Juan José González

Clinical course, treatment, and multivariate analysis of risk factors for pyogenic liver abscess.

BACKGROUND Pyogenic liver abscess is a threatening condition. The purpose of this study was to audit the clinical behavior and to analyze the risk factors. METHODS One hundred and thirty-three patients treated in five hospitals during the years 1985 to 1997 were studied. By univariate and multivariate analysis we tried to identify any risk factor associated with complicated clinical course and complicated-related clinical course, and with hospital mortality. RESULTS Sixty-three patients (47%) were subjected to a percutaneous drainage, 45 (34%) were treated by open surgical drainage, and the remaining 25 cases (19%) received antibiotic therapy alone. Prognostic variables for a complicated clinical course were the presence of shock, low hemoglobin level, elevated prothrombin time, and polymicrobial infection. Shock, distress, low hemoglobin level, increased creatinine, and positive blood culture were significant predictors of a complicated-related clinical course. Concerning mortality, a biliary origin, shock, multiple abscesses, low hemoglobin level, and high concentration of blood urea nitrogen were independent predictors. CONCLUSIONS Treatment of pyogenic liver abscesses should be tailored to each patient, however, the majority of them can be successfully treated with antibiotics and percutaneous methods. Those with signs of organ failure or septicemia should preferably be managed in the intensive care unit.

Single and Multiple Pyogenic Liver Abscesses: Etiology, Clinical Course, and Outcome

Background: Pyogenic liver abscesses are uncommon but they still carry a high mortality rate when encountered. This study was undertaken to evaluate the differences in the clinical behaviour of patients with single and multiple abscesses. Methods: From January 1985 to December 1997, 133 patients with this disease were treated in the surgical departments of five hospitals, 97 had a single abscess and 36 had multiple abscesses. Clinical features, methods of treatment, and outcome were assessed and compared in both types of abscesses. Results: A biliary origin from ascending cholangitis was most frequently found in multiple abscesses (p = 0.007). Mean age and duration of symptoms were higher in multiple lesions (p = 0.03 and p = 0.001). High levels of alkaline phosphatase were more frequently seen in multiple abscesses than in solitary ones (p = 0.02). They were both most frequently located on the right side. Antibiotic therapy alone was most frequently used in multiple abscesses (p = 0.01). Mortality rate was also higher in this type of patients (p = 0.01). The abscess-related morbidity rate was higher in multiple lesions as well but the statistical difference was not significant. Conclusions: These results suggest that multiple liver abscesses comprise a disease of biliary origin, higher age, longer symptomatic periods, and also higher mortality rate than in single abscess.

Glucagonoma syndrome: a case report

IntroductionGlucagonoma syndrome is a rare paraneoplastic phenomenon, with an estimated incidence of one in 20 million, characterized by necrolytic migratory erythema, hyperglucagonemia, diabetes mellitus, anemia, weight loss, glossitis, cheilitis, steatorrhea, diarrhea, venous thrombosis and neuropsychiatric disturbances in the setting of a glucagon-producing alpha-cell tumor of the pancreas. Necrolytic migratory erythema is the presenting manifestation in the majority of cases, so its early suspicion and correct diagnosis is a key factor in the management of the patient.Case presentationWe present the case of a 70-year-old Caucasian woman with glucagonoma syndrome due to an alpha-cell tumor located in the tail of the pancreas, successfully treated with surgical resection.ConclusionClinicians should be aware of the unusual initial manifestations of glucagonoma. Early diagnosis allows complete surgical resection of the neoplasm and provides the only chance of a cure.

Pyogenic liver abscesses: a comparison of older and younger patients.

BACKGROUND Pyogenic liver abscess is a life-threatening disease. Few studies have specifically explored the way in which the clinical features and management of elderly patients with pyogenic liver abscess differ from those of younger individuals. METHODS A retrospective study was undertaken to evaluate whether older patients with pyogenic liver abscess have distinctive presenting features or whether their management and outcome differ from that of younger patients. A total of 133 patients with liver abscess treated in five hospitals during 13 years comprised two groups: 78 patients aged 60 years or above (older group) and 55 patients below age 60 years (younger group). Clinical features, laboratory data, imaging and microbiological findings, management and outcome were determined in each group. RESULTS The older group contained more patients with associated diseases (p=0.03), nausea and vomiting at presentation (p=0.02), higher APACHE II (Acute Physiological and Chronic Health Evaluation II scale) score (p<0.001) and blood urea nitrogen (p<0.001) and serum creatinine levels (p=0.002). Multiple abscess (p=0.05) and bilobar (p=0.03) abscess were also commoner in this group. By contrast, in the younger group men predominated (p=0.01), and there was a higher overall complication rate (p=0.05).Time to diagnosis, hospital mortality rate and other variables analysed were similar in both groups. DISCUSSION Elderly patients with pyogenic liver abscess have some subtle differences in clinical and laboratory presentation, but these do not appear to delay diagnosis. Active management is tolerated well, with a lower morbidity rate than in younger patients and no difference in the mortality rate.

