Angel Carrillo

La cirugía laparoscópica en España. Resultados de la encuesta nacional de la Sección de Cirugía Endoscópica de la Asociación Española de Cirujanos

Resumen Objetivo Conocer la opinion de los cirujanos miembros de la Asociacion Espanola de Cirujanos (AEC) sobre la cirugia laparoscopica (CL) y su implantacion en nuestros hospitales. Material y metodos Dos encuestas de opinion. Una remitida a todos los miembros de la AEC en abril de 2003. Incluia aspectos generales y situaciones clinicas. La otra se remitio a todos los servicios de cirugia del pais e incluia aspectos sobre dotacion e implantacion de la CL. Resultados Han contestado 106 servicios (40%) y 855 cirujanos (32,3%). Solo 209 (25%) cirujanos realizan procedimientos avanzados. El 49% de cirujanos creen que los resultados de la CL son mejores que los de la cirugia convencional y 324 (40%) creen que la CL acabara siendo una superespecialidad. La CL se considera de primera eleccion en el tratamiento de la colelitiasis (99%), reflujo gastroesofagico (RGE) (94%) y colecistitis aguda (81%). En otras afecciones como la hernia inguinal, las enfermedades del bazo, patologia benigna de colon, la obesidad y enfermedades suprarrenales se utilizaria en casos seleccionados. El cancer de colon, la apendicitis y la eventracion tienen una baja aceptacion como primera indicacion en la CL. El 59% de cirujanos considera que la CL no ha tenido el crecimiento esperado. Conclusiones La CL, en nuestro medio y para un amplio colectivo de cirujanos, es ampliamente aceptada para el tratamiento de la colelitiasis y el RGE. A pesar de que nuestros hospitales tienen medios tecnicos suficientes para realizar la CL avanzada, esta se practica por pocos cirujanos. Aspectos como la formacion en CL y la superespecializacion aun quedan por perfilar en un futuro.

Relationship between energy expenditure, nutritional status and clinical severity before starting enteral nutrition in critically ill children

The objective of the present study was to investigate the relationship between energy expenditure (EE), biochemical and anthropometric nutritional status and severity scales in critically ill children. We performed a prospective observational study in forty-six critically ill children. The following variables were recorded before starting nutrition: age, sex, diagnosis, weight, height, risk of mortality according to the Paediatric Risk Score of Mortality (PRISM), the Revised Paediatric Index of Mortality (PIM2) and the Paediatric Logistic Organ Dysfunction (PELOD) scales, laboratory parameters (albumin, total proteins, prealbumin, transferrin, retinol-binding protein, cholesterol and TAG, and nitrogen balance) and EE measured by indirect calorimetry. The results showed that there was no relationship between EE and clinical severity evaluated using the PRISM, PIM2 and PELOD scales or with the anthropometric nutritional status or biochemical alterations. Finally, it was concluded that neither nutritional status nor clinical severity is related to EE. Therefore, EE must be measured individually in each critically ill child using indirect calorimetry.

Análisis del Registro Nacional Español de la Cirugía Laparoscópica del Páncreas

Resumen Introduccion En el pasado, la experiencia de la cirugia laparoscopica del pancreas se mantenia limitada a experiencias individuales con un reducido nucleo de pacientes. El reciente estudio multicentrico europeo ha permitido conocer los limites y los resultados de la tecnica. En este trabajo se presenta el analisis de los resultados del Registro Nacional Espanol de la Cirugia Laparoscopica del Pancreas (RNEP). Material y metodos Se ha incluido a 132 pacientes con lesiones localizadas en el pancreas izquierdo: 42 tumores neuroendocrinos, 40 neoplasias quisticas, 24 quistes y seudoquistes, 8 tumores inflamatorios, 8 carcinomas ductales, 7 neoplasias papilares mucinosa, 1 carcinoma acinar, 2 tumores solidos seudopapilares. Resultados El indice de conversion fue del 9,7%. La tecnica de enucleacion se realizo tan solo en pacientes portadores de un insulinoma. La pancreatectomia distal con preservacion esplenica fue la utilizada con mas frecuencia. La mortalidad fue nula y, como morbilidad, la fistula pancreatica aparecio en el 16% de los casos. Conclusiones A pesar de que el numero de hospitales espanoles es limitado, los resultados obtenidos hacen esperar una mayor experiencia en un futuro proximo.

