Roberto de Cleva

Bacterial translocation: Overview of mechanisms and clinical impact

Bacterial translocation (BT) is a phenomenon in which live bacteria or its products cross the intestinal barrier. Gut translocation of bacteria has been shown in both animal and human studies. BT and its complications have been shown clearly to occur in animal models, but its existence and importance in humans has been difficult to ascertain. We review the mechanisms of BT and its clinical impact based on the current literature.

Constipation in intensive care unit: Incidence and risk factors

PURPOSE Although gastrointestinal motility disorders are common in critically ill patients, constipation and its implications have received very little attention. We aimed to determine the incidence of constipation to find risk factors and its implications in critically ill patients MATERIALS AND METHODS During a 6-month period, we enrolled all patients admitted to an intensive care unit from an universitary hospital who stayed 3 or more days. Patients submitted to bowel surgery were excluded. RESULTS Constipation occurred in 69.9% of the patients. There was no difference between constipated and not constipated in terms of sex, age, Acute Physiology and Chronic Health Evaluation II, type of admission (surgical, clinical, or trauma), opiate use, antibiotic therapy, and mechanical ventilation. Early (<24 hours) enteral nutrition was associated with less constipation, a finding that persisted at multivariable analysis (P < .01). Constipation was not associated with greater intensive care unit or mortality, length of stay, or days free from mechanical ventilation. CONCLUSIONS Constipation is very common among critically ill patients. Early enteral nutrition is associated with earlier return of bowel function.

Complications of gastrectomy with lymphadenectomy in gastric cancer

BackgroundCurrently, gastrectomy and extended lymphadenectomy (LN) is the treatment of choice for gastric cancer. Although a survival rate benefit of D2 LN compared to D1 LN has been shown, the D2 LN procedure is not fully employed, due to possible higher morbidity and mortality rates. These higher rates are being questioned in more recent series, in which D1 and D2 LN complication rates have been similar. The aim of this study was to analyze the immediate postoperative complications of patients submitted to total or subtotal gastrectomy with D1 or D2 LN (according to the Japanese guidelines for gastric cancer) at the Gastrointestinal Surgery Division of the Medical School of São Paulo University, between January 2001 and April 2003.MethodsOne hundred consecutive patients were studied; 61 were men and 39, women. Total gastrectomy was performed in 52 patients (13 with D1 LN and 39 with D2 LN), and subtotal gastrectomy was performed in 48 (11 with D1 LN and 37 with D2 LN). Total or subtotal gastrectomy with D1 or D2 LN was performed according to the tumor extent and histological classification (Lauren’s diffuse or intestinal type), considering the patient’s general condition and the gastric cancer stage. Roux-en-Y reconstruction was performed in almost all patients.ResultsNo difference was observed regarding complications and mortality related to the extent of the gastrectomy. Although morbidity was higher in the D1 group, no significant difference was observed. Mortality was higher in the D1 group, and this was probably related to their poor surgical condition and more advanced tumors.ConclusionAccording to these results, it appears that total or subtotal gastrectomy with D2 LN in gastric cancer treatment, performed according to the Japanese guidelines, can be considered a safe procedure, with acceptable morbidity and mortality, when performed by a trained surgical team.

Acute renal failure due to abdominal compartment syndrome: report on four cases and literature review

We report on 4 cases of abdominal compartment syndrome complicated by acute renal failure that were promptly reversed by different abdominal decompression methods. Case 1: A 57-year-old obese woman in the post-operative period after giant incisional hernia correction with an intra-abdominal pressure of 24 mm Hg. She was sedated and curarized, and the intra-abdominal pressure fell to 15 mm Hg. Case 2: A 73-year-old woman with acute inflammatory abdomen was undergoing exploratory laparotomy when a hypertensive pneumoperitoneum was noticed. During the surgery, enhancement of urinary output was observed. Case 3: An 18-year-old man who underwent hepatectomy and developed coagulopathy and hepatic bleeding that required abdominal packing, developed oliguria with a transvesical intra-abdominal pressure of 22 mm Hg. During reoperation, the compresses were removed with a prompt improvement in urinary flow. Case 4: A 46-year-old man with hepatic cirrhosis was admitted after incisional hernia repair with intra-abdominal pressure of 16 mm Hg. After paracentesis, the intra-abdominal pressure fell to 11 mm Hg.

