Scoping review for the SAGES EAES joint collaborative on sustainability in surgical practice.

BACKGROUND: Surgical care in the operating room (OR) contributes one-third of the greenhouse gas (GHG) emissions in healthcare. The European Association of Endoscopic Surgery (EAES) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) initiated a joint Task Force to promote sustainability within minimally invasive gastrointestinal surgery. METHODS: A scoping review was conducted by searching MEDLINE via Ovid, Embase via Elsevier, Cochrane Central Register of Controlled Trials, and Scopus on August 25th, 2023 to identify articles reporting on the impact of gastrointestinal surgical care on the environment. The objectives were to establish the terminology, outcome measures, and scope associated with sustainable surgical practice. Quantitative data were summarized using descriptive statistics. RESULTS: We screened 22,439 articles to identify 85 articles relevant to anesthesia, general surgical practice, and gastrointestinal surgery. There were 58/85 (68.2%) cohort studies and 12/85 (14.1%) Life Cycle Assessment (LCA) studies. The most commonly measured outcomes were kilograms of carbon dioxide equivalents (kg CO2eq), cost of resource consumption in US dollars or euros, surgical waste in kg, water consumption in liters, and energy consumption in kilowatt-hours. Surgical waste production and the use of anesthetic gases were among the largest contributors to the climate impact of surgical practice. Educational initiatives to educate surgical staff on the climate impact of surgery, recycling programs, and strategies to restrict the use of noxious anesthetic gases had the highest impact in reducing the carbon footprint of surgical care. Establishing green teams with multidisciplinary champions is an effective strategy to initiate a sustainability program in gastrointestinal surgery. CONCLUSION: This review establishes standard terminology and outcome measures used to define the environmental footprint of surgical practices. Impactful initiatives to achieve sustainability in surgical practice will require education and multidisciplinary collaborations among key stakeholders including surgeons, researchers, operating room staff, hospital managers, industry partners, and policymakers.

Sustainability in surgical practice: a collaborative call toward environmental sustainability in operating rooms.

BACKGROUND: The healthcare system plays a pivotal role in environmental sustainability, and the operating room (OR) significantly contributes to its overall carbon footprint. In response to this critical challenge, leading medical societies, government bodies, regulatory agencies, and industry stakeholders are taking measures to address healthcare sustainability and its impact on climate change. Healthcare now represents almost 20% of the US national economy and 8.5% of US carbon emissions. Internationally, healthcare represents 5% of global carbon emissions. US Healthcare is an outlier in both per capita cost, and per capita greenhouse gas emission, with almost twice per capita emissions compared to every other country in the world. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) established the Sustainability in Surgical Practice joint task force in 2023. This collaborative effort aims to actively promote education, mitigation, and innovation, steering surgical practices toward a more sustainable future. RESULTS: Several key initiatives have included a survey of members' knowledge and awareness, a scoping review of terminology, metrics, and initiatives, and deep engagement of key stakeholders. DISCUSSION: This position paper serves as a Call to Action, proposing a series of actions to catalyze and accelerate the surgical sustainability leadership needed to respond effectively to climate change, and to lead the societal transformation towards health that our times demand.

Perspectives on sustainability among surgeons: findings from the SAGES-EAES sustainability in surgical practice task force survey.

BACKGROUND: Surgical care significantly contributes to healthcare-associated greenhouse gas emissions (GHG). Surgeon attitudes about mitigation of the impact of surgical practice on environmental sustainability remains poorly understood. To better understand surgeon perspectives globally, the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery established a joint Sustainability in Surgical Practice (SSP) Task Force and distributed a survey on sustainability. METHODS: Our survey asked about (1) surgeon attitudes toward sustainability, (2) ability to estimate the carbon footprint of surgical procedures and supplies, (3) concerns about the negative impacts of sustainable interventions, (4) willingness to change specific practices, and (5) preferred educational topics and modalities. Questions were primarily written in Likert-scale format. A clustering analysis was performed to determine whether survey respondents could be grouped into distinct subsets to inform future outreach and education efforts. RESULTS: We received 1024 responses, predominantly from North America and Europe. The study revealed that while 63% of respondents were motivated to enhance the sustainability of their practice, less than 10% could accurately estimate the carbon footprint of surgical activities. Most were not concerned that sustainability efforts would negatively impact their practice and showed readiness to adopt proposed sustainable practices. Online webinars and modules were the preferred educational methods. A clustering analysis identified a group particularly concerned yet willing to adopt sustainable changes. CONCLUSION: Surgeons believe that operating room waste is a critical issue and are willing to change practice to improve it. However, there exists a gap in understanding the environmental impact of surgical procedures and supplies, and a sizable minority have some degree of concern about potential adverse consequences of implementing sustainable policies. This study uniquely provides an international, multidisciplinary snapshot of surgeons' attitudes, knowledge, concerns, willingness, and preferred educational modalities related to mitigating the environmental impact of surgical practice.