Cardiac arrest and resuscitation in the pediatric intensive care unit: a prospective multicenter multinational study.

OBJECTIVE The aim of the study was to analyze the mortality and neurological outcome factors of in-pediatric intensive care unit (in-PICU) cardiac arrest (CA) in a multicenter international study. PATIENTS AND METHODS It was a prospective observational multicenter study in Latin-American countries, Spain, Portugal, and Italy. A total of 250 children aged from 1 month to 18 years who suffered in-PICU CA were studied. Countries and patient-related variables, arrest life, support-related variables, procedures, and clinical and neurological status at hospital discharge according to the Pediatric Cerebral Performance Category (PCPC) scale were registered. The primary endpoint was survival at hospital discharge and neurological outcome at the same time was the secondary endpoint. Univariate and multivariate logistic regression analyses were performed. RESULTS Return of spontaneous circulation maintained longer than 20 min was achieved in 172 patients (69.1%) and 101 (40.4%) survived to hospital discharge. In the univariate analysis, oncohematologic diseases, inotropic infusion at the time of CA, sepsis and neurologic causes of CA, primary cardiac arrest, need of adrenaline, bicarbonate or volume expansion during resuscitation, and long duration of resuscitation were related with mortality. In the multivariate logistic regression analysis, factors related to mortality were hemato-oncologic illness and previous treatment with vasoactive drugs at the time of CA event, neurological etiology of CA, and cardiopulmonary resuscitation (CPR) duration for more than 10 min. One year after CA, neurological status was assessed in 65 patients; among them, 81.5% had mild disabilities or none. CONCLUSIONS Survival with good neurological outcome of CA in the PICU is improving. The most important prognostic indicator is the duration of resuscitation.

Postoperative neutrophil gelatinase-associated lipocalin predicts acute kidney injury after pediatric cardiac surgery*.

Objective: We investigated the temporal pattern and predictive value of neutrophil gelatinase–associated lipocalin for early identification of acute kidney injury in children undergoing cardiac surgery. Design: Prospective observational cohort study. Setting: One PICU in a tertiary medical center in Madrid, Spain. Patients: One hundred six children older than 15 days and younger than 16 years undergoing surgery for congenital cardiac lesions. Interventions: None. Measurements and Main Results: Urine samples were obtained before and at intervals after surgery. Acute kidney injury was defined according to pediatric Risk, Injury, Failure, Loss, and End-stage kidney disease criteria. The temporal pattern of both urine neutrophil gelatinase–associated lipocalin absolute concentration elevation and normalized to urine creatinine concentration was correlated with the development of acute kidney injury and other clinical outcomes. We evaluated the predictive ability of both urine neutrophil gelatinase–associated lipocalin and urine neutrophil gelatinase–associated lipocalin/creatinine by area under the curve, when added to a clinical predictive model. Data from 106 pediatric patients were analyzed. Acute kidney injury occurred in 42 patients (39.6%). Urine neutrophil gelatinase–associated lipocalin significantly increased in patients with acute kidney injury at 1, 3, and 15 hours postoperatively. Urine neutrophil gelatinase–associated lipocalin and urine neutrophil gelatinase–associated lipocalin/creatinine correlated with surgical variables and clinical outcomes. Acute kidney injury prediction improved when urine neutrophil gelatinase–associated lipocalin was added to a clinical model (area under the curve increased at 1 hr from 0.85 to 0.91 and at 3 hr to 0.92). Neither the urine neutrophil gelatinase–associated lipocalin nor the urine neutrophil gelatinase–associated lipocalin/creatinine values were significantly different between patients with prerenal and sustained acute kidney injury. Conclusions: Urine neutrophil gelatinase–associated lipocalin is a predictive biomarker for acute kidney injury after pediatric cardiac surgery, and it may permit earlier intervention that improves outcome of acute kidney injury. Urine neutrophil gelatinase–associated lipocalin normalized to urine creatinine improves the prediction of acute kidney injury severity but offers no advantage in acute kidney injury diagnosis.