Emergency surgery in chronic intestinal pseudo-obstruction due to mitochondrial neurogastrointestinal encephalomyopathy: case reports

Chronic intestinal pseudo-obstruction (CIPO) is a syndrome characterized by recurrent clinical episodes of intestinal obstruction in the absence of any mechanical cause occluding the gut. There are multiple causes related to this rare syndrome. Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is one of the causes related to primary CIPO. MNGIE is caused by mutations in the gene encoding thymidine phosphorylase. These mutations lead to an accumulation of thymidine and deoxyuridine in blood and tissues of these patients. Toxic levels of these nucleosides induce mitochondrial DNA abnormalities leading to an abnormal intestinal motility. Herein, we described two rare cases of MNGIE syndrome associated with CIPO, which needed surgical treatment for gastrointestinal complications. In one patient, intra-abdominal hypertension and compartment syndrome generated as a result of the colonic distension forced to perform emergency surgery. In the other patient, a perforated duodenal diverticulum was the cause that forced to perform surgery. There is not a definitive treatment for MNGIE syndrome and survival does not exceed 40 years of age. Surgery only should be considered in some selected patients.Chronic intestinal pseudo-obstruction (CIPO) is a syndrome characterized by recurrent clinical episodes of intestinal obstruction in the absence of any mechanical cause occluding the gut. There are multiple causes related to this rare syndrome. Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is one of the causes related to primary CIPO. MNGIE is caused by mutations in the gene encoding thymidine phosphorylase. These mutations lead to an accumulation of thymidine and deoxyuridine in blood and tissues of these patients. Toxic levels of these nucleosides induce mitochondrial DNA abnormalities leading to an abnormal intestinal motility. Herein, we described two rare cases of MNGIE syndrome associated with CIPO, which needed surgical treatment for gastrointestinal complications. In one patient, intra-abdominal hypertension and compartment syndrome generated as a result of the colonic distension forced to perform emergency surgery. In the other patient, a perforated duodenal diverticulum was the cause that forced to perform surgery. There is not a definitive treatment for MNGIE syndrome and survival does not exceed 40 years of age. Surgery only should be considered in some selected patients.

Mejora la incorporación de un simulador virtual las capacidades en cirugía endoscópica adquiridas con simuladores inanimados

INTRODUCTION The carrying out of training courses in surgical endoscopy for surgeons in training centres, is becoming more common. In addition to adequately planning activities, simulation systems are used to improve learning and monitor progression. Inanimate models and virtual reality programs increase psychomotor skills and assessment of performance. In this work we tried to improve our training program, basically in training boxes by introducing a virtual simulator. MATERIAL AND METHOD Seventeen surgical residents, with a basic training were chosen as the control group. Two additional groups were established, group A: with 6 hours of training with inanimate simulator. Group B: the same training system plus 4h of practice with LapSim. Exercises in the endotrainer and virtual simulator with moving-replacing objects, cutting and suturing-knotting were planned. End-point was time (mean with 95% confidence interval) in every exercise in box trainer, before and after the training period. RESULTS Movement exercises: Time in control group was 223.6s, A:103.7s, and B:89.9s (Control vs. A, P < 0.05). Cutting exercises: Time in control group was 317.7s, group A: 232.8s and in the B: 163.6s, (Control vs. B, P < 0.05). In the suture/knot exercise everyone was able to carry out a stitch after the training period. Time in control group was 518.4s, in group A: 309.4s, P < 0.05, and in B:189.5s (Control vs. A, P < 0.05). CONCLUSIONS Training in inanimate boxes was able to improve the skills of students, particularly for moving and suture/knots. The incorporation of a virtual simulator increased the learning capabilities, mainly in cutting exercises.

Using Automatic Dependent Surveillance-Broadcast Data for Monitoring Aircraft Altimetry System Error

*† ‡ Altimetry System Error (ASE) is a measure of the height-keeping performance of an aircraft. In airspace where the Reduced Vertical Separation Minimum (RVSM) is applied, the importance of accurate aircraft height-keeping is magnified. ASE is not detectible in routine operations; specialized measurement equipment is necessary to independently measure the errors. To be eligible for RVSM operations, operators must adhere to the height-keeping performance monitoring requirements established for the airspace in which operations are to be conducted. The Federal Aviation Administration (FAA) developed a process to monitor the height-keeping performance of aircraft for RVSM operations. The International Civil Aviation Organization (ICAO) has established long-term minimum monitoring requirements to be used by the regions where the RVSM is implemented which go into effect in November 2010. This paper progresses the work which considers the role of a Next Generation Air Transportation System (NextGen) technology, Automatic Dependent Surveillance–Broadcast (ADS-B), to monitor the height-keeping performance of aircraft. This paper contains results from test flights conducted at the FAA Technical Center to compare aircraft geometric height obtained from three sources; ADS-B, EGMU, and an onboard independent GPS reference receiver. In addition, this paper presents initial results from ADS-B data collected from real airspace operations. The ADS-B data made available for this work result from a cooperative research agreement between the FAA and Airservices Australia The results of this study will be used to determine the quality control processes needed for monitoring aircraft ASE using ADS-B geometric height data.