Rhabdomyolysis after Gastric Bypass: Severity and Outcome Patterns

Background: Rhabdomyolysis (RML) is a recently recognized complication of bariatric operations, but it is not known whether creatine kinase (CK) levels along with clinical markers are able to define the course and outcome. Methods: Bariatric patients (n=324) were reviewed retrospectively. Substantially elevated plasma CK after operation was identified in 4.9% (16/324). The affected population was divided into Group I (n=11, 68.8%) with CK 1050-8000 IU/L and no conspicuous muscle pain, weakness or swelling, and Group II (n=5, 31.2%) displaying CK >8000 IU/L and severe pain and dysfunction. The main outcome measures were CK concentration, frequency of renal failure, need for hemodialysis and mortality. Results: Group I subjects compared to Group II were younger (37.7 ± 10.9 vs 44.0 ± 5.5 years, P<0.05) and predominantly females (72.7% vs 40.0%, P<0.05). Peak CK values were definitely lower (2811 ± 952 vs 28136 ± 19000 IU/L, P<0.001), and none progressed to renal failure (0% vs 40.0%, P<0.05). No difference was detected regarding preoperative BMI (50.8 ± 8.1 vs 54.6 ± 7.0 kg/m2, NS), duration of operation (5.3 ± 1.6 vs 5.6 ± 2.1 hours, NS) or types of anesthetic drugs (basically fentanyl, nitrogen oxide and halothane/isoflurane). Conclusions: 1) Demographic features, nominally gender and age, were different between the two degrees of RML; 2) Renal failure and hemodialysis were a danger only in patients with massive CK elevation and muscle pain; 3) Moderate CK increase was very well tolerated and rarely entailed major clinical symptoms; 4) Early diagnosis, fluid replenishment and general supportive therapy probably contributed to avert mortality.

Pulmonary artery catheter complications: report on a case of a knot accident and literature review

A particular event concerning a Swan-Ganz catheter complication is reported. A 41-year-old woman was admitted at the emergency room of our hospital with massive gastrointestinal bleeding. A total gastrectomy was performed. During the postoperative period in the intensive care unit, the patient maintained hemodynamic instability. Invasive hemodynamic monitoring with a pulmonary artery catheter was then indicated. During the maneuvers to insert the catheter, a true knot formation was identified at the level of the superior vena cava. Several maneuvers by radiological endovascular invasive techniques allowed removal of the catheter. The authors describe the details of this procedure and provide comments regarding the various techniques that were employed in overcoming this event. A comprehensive review of evidence regarding the benefits and risks of pulmonary artery catheterization was performed. The consensus statement regarding the indications, utilization, and management of the pulmonary artery catheterization that were issued by a consensus conference held in 1996 are also discussed in detail.

Systemic hemodynamic changes in mansonic schistosomiasis with portal hypertension treated by azygoportal disconnection and splenectomy

ObjectiveThe aim of this study was to assess systemic hemodynamic changes in patients with Mansons schistosomiasis and portal hypertension during azygoportal disconnection and splenectomy.MethodsSixteen patients with portal hypertension secondary to hepatosplenic schistosomiasis with indication for surgery were studied prospectively. All underwent invasive hemodynamic monitoring with pulmonary artery catheter. The first systemic hemodynamic assessment was performed preoperatively. In the intraoperative period new hemodynamic data were collected as follows: a) after laparotomy; b) 15–30 min after splenic artery ligature; c) 15–30 min after splenectomy; and d) after ligation of the collateral circulation.ResultsThe results indicated preoperatively that the patients presented with an increased cardiac index (4.40 ± 0.94 L/min/m2) together with a reduction in the systemic vascular resistance index (1692.25 ± 434.91 dyne.s/cm5.m2). The stroke index (53.74 ± 10.40 ml/beat/m2) and both left (5.71 ± 1.50 kg.m/m2) and right heart work indexes (1.12 ± 0.74 kg.m/m2) were also elevated. The mean pulmonary artery pressure was increased (17.81 ± 9.00 mm Hg) and the pulmonary vascular resistance index decreased (164.31 ± 138.69 dyne.s/cm5.m2). From the moment that the splenic artery was ligated until the end of the procedure, the cardiac index (3.45 ± 0.90 L/min/m2) was reduced and the systemic vascular resistance index (2059.50 ± 590.05 dyne.s/cm5.m5) increased. The systolic index (44.25 ± 11.01 ml/beat/m2) and the left ventricle work index (4.33 ± 1.29 kg.m/m2) also reduced. The mean pulmonary artery pressure (19.18 ± 9.21 mm Hg) and the right ventricle work index (0.94 ± 0.62 mm Hg) remained elevated after the surgical procedure.ConclusionsThe data allowed us to conclude that hepatosplenic schistosomiasis induces a hyperdynamic circulatory state that was corrected after splenectomy and azygoportal disconnection, remaining a mild pulmonary hypertension. Therefore, these changes are correlated with the portosystemic collateral circulation, especially as a consequence of splanchnic hyperflow.