Prediction of surgical site infection after colorectal surgery

BACKGROUND Surgical site infection (SSI) after colorectal surgery is a frequent complication associated with substantial morbidity. Our objective was to identify surgical predictors of SSI in patients undergoing colorectal surgery using a retrospective case-control design. MATERIAL AND METHODS Randomly selected patients from all those undergoing colorectal surgery (2007-2013). Cases were patients who developed SSI within 30 days. Controls were patients who did not develop SSI within 30 days. Patients undergoing multiple procedures during a single surgical intervention were excluded. SSI was diagnosed according to Centers for Disease Control and Prevention definitions. The main outcome measures were SSI, surgical variables, and cumulative survival (Kaplan-Meier method). Variables considered predictors were compared using log-rank test. RESULTS Of 911 patients undergoing colorectal surgery, 221 developed SSI (24.3%; 95% confidence interval, 24.0-24.6). On univariate analysis, significant risk factors for SSI were: female sex (P = .02), >72 hours preoperative stay (P = .04), open surgery (P = .08), incision class: contaminated and dirty (P = .001), and emergency procedures (P = .006). On multivariate analysis, significant independent predictors of SSI and survival were dirty surgery (hazard ratio [HR], 2.12; P = .015), contaminated surgery (HR, 1.74; P = .009), female sex (HR, 1.58; P = .003), open surgery, (HR, 1.51; P = .015) and >72 hours preoperative stay (HR, 1.48; P = .024). CONCLUSIONS Dirty or contaminated surgery, female sex, open surgery, and >72 hours preoperative stay were significant predictors of SSI.

The Development of Laparoscopic Surgery in Spain

Aim: To assess degree of development and level of acceptance of laparoscopic surgery in Spain. Method: A questionnaire was sent to all members of the Spanish Association of Surgeons in April 2003. It included 32 questions, 9 of which were general, and 23 referred to specific clinical situations, techniques, and standard practice. Results: Eight hundred and fifty-eight (33.1%) surgeons replied. Only 211 (25%) surgeons reported performing advanced laparoscopic procedures. Four hundred and twenty (49%) surgeons believed that the results obtained with laparoscopic surgery were better than those obtained with conventional surgery, and 325 (40%) surgeons believed that laparoscopy would become a superspecialty. Laparoscopic surgery was considered the method of choice in the treatment of gallbladder stones (99%), gastroesophageal reflux disease (94%), acute cholecystitis (81%), in selected cases of inguinal hernia repair, and in procedures to be performed in spleen and adrenals, benign colon disease, and obesity. Three hundred and ninety-eight (47%) surgeons considered laparoscopic surgery the preferred approach for colon cancer, 292 (34%) for appendicitis, and 155 (18%) for incisional hernia. Five hundred and five (59%) surgeons considered that the use of laparoscopic surgery had grown less than expected. Conclusions: The vast majority of surgeons advocated laparoscopic surgery for the treatment of gallbladder stones and gastroesophageal reflux disease. Although most hospitals had the appropriate technical facilities for performing advanced laparoscopic procedures, few surgeons actually did so.

Population pharmacokinetics of omeprazole in critically ill pediatric patients.

Background: To develop a population pharmacokinetic model for intravenous omeprazole in critically ill children. Methods: One hundred eighty-six omeprazole concentration-time data from 40 critically ill children were analyzed using the nonlinear mixed-effects approach with the nonlinear mixed-effects modeling software, version 7.2 software. Patients were randomized into 2 groups and received intravenous omeprazole at a dose of 0.5 or 1 mg/kg twice daily. Blood samples were drawn at 0.5, 2, 6, 12, 24, and 48 hours after the first infusion. Results: The pharmacokinetic profile was best described by a 2-compartment model with a first-order elimination process. Between-patient variability could only be associated with plasma clearance (CL). The typical values for plasma CL were 24.9 L·h−1·70 kg−1 (10.08%), with a distributional clearance of 53.9 L·h−1·70 kg−1 (11.00%) and central and peripheral compartment distribution volumes of 4.23 L/70 kg (19.62%) and 674 L/70 kg (0.89%), respectively. Allometric size models seemed to predict changes adequately in all the pharmacokinetic parameters. High values of between-patient variability of CL [75.50% (2.60%)] and residual variability [130.0% (5.26%)] were still found in the final model. Model-based simulations suggested that the most suitable dose was 1 mg/kg because this yielded similar exposure (defined by the area under the concentration-time curve) to that obtained in adults after a 20-mg dose of omeprazole intravenously. Conclusions: An allometric size model allows changes to be predicted in all the pharmacokinetic parameters, making dose adjustment by body weight important to achieve the most effective omeprazole exposure. This is the first step toward a population pharmacokinetic study, including more data to develop a predictable model to be used during therapeutic drug monitoring.