Preferred Feedback Styles Among Different Groups in an Academic Medical Center.

INTRODUCTION: Feedback is an essential component in complex work environments. Different generations have been shown to have different sets of values, derived from societal and cultural changes. We hypothesize that generational differences may be associated with preferred feedback patterns among medical trainees and faculty in a large academic institution. METHODS: A survey was distributed to all students, residents/fellows, and faculty at a large academic medical institution from April 2020 through June 2020. Survey questions evaluated feedback methods for six domains: preparedness, performance, attitude, technical procedures, inpatient, and outpatient care. Participants selected a preferred feedback method for each category. Patient demographics and survey responses were described using frequency statistics. We compared differences in feedback preferences based on generation and field of practice. RESULTS: A total of 871 participants completed the survey. Preferred feedback patterns in the medical field do not seem to align with sociologic theories of generational gaps. Most participants preferred to receive direct feedback after an activity away from their team, irrespective of their age or medical specialty. Individuals preferred direct feedback during an activity in front of their team only for technical procedures. Compared to nonsurgeons, surgeons were more likely to prefer direct feedback in front of team members for preparedness, performance, and attitude. CONCLUSIONS: Generational membership is not significantly associated with preferred feedback patterns in this complex medical academic environment. Variations in feedback preferences are associated with field of practice that may be due to specialty-specific differences in culture and personality traits present within certain medical specialties, particularly surgery.

Comparison of early post-operative complications in primary and revisional laparoscopic sleeve gastrectomy, gastric bypass, and duodenal switch MBSAQIP-reported cases from 2015 to 2019.

BACKGROUND: Sleeve gastrectomy (SG) is now the most performed bariatric surgery, though gastric bypass (GB) and duodenal switch (DS) remain common, especially as conversion/revision (C/R) procedures. This analysis compared early postoperative outcomes of primary and C/R laparoscopic SG to DS and GB; and primary procedures of each vs C/R counterparts. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) dataset was queried for SG, GB, and DS cases from 2015 to 2019. Multivariable logistic regression calculated crude and adjusted odds ratios for surgical site infection (SSI), reoperation, and readmission at 30 days in two initial comparisons: (1) primary SG vs DS or GB and (2) C/R SG vs DS or GB. A secondary analysis compared primary GS, GB, or DS with C/R counterparts. Models were adjusted for confounding demographics and comorbidities. RESULTS: Of 755,968 primary cases, most were SG (72.8%), followed by GB (26.3%), then DS (0.9%). Compared to SG, GB and DS demonstrated higher odds of SSI (aOR 3.02 [2.84, 3.2]), readmission (aOR 1.97 [1.92, 2.03]), and reoperation (aOR 2.74 [2.62, 2.86]), respectively. Of 68,716 C/R cases, SG was most common (43.2%), followed by GB (37.5%), then DS (19.2%). C/R GB and DS demonstrated greater risk of SSI (aOR 2.28 [1.98, 2.62]), readmission (aOR 2.10 [1.94, 2.27]), and reoperation (aOR 2.3 [2.04, 2.59]) vs SG, respectively. C/R SG and DS demonstrated greater risk of SSI (OR 2.09 [1.66, 2.63]; 1.63 [1.24, 2.14), readmission (OR 1.13 [1.02, 1.26]), and reoperation (OR 1.27 [1.06, 1.52]; 1.58 [1.24, 2.0]), vs primary procedures. C/R DS demonstrated greater risk of SSI (OR 1.23 [1.66, 2.63]). CONCLUSIONS: Early complications are comparable between GB and DS, and greater than SG. In C/R procedures, GB and DS demonstrate greater risk than SG. Overall, C/R procedures demonstrate greater risk of most, but not all, early postoperative complications.