Early complications in bariatric surgery: incidence, diagnosis and treatment.

CONTEXT Bariatric surgery has proven to be the most effective method of treating severe obesity. Nevertheless, the acceptance of bariatric surgery is still questioned. The surgical complications observed in the early postoperative period following surgeries performed to treat severe obesity are similar to those associated with other major surgeries of the gastrointestinal tract. However, given the more frequent occurrence of medical comorbidities, these patients require special attention in the early postoperative follow-up. Early diagnosis and appropriate treatment of these complications are directly associated with a greater probability of control. METHOD The medical records of 538 morbidly obese patients who underwent surgical treatment (Roux-en-Y gastric bypass surgery) were reviewed. Ninety-three (17.2%) patients were male and 445 (82.8%) were female. The ages of the patients ranged from 18 to 70 years (average = 46), and their body mass indices ranged from 34.6 to 77 kg/m2. RESULTS Early complications occurred in 9.6% and were distributed as follows: 2.6% presented bleeding, intestinal obstruction occurred in 1.1%, peritoneal infections occurred in 3.2%, and 2.2% developed abdominal wall infections that required hospitalization. Three (0.5%) patients experienced pulmonary thromboembolism. The mortality rate was 0,55%. CONCLUSION The incidence of early complications was low. The diagnosis of these complications was mostly clinical, based on the presence of signs and symptoms. The value of the clinical signs and early treatment, specially in cases of sepsis, were essential to the favorable surgical outcome. The mortality was mainly related to thromboembolism and advanced age, over 65 years.

Cervical necrotizing fasciitis due to bacterial tonsillitis

Necrotizing fasciitis is a severe and potentially fatal soft tissue infection, but involvement of the head and neck is rare. We report on 4 cases of cervical necrotizing fasciitis arising from tonsillitis. One patient was diabetic and one had received steroids before disease development. One patient developed acute respiratory failure and died of septic shock. Three patients recovered, helped by early recognition, aggressive surgical intervention, appropriate broad-spectrum antibiotics, and supportive therapy. The common bacteria found in all abscess samples were Streptococcus sp., but mixed flora with anaerobic organisms was seen in all but 1 case. Tonsillitis and peritonsillar abscess must be suspected as a cause of cervical necrotizing fasciitis and a successful result can be achieved with immediate aggressive treatment.

Portal hyperflow in patients with hepatosplenic mansonic schistosomiasis

PURPOSE The purpose of this study was to assess portal hemodynamics in patients with portal hypertension due to hepatosplenic schistosomiasis as well as to assess the contribution of splanchnic hyperflow to the pathophysiology of the portal hypertension. METHODS Sixteen patients with schistosomal portal hypertension and previous history of upper digestive bleeding due to esophageal varices rupture underwent elective esophagogastric devascularization and splenectomy and were prospectively studied. All patients underwent intraoperative invasive hemodynamic portal monitoring with a 4F-thermodilution catheter. The intraoperative portal hemodynamic assessment was conducted after laparotomy (initial) and after esophagogastric devascularization (final). RESULTS The initial portal pressure was elevated (mean 28.5 +/- 4.5 mm Hg), and a significant drop of 25% was observed at the end of the surgery (21.9 +/- 4.9 mm Hg). The initial portal flow was elevated (mean 1766.9 +/- 686.6 mL/min). A significant fall (42%) occurred at the end of the surgical procedure (1025.62 +/- 338.7 mL/min). Fourteen patients (87.5%) presented a portal flow of more than 1200 mL/min, and in 5 cases, values greater than 2000 mL/min were observed. CONCLUSIONS Esophagogastric devascularization and splenectomy promote a significant reduction of the elevated portal pressure and flow in schistosomal portal hypertension. These data favor the hypothesis of portal hyperflow in the physiopathology of portal hypertension of schistosomiasis.