Multichannel intraluminal impedance to study gastroesophageal reflux in mechanically ventilated children in the first 48 h after PICU admission

OBJECTIVE The aim of this study was to determine the incidence, characteristics, related factors, and clinical implications of gastroesophageal reflux (GER) in critically ill children using esophageal pH monitoring and multichannel intraluminal impedance. METHODS A prospective observational clinical study was performed including 36 non-enterally fed critically ill children with mechanical ventilation, aged 1 mo to 7 y, in the first 48 h after admission in the pediatric intensive care unit (PICU). Esophageal pH monitoring and multichannel intraluminal impedance were used. RESULTS Multichannel intraluminal impedance detected 352 episodes of GER (20.1% acid, 53.8% weak acid, 26% alkaline), whereas pH monitoring detected 171 episodes (100% acid). There were no differences in the type of reflux according to age and no differences in the number or type of reflux according to the administration of inotropic or sedatives drugs or the duration of mechanical ventilation. Patients treated with vecuronium had fewer episodes of GER than those without muscle relaxant drugs. CONCLUSIONS The incidence of GER in non-enterally fed critically ill children with mechanical ventilation is high in the first 48 h after admission to the PICU. Multichannel intraluminal impedance is more sensitive than pH monitoring for establishing the diagnosis of GER because the refluxate is alkaline or weak acid in the majority of episodes. Patients who received muscle relaxants had a lower frequency of GER.

Laparoscopia colorrectal en Canarias. Estudio multicéntrico en 144 pacientes

Resumen Introduccion Analizar los resultados a corto plazo de la cirugia laparoscopica colorrectal (CLCR) en Canarias. Material y metodos Enviamos una encuesta a los hospitales que realizan esta actividad y obtuvimos retrospectivamente datos sobre las variables demograficas, peroperatorias y anatomopatologicas de 144 pacientes intervenidos de CLCR desde mayo de 1993 hasta mayo de 2003. Resultados Se intervino quirurgicamente a 65 varones y 79 mujeres, 68 (47,2%) en los ultimos 16 meses del periodo estudiado. Se realizaron 126 procedimientos colonicos y 18 rectales. El procedimiento mas realizado fue la sigmoidectomia, con 85 casos (59%). El adenocarcinoma, con 73 casos (50%), fue el diagnostico mas habitual, y la diverticulosis, con 36 casos (25%), fue el segundo en frecuencia. Los valores medios de las variables estudiadas fueron: indice de masa corporal medio, 27,3 (rango, 22-35); tiempo quirurgico, 175 min (rango, 60-255), y perdidas hematicas, 183,6 ml (rango, 50-500). La peristalsis se presento a las 45 h, la dieta oral se inicio a las 67 h y la estancia hospitalaria media global fue de 7,8 dias (rango, 3-30). Los pacientes que presentaban complicaciones tuvieron una estancia significativamente mayor (14,5 frente a 6,4 dias; p No se registro ninguna muerte. La tasa de morbilidad global fue del 28%. La complicacion precoz mas frecuente fue la infeccion de la herida en 9 ocasiones (6,2%). Se detectaron 5 casos de fuga anastomotica (3,4%). Conclusiones La CLCR se ha mostrado como una tecnica segura y eficaz, y su uso se ha incrementado en todos los centros consultados en el ultimo ano. La aparicion de complicaciones posquirurgicas fue el factor que mas influyo en la estancia hospitalaria.