Comparison of robot-assisted sleeve gastrectomy outcomes in multiple staple line treatment modalities from 2015 to 2019: a 5-year propensity score-adjusted MBSAQIP® analysis.

BACKGROUND: Robot-assisted sleeve gastrectomy (RSG) is an increasingly common approach to sleeve gastrectomy (SG). Staple line reinforcement (SLR) is well-discussed in laparoscopic SG literature, but not RSG- likely due to the absence of dedicated robotic SLR devices. However, most RSG cases report SLR. This retrospective analysis compares outcomes in RSG cases reporting (1) any staple line treatment (SLT) vs none and (2) SLR vs oversewing. METHODS: MBSAQIP was queried for adults who underwent RSG from 2015 to 2019. Open procedures, Natural Orifice Transluminal Endoscopic Surgery, hand-assisted, single-incision, concurrent procedures, and illogical BMIs were excluded (n = 3444). Final sample included 52,354 patients. Two comparisons were made: SLT (n = 34,886) vs none (n = 17,468) and SLR (n = 22,217) vs oversew (n = 5620). We fitted multivariable regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) and performed propensity score analysis with inverse probability of treatment weight based on patient factors. RESULTS: Most RSG cases utilized SLT (66.6%). Cases with SLT had a reduced risk of organ space SSI (RR 0.68 [0.49, 0.94]), 30-day reoperation (RR 0.77 [0.64, 0.93]), 30-day re-intervention (RR 0.80 [0.67, 0.96]), sepsis (RR 0.58 [0.35, 0.96]), unplanned intubation (RR 0.59 [0.37, 0.93]), extended ventilator use (RR 0.46 [0.23, 0.91]), and renal failure (RR 0.40 [0.19, 0.82]) compared to no-treatment cases. In single-treatment cases (n = 27,837), most utilized SLR (79.8%). Cases with oversew had a higher risk of any SSI (RR 1.70 [1.19, 2.42]), superficial incisional SSI (RR 1.71 [1.06, 2.76]), septic shock (RR 6.47 [2.11, 19.87]), unplanned intubation (RR 2.18 [1.06, 4.47]), and extended ventilator use (> 48 h) (RR 4.55 [1.63, 12.71]) than SLR. CONCLUSIONS: Our data suggest SLT in RSG is associated with reduced risk of some adverse outcomes vs no-treatment. Among SLT, SLR demonstrated lower risk than oversewing. However, risk of all-cause mortality, cardiac arrest, and unplanned ICU admission were not significant.

Comparison of post-operative outcomes of large direct inguinal hernia repairs based on operative approach (open vs. laparoscopic vs. robotic) using the ACHQC (Abdominal Core Health Quality Collaborative) database.

PURPOSE: To compare clinical outcomes for open, laparoscopic, and robotic hernia repairs for direct, unilateral inguinal hernia repairs, with particular focus on 30-day morbidity surgical site infection (SSI); surgical site occurrence (SSO); SSI/SSO requiring procedural interventions (SSOPI), reoperation, and recurrence. METHODS: The Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective, primary, > 3 cm medial, unilateral inguinal hernia repairs with an open (Lichtenstein), laparoscopic, or robotic operative approach. Preoperative demographics and patient characteristics, operative techniques, and outcomes were studied. A 1-to-1 propensity score matching algorithm was used for each operative approach pair to reduce selection bias. RESULTS: There were 848 operations included: 297 were open, 285 laparoscopic, and 266 robotic hernia repairs. There was no evidence of a difference in primary endpoints at 30 days including SSI, SSO, SSI/SSO requiring procedural interventions (SSOPI), reoperation, readmission, or recurrence for any of the operative approach pairs (open vs. robotic, open vs. laparoscopic, robotic vs. laparoscopic). For the open vs. laparoscopic groups, QoL score at 30 day was lower (better) for laparoscopic surgery compared to open surgery (OR 0.