Estela Membrilla

Prophylactic synthetic mesh can be safely used to close emergency laparotomies, even in peritonitis

BACKGROUND This study was conducted to determine the efficacy and safety of the use of a partially absorbable large pore synthetic prophylactic mesh in emergent midline laparotomies for the prevention of evisceration and incisional hernia. METHODS Retrospective analysis of all patients who underwent an emergency midline laparotomy between January of 2009 and July of 2010 was performed. Patients with complicated ventral hernia repair, postoperative death, and lack of follow-up were excluded. RESULTS A total of 266 patients were included. Laparotomies were closed with a running suture of slow-reabsorbable material in 190 patients (Group S), and 50 patients within this group (26.3%) received additional retention sutures. In 76 patients (Group M), an additional partially absorbable lightweight mesh was placed in the Supra-aponeurotic space. Both groups presented similar complication rates (71.1% Group S vs 80.3% Group M, P = .97). There were no differences regarding surgical-site infection rates (17.9% Group S vs 26.3% Group M; P = .13) or postoperative mortality (13.7% Group S vs 18.3% Group M; P = .346). A total of 150 patients completed the follow-up (99 Group S; 51 Group M) at a mean time of 16.7 months. During follow-up, 36 cases of incisional hernia (24%) were diagnosed: 33 (33%) in Group S, whereas there were only three cases (5.9%) in Group M (P = .0001). Mesh removal for chronic infection was not required in any case. CONCLUSION The use of a partially absorbable, lightweight large pore prophylactic mesh in the closure of emergency midline laparotomies is feasible for the prevention of incisional hernia without adding a substantial rate of morbidity to the procedure, even if high contamination or infections are present.

Preoperative risk factors for mortality after relaparotomy: analysis of 254 patients

IntroductionThe aim of this work was to analyze preoperative mortality risk factors after relaparotomy for abdominal surgery in a unit of General Surgery at a University Hospital.MethodsA total of 314 relaparotomies in 254 patients were performed between February 2004 and February 2008. We analyzed data about past medical history, first operation, as well as clinical and biochemical parameters previous to reoperation.ResultsIndications for relaparotomy were peritonitis, bleeding, abscess, exploratory laparotomy, and evisceration. Overall mortality was 22%. Mortality of the patients with a single relaparotomy was 20% vs. 44% if they were reoperated upon twice. Mortality was associated with age, past history of cardiovascular disease, active neoplasm, previous treatment with platelet anti-aggregant drugs, first surgery American Society of Anesthesia score, and the presence of an anastomosis. Preoperative data associated with mortality were the number of systemic inflammatory response syndrome criteria, suture dehiscense, ileus, positive blood cultures, mechanical ventilation, artificial nutrition, antibiotics or vasoactive drugs, tachycardia, and abnormal body temperature. High white blood cell count or bilirrubin levels and low albumin or prothrombin time were also associated with mortality. Multivariate logistic regression analysis isolated age (P = 0.02), abnormal body temperature (P = 0.02), and the need of mechanical ventilation (P = 0.004) as independent preoperative variables predictive for mortality after relaparotomy.ConclusionsAdvanced age, the presence of either fever or hypothermia, and the need of mechanical ventilation are preoperative risk factors associated with mortality after relaparotomy and should be considered when planning reintervention.

Resultados de un proyecto multidisciplinar y multifocal para la disminución de la bacteriemia causada por catéter venoso central, en pacientes no críticos, en un hospital universitario

OBJECTIVE To evaluate a multidisciplinary and multifocal intervention in order to reduce catheter related bloodstream infections (CRBI), based on previously identified risk factors in non-critical patients. METHODS A pre-post-intervention study, 2004-2006. POPULATION patients with a central venous catheter (CVC). The primary endpoint was the CRBI. Other studied variables were patient characteristics, insertion, maintenance and removal of the catheter. The intervention consisted of baseline knowledge and identifying risk factors. In a second period, there was specific training on these identified risk factors and communication of the results, monitoring and evaluation of the CVC inserted. RESULTS We analysed 175 and 200 CVC, respectively. The incidence of CRBI was 15.4% during the pre-intervention and 4.0% in the post-intervention period (P<.001). The incidence of BRC by CVC days in the first group was 8.8 infections 1.000 days of CVC and the second 2,3 (P=.0009). The multivariate analysis found an increased risk of CRBI during the first period (OR 4.32; 95% CI: 1.81-10.29) and the use of total parenteral nutrition (OR: 2.37; 95% CI: 1.10-5. 12). CONCLUSION The application of specific measures directed at all non-critical patients in the entire hospital and involving a large number of professionals has achieved a decrease incidence of 73.9% of CRBI. An acceptable incidence of CRBI was obtained, and, with the completion of the project together with a new awareness, the situation will continue to improve.