Abscesos hepáticos piógenos. Importancia de la existencia de gas

Resumen Introduccion Nuestro objetivo fue analizar el comportamiento clinico de los pacientes con abscesos hepaticos piogenos formadores de gas y, ademas, determinar si existia alguna diferencia en relacion con los enfermos con abscesos sin produccion de gas Pacientes y metodos Mediante un estudio multicentrico se han revisado, retrospectivamente, las historias clinicas de 126 pacientes diagnosticados de abscesos hepaticos piogenos, durante un periodo de 13 anos. Los enfermos fueron divididos en dos grupos: 25 con visualizacion radiologica de gas en el absceso (grupo 1) y 101 sin formacion de gas (grupo 2). Los aspectos estudiados y comparados entre ambos grupos fueron: caracteristicas clinicas, biologicas y bacteriologicas, morfologia y topografia lesional, tratamiento y evolucion clinica Resultados La presentacion clinica de los pacientes del grupo 1 se caracterizo por la mayor frecuencia de perdida de peso (60 frente al 37,6%; p = 0,03), shock (16 frente al 4%; p = 0,04) y derrame pleural (48 frente al 26%; p = 0,03).Tambien en dicho grupo hubo mayor tasa de complicaciones relacionadas con el absceso (36 frente al 18%; p = 0,04). En el resto de datos clinicos, microbiologicos y terapeuticos no hubo diferencias siginificativas entre los dos grupos Conclusiones La aparicion de gas en los abscesos genera escasas peculiaridades en la presentacion clinica, pero su presencia implica peor evolucion clinica, sobre todo en lo concerniente a la morbilidad relacionada con el absceso

Estudio ergonómico del cirujano durante la colecistectomía por vía abierta y laparoscópica

Resumen Introduccion La ingenieria del factor humano (la ergonomia) ha investigado muy poco el trabajo quirurgico. Nuestro objetivo es determinar la carga postural de la colecistectomia laparoscopica y compararla con la abierta, para establecer el nivel de riesgo de lesion musculosqueletica y buscar soluciones ergonomicas que mejoren la comodidad del cirujano y la eficacia del acto quirurgico. Material y metodo Se recogieron datos sobre 16 intervenciones quirurgicas (11 laparoscopicas y 5 abiertas) aplicando el metodo OWAS (Ovako Working Posture Analysis System) y se compararon ambas tecnicas quirurgicas respecto a la carga estatica. Resultados Encontramos diferencias importantes entre la colecistectomia laparoscopica y la abierta respecto a la posicion de los brazos (p Conclusiones Ambas tecnicas de colecistectomia comportan un nivel de riesgo de lesion musculosqueletica mas que moderado. La aplicacion de criterios ergonomicos derivados del mundo industrial en el diseno del instrumental quirurgico y del quirofano pueden mejorar la comodidad del cirujano y, por tanto, la eficacia de su trabajo.

Mismatch repair protein MSH2 expression and prognosis of colorectal cancer patients

INTRODUCTION AND AIMS The role of genetic factors in the etiology and prognosis of patients with sporadic colo-rectal cancer is controversial. We have therefore investigated the biological and clinicopathological influence of immunohistochemical MSH2 expression in colorectal cancer. PATIENTS AND METHODS A total of 49 consecutive patients with unselected colorectal cancer operated on in our unit were included in the study. All tumors were resected and tumor specimens were evaluated for MSH2 expression. Clinicopathological data and patient survival were correlated with MSH2 staining. Uni- and multivariate analyses were performed. The minimum follow-up period was five years. RESULTS Curative resection was performed in 34 patients (64.9%), 14 of whom subsequently relapsed. At the end of the overall follow-up 25 (51%) patients had died, 21 of cancer-related causes. Twenty-eight patients (57.1%) were negative for MSH2 staining. Only vascular invasion was significantly correlated with MSH2 expression (lower median values; p=0.04). The overall median survival was 47.9 months (95% CI=27-86.6%). Multivariate analysis of variables in relation to survival showed that T stage (p=0.001), N stage (p<0.001) and MSH2 expression (p=0.01) were independent factors for survival. CONCLUSIONS Reduced MSH2 expression is frequent in unselected colorectal cancer patients. Only vascular invasion was correlated with MSH2 expression in this study. Survival was related to TN stage and MSH2 staining. (Int J Biol Markers 2004; 19: 190-5).