RESUMO
The training of residents in abdominal wall surgery is a fundamental aspect of surgical training, representing globally 20% of its activity. In this paper, we analyze the current state of resident training in this kind of surgery in Spain, taking into account the broad spectrum it covers: general services, specific functional units, ambulatory surgery programs. To do this, based on the specifications of the specialty program, specific data were used from several different sources of direct information and a review of the results obtained by residents in hernia surgery. In general, our residents agree with their training and the recorded results are in line with objectives outlined in the program. However, it would be important to structure their teaching schedules, a rotation period in any specific unit and their involvement in outpatient surgery programs.
Assuntos
Parede Abdominal/cirurgia , Internato e Residência , Especialidades Cirúrgicas/educação , Herniorrafia/educação , Humanos , EspanhaRESUMO
BACKGROUND: Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI. METHODS: We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS. RESULTS: The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo's grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1-6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h. CONCLUSIONS: Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.
Assuntos
Traumatismos por Explosões/epidemiologia , Bombas (Dispositivos Explosivos)/estatística & dados numéricos , Terrorismo/estatística & dados numéricos , Humanos , Incidentes com Feridos em Massa/estatística & dados numéricos , Espanha/epidemiologia , População UrbanaRESUMO
Congenital fistulae between the tracheobronchial tree and oesophagus usually originate from the lower end of the trachea or right main bronchus. The case history is presented of a man in whom a fistula between the oesophagus and left main bronchus was not diagnosed until the age of 48.
Assuntos
Fístula Brônquica/congênito , Fístula Traqueoesofágica/congênito , Fístula Brônquica/diagnóstico por imagem , Broncografia , Esôfago/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Fístula Traqueoesofágica/diagnóstico por imagemRESUMO
A case of massive intra and extrahepatic lithiasis in a 52 year-old-man is presented. Diagnosis was confirmed by ultrasonography, CT and percutaneous cholangiography. The value of the different diagnostic procedures is analyzed. The need for elective surgical treatment is insisted on in order to remove the majority of the calculi, treatment of stenosis and adequate biliary drainage. Our case was treated with an hepatico-jejuno-duodenostomy (end to side) on an isolated jejunal loop with sphincteroplasty for drainage of the distal choledochus. In the postoperative period the patient was treated with Methyl-tert-butyl-ether for dissolution of the remaining calculi.
Assuntos
Ductos Biliares Intra-Hepáticos , Colelitíase/diagnóstico , Éteres Metílicos , Colelitíase/epidemiologia , Colelitíase/terapia , Terapia Combinada , Diagnóstico por Imagem , Duodeno/cirurgia , Éteres/uso terapêutico , Humanos , Incidência , Jejunostomia , Fígado/cirurgia , Masculino , Pessoa de Meia-Idade , Solventes/uso terapêuticoRESUMO
Since the inauguration of our liver transplant program two years ago, retrospectively we can distinguish two different periods as regards postoperative results. The patients studied were distributed in two groups by chronological order and date of introduction of an improved surgical and anesthetic strategy: retrohepatic dissection during the veno-venous bypass phase and meticulous hemostasis in the anhepatic phase: Group A: 11 transplants in 10 patients and Group B: 22 transplants in 21 patients. Preoperatively, both groups were homogeneous with respect to the clinical situation. During the operation, significantly larger transfusion volumes were given in group A (25.4 +/- 10.5 ml/kg/hr) than in group B (10.0 +/- 5.7 ml/kg/hr) (p less than 0.01). The anhepatic phase lasted 1'50" +/- 20" in group B (p less than 0.05). The postoperative outcome of group B was better than that of A as regards hemodynamic and respiratory parameters, functional impairment of the graft and mortality (p less than 0.05). We conclude that the realization of retrohepatic dissection and careful hemostasis during the anhepatic phase, which prolongs the duration of venovenous by-pass but does not increase intraoperative morbidity, reduces the need for blood transfusion, and yields better postoperative results.