Tratamiento quirúrgico de la úlcera péptica perforada: comparación entre los abordajes laparoscópico y abierto

OBJECTIVE To analyse the outcomes of laparoscopic versus open repair for perforated peptic ulcers (PPU). METHODS All patients undergoing PPU repair between January 2002 and March 2012 were included in the study. Demographic characteristics, operation time, complications, and length of hospital stay were evaluated. RESULTS Two hundred and twelve patients (median age, 49 years) were included, 60 in the laparoscopic group and 52 in the open group. Patients operated laparoscopically were significantly younger and had a higher consumption of tobacco, alcohol and cannabis. Median acute symptoms time was shorter in the laparoscopic group (6h) compared to the open group (12h; P=.025) Symptoms time was shorter in the laparoscopic group. Median operating time was significantly longer in the laparoscopic group (104.5min vs. 76min, P=.025). The percentage of conversion to open repair was 25%. There was no difference in morbidity between 2 groups, but there were 3 deaths in the open group. Median hospital stay was significantly shorter in patients treated laparoscopically when compared with the open group (6 days vs. 8 days; P=.041). CONCLUSION Laparoscopic and open repair are equally safe in the management of PPU. A shorter hospital stay can be achieved in the laparoscopic group.

Resultados del abordaje laparoscópico en el tratamiento de la obstrucción aguda del intestino delgado por adherencias y hernias internas

INTRODUCTION Laparotomy is the standard approach for the surgical treatment of acute small bowel obstruction (ASBO). PATIENTS AND METHODS From February 2007 to May 2012 we prospectively recorded all patients operated by laparoscopy in our hospital because of ASBO due to adhesions (27 cases) and/or internal hernia (6 cases). A preoperative abdominal CT was performed in all cases. Patients suffering from peritonitis and/or sepsis were excluded from the laparoscopic approach. It was decided to convert to laparotomy if intestinal resection was required. RESULTS The mean age of the 33 patients who underwent surgery was 61.1 ± 17.6 years. 64% had previous history of abdominal surgery. 72% of the cases were operated by surgeons highly skilled in laparoscopy. Conversion rate was 21%. Operative time and postoperative length of stay were 83 ± 44 min. and 7.8 ± 11.2 days, respectively. Operative time (72 ± 30 vs 123 ± 63 min.), tolerance to oral intake (1.8 ± 0.9 vs 5.7 ± 3.3 days) and length of postoperative stay (4.7 ± 2.5 vs 19.4 ± 21 days) were significantly lower in the laparoscopy group compared with the conversion group, although converted patients had greater clinical severity (2 bowel resections). There were two severe complications (Clavien-Dindo III and V) in the conversion group. CONCLUSIONS In selected cases of ASBO caused by adhesions and internal hernias and when performed by surgeons highly skilled in laparoscopy, a laparoscopic approach has a high probability of success (low conversion rate, short hospital length of stay and low morbidity); its use would be fully justified in these cases.

Mastopatía diabética en diabetes mellitus tipo 2

La mastopatia diabetica es una entidad muy poco conocida y, por ello, poco descrita que puede confundirse facilmente con carcinoma mamario. Ha sido descrita principalmente en pacientes con diabetes mellitus tipo 1 y, en mucho menor medida, otras endocrinopatias. En este articulo se muestra un caso clinico en el que la mastopatia diabetica se encuentra asociada a diabetes mellitus tipo 2 y presenta una evolucion muy rapida en muy poco tiempo. El gran desconocimiento de esta entidad puede llevar a multitud de actuaciones clinicas equivocas. Al no reconocer histologicamente la lesion y carecer de datos clinicos de sospecha, es posible emitir un diagnostico negativo de neoplasia. se puede juzgar de erronea la toma de muestras y requerir una nueva prueba innecesaria. Unicamente sospechandola se puede llegar a un diagnostico correcto y a la actuacion clinica adecuada. Los resultados de las pruebas diagnosticas son inespecificos, y la biopsia con aguja gruesa es la clave diagnostica.

Celulitis necrosante urogenital y de pared abdominal como presentación de un carcinoma escamoso de uretra

Varón de 52 años, con antecedentes de esquizofrenia, consultó por una supuración escrotal de 2 semanas de evolución y ú lcera peniana. Referı́a dolor local y abdominal de moderada intensidad y pérdida de peso en los ú ltimos meses. Se encontraba consciente y orientado, normotenso, afebril y eupneico, con taquicardia a 107 lpm. La exploración fı́sica reveló eritema y edema en hipogastrio y fosas ilı́acas, que se extendı́a hasta epigastrio y regiones lumbares. La palpación resultaba muy dolorosa, con fluctuación y crepitación evidentes. Presentaba edema escrotal, con testes La aponeurosis se exponı́a en varios puntos, mostrando un aspecto nacarado sano y mú sculo recto anterior indemne que descartaban fascitis necrosante profunda y miositis. Se confirmó la integridad del peritoneo. Se tomaron muestras para cultivo y biopsia de la lesión en uretra esponjosa, que presentaba un borde indurado. Se realizaron varias contraaberturas cutáneas en pared abdominal y escroto, reavivando en este los bordes de las heridas, y se colocaron drenajes de Penrose (fig. 1B). Se instauró antibioticoterapia empı́rica con imipenem i.v. c i r e s p . 2 0 1 1 ; 8 9 ( 1 0 ) : 6 8 2 – 6 9 3 684