parathyroid glands in renal transplant patients with tertiary hyperparathyroidism increases the bone mineral density. Furthermore, the calcium, PTH and alkaline phosphatase returned to normal in the long-term.

Toracotomía de emergencia: una evaluación crítica de la técnica / Emergency room thoracotomy: a critical assessment of the technique

Objetivo. Análisis de la bibliografía y del estado actual de la toracotomía de emergencia. Obtención de los datos. Revisión de la bibliografía, desde las primeras experiencias en su utilización hasta los estudios más recientes en el área. Resultados. Desde su introducción en la década de los sesenta, su uso se ha extendido de forma considerable y forma parte de los protocolos de reanimación cardiopulmonar en todos los centros de politraumatizados norteamericanos. En 42 series analizadas sobre toracotomía de emergencia se hallaron 7.035 procedimientos, de los cuales sobrevivieron 551 (7,8 por ciento). Según el mecanismo de lesión, se realizaron 4.482 toracotomías por lesiones penetrantes, de las que sobrevivieron 500 pacientes (11,1 por ciento), y 2.193 toracotomías por lesiones contusas, de las que sobrevivieron 35 (1,6 por ciento). En las 14 series que comunicaban el pronóstico neurológico se registraron 4.520 pacientes con 226 sobrevivientes (5 por ciento), de los que 34 (15 por ciento) presentaban secuelas neurológicas. Además, de 1.165 pacientes con lesiones cardíacas penetrantes hubo 363 (31,1 por ciento) supervivientes. Por último, de 4 series sobre población pediátrica se hallaron 142 pacientes, de los cuales 57 fueron por lesiones penetrantes, con una tasa de supervivencia del 12,2 por ciento. Conclusión. Es una técnica muy útil para el cirujano, que debe emplearse de forma prudente y juiciosa, y con indicaciones muy estrictas, ya que su uso de forma indiscriminada lleva asociada una elevada tasa de mortalidad y morbilidad. A pesar de estos riesgos, es una maniobra útil y con frecuencia la última esperanza para muchos pacientes que llegan a los servicios de urgencias en condiciones extremas, y debe practicarse por cirujanos apropiadamente entrenados en esta técnica (AU)