Assuntos
Anestesia , Transplante de Fígado , Adulto , Transfusão de Sangue , Criança , Feminino , Hemostasia Cirúrgica , Humanos , Cuidados Intraoperatórios/métodos , Transplante de Fígado/métodos , Transplante de Fígado/mortalidade , Masculino , Cuidados Pós-Operatórios , Estudos RetrospectivosRESUMO
No periodo compreendido entre abril de 1986 e janeiro de 1989, foram realizados no Hospital 12 de Octubre de Madrid (Espanha), 74 transplantes hepaticos ortotopicos em 62 pacientes (38 do sexo masculino e 24 do sexo feminino). A idade media dos receptores foi de 35,7 por cento anos (limites de 18 meses a 62 anos). A indicacao mais frequente nos adultos foi a cirrose hepatica (61,4 por cento ), sendo que em 10 pacientes (28,5 por cento ) foi de origem etilica. Seis pacientes apresentavam hepatocarcinoma sobre um figado cirrotico (9,6 por cento ). Dois pacientes receberam duplo transplante hepato-renal. A indicacao preferente na idade pediatrica foi a atresia das vias biliares, seguida da insuficiencia hepatica primaria por hepatite fulminante. Foram realizados 68 transplantes totais e 6 parciais (figado esquerdo). Em todos os adultos e em um transplante pediatrico, se instalou o circuito extracorporeo parcial. Em 67 transplante se praticou uma unica anastomose arterial (93,1 por cento ) e nos cinco restantes, foi necessario realizar duas anastomoses independentes. As arterias dos receptores mais frequentemente utilizadas foram a arteria hepatica direita (23,6 por cento ) e a arteria hepatica primitiva (23,6 por cento ). A reconstrucao biliar foi realizada mediante coledoco-coledocostomia em 65,2 por cento dos transplantes. O retransplante foi realizado em 12 ocasioes.
Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Criança , Adolescente , Adulto , Pessoa de Meia-Idade , Transplante de Fígado/patologia , Hepatopatias/complicações , Hepatopatias/terapiaRESUMO
Three patients are reported who had liver hydatidosis that was not resolved by conventional surgery and who eventually underwent liver transplantation. In view of the satisfactory results obtained, with 100% postoperative survival, possible indications for liver transplant in this type of patients are discussed, fundamentally for secondary sclerosing cholangitis, secondary biliary cirrhosis and acute Budd-Chiari syndrome.
Assuntos
Equinococose Hepática/cirurgia , Transplante de Fígado , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
The quality of the socio-affective adaptation of liver transplant patients is a fundamental assessment parameter in the context of postoperative recuperation. The patient's reinsertion into the socio-occupational environment, gradual recuperation of professional and recreational habits and psycho-affective reorganization represent, in our opinion, the most significant criteria for evaluation of the "modus vivendi" of the transplant patient. A total of 21 patients between 21 and 62 years were evaluated. They were divided into three groups for study and analysis. The remission of symptoms and normalization of organic activities, in addition to achievement of an adequate quality of life, constitute the basic rationale for any surgical intervention.
Assuntos
Hepatectomia/psicologia , Transplante de Fígado , Ajustamento Social , Adulto , Idoso , Feminino , Hepatectomia/reabilitação , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
Two cases are presented of liver transplantation in adult patients with fulminant liver failure using grafts from incompatible blood group donors due to the urgency of the situation. The patients evolved well as first but later both developed ischemia and necrosis of the bile tract secondary to severe rejection. It is concluded that the use of incompatible grafts can save the patient's life in acute irreversible liver failure, but in most cases retransplantation may be necessary as the definitive treatment of postoperative complications.
Assuntos
Sistema ABO de Grupos Sanguíneos , Doenças dos Ductos Biliares/patologia , Incompatibilidade de Grupos Sanguíneos/complicações , Rejeição de Enxerto , Transplante de Fígado , Adulto , Doenças dos Ductos Biliares/diagnóstico por imagem , Doenças dos Ductos Biliares/etiologia , Colangiografia , Feminino , Humanos , NecroseRESUMO
The initial results of biliary reconstruction in 72 liver transplants realized in 62 patients, 50 adults and 12 children, are presented. Three reconstruction techniques were used: end-to-end choledocho-choledochostomy on a Kehr tube in 44 transplants (61.1%); choledocho-jejunostomy on a Roux-en-Y loop in 24 transplants (33.3%); double derivation cholecysto-choledocho-jejunostomy in 2 transplants (2.7%). The number of early complications related to biliary reconstruction was 5 (7.14%): 3 fistulas in the choledocho-choledochostomy series (6.8%) and 2 fistulas among the choledocho-jejunostomies (8.3%). All complications required reoperation and mortality was nil. Thirty-two months after the onset of the program, no late complications of the biliary anastomosis have been registered.
Assuntos
Vesícula Biliar/cirurgia , Ducto Hepático Comum/cirurgia , Jejuno/cirurgia , Adolescente , Adulto , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Criança , Pré-Escolar , Feminino , Ducto Hepático Comum/fisiologia , Humanos , Lactente , Transplante de Fígado , Masculino , Pessoa de Meia-IdadeRESUMO
La volorizacion de la adaptacion socio-afectiva del paciente con trasplante hepatico, constituye un parametro fundamental dentro del marco de recuperacion postoperatoria del paciente trasplantado. La reinsercion al medio social-laboral, la recuperacion paulativa de habitos ocupacionales y recreativos, asi como el restablecimiento y la reorganizacion del aparato psico-afectivo conforman, a nuestro juicio, los criterios mas significativos de la evaluacion del "modus vivendi" del paciente que ha recibido trasplante de higado. La remision de la sintomatologia con la normalizacion de la actividad organica, sumado a una calidad de vida adecuada, constituyen el respaldo basico de cualquier intervencion quirurgica
Assuntos
Adulto , Humanos , Masculino , Feminino , Fígado/cirurgia , Qualidade de Vida/tendências , Transplante/tendências , Adaptação Psicológica , Fígado/patologia , Cuidados Pós-Operatórios , Ajustamento SocialRESUMO
A study was made of 44 patients who underwent liver transplant, distributed into three groups: Group A: patients who had ample liver dissection before entering bypass. Group B: patients who entered bypass after dissection of the hepatic hilum and prior to any other dissection; bypass time was prolonged for meticulous hemostasia. Group C: patients with perfectly defined hemodynamic problems, not secondary to bleeding, during the anhepatic phase. Preoperatively the three groups were homogeneous as regards clinical situation. During the operation a significantly larger transfusion volume (p less than 0.01) was administered in group C during phase II (70.1 +/- 27.2 ml/kg/h), phase III (32.6 +/- 9.6 ml/kg/h) and throughout surgery (32.7 +/- 10.3 ml/kg/h) than in the other two groups. Group B received a smaller transfusion volume during phase II (14.6 +/- 8.1 ml/kg/h), phase III (12.7 +/- 5.5 ml/kg/h) and throughout surgery (11.6 +/- 4.9 ml/kg/h) than the other two groups (p less than 0.01). The transfusion needs of group A were 28.4 +/- 15.6 ml/kg/h in phase II, 26.8 +/- 17.1 ml/kg/h in phase III and 21.2 +/- 11.2 ml/kg/h throughout surgery. The duration of the anhepatic phase was significantly shorter (p less than 0.01) in group A (1 h 10' +/- 10) than in (1 h 50' +/- 10) and C (1 h 40' +/- 45'). In the postoperative period a higher mortality was associated with group C (37.5%) and a lower mortality with group B (3.33%), the mortality of group A being 16.6%. The differences were statistically significant with p less than 0.01.
Assuntos
Transfusão de Sangue , Circulação Extracorpórea/métodos , Transplante de Fígado , Adulto , Humanos , Período Intraoperatório , Pessoa de Meia-Idade , Veia Porta , Veias CavasAssuntos
Transtornos de Deglutição/fisiopatologia , Esofagoplastia/métodos , Esôfago/cirurgia , Adulto , Colo/fisiopatologia , Doenças do Esôfago/cirurgia , Esôfago/fisiopatologia , Feminino , Humanos , Íleo/fisiopatologia , Masculino , Manometria , Pessoa de Meia-Idade , Peristaltismo , Estômago/fisiopatologiaAssuntos
Hepatopatias/cirurgia , Transplante de Fígado , Adolescente , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , PrognósticoRESUMO
Over a period of 6.5 years, 29 patients with liver hemangiomas have been examined. In 8 patients, the most frequent symptom was pain; in 11, a tumor was found. The diagnosis was made by means of scintigraphy with 99mTc, followed by real-time sonography, computed tomography using a contrast medium, and selective arteriography. In 16 patients (15 women, 1 man), the tumor radius was more than 6 cm and in 9 of these, more than 10 cm. In 3 patients, a left lobectomy was carried out, and in 5 a right lobectomy; in an additional 5 patients, a extended right lobectomy (three segments excised) was done. In the rest, a medial lobectomy, a segmentectomy on the left side, or a segmentectomy on the right was performed. The only complications observed in the whole series were: pleural effusion (1 case), subphrenic abscess (1), and transitory biliary fistula (1). All hemangiomas with a radius of more than 10 cm should be removed operatively, as should smaller symptomatic hemangiomas and tumors that are not clearly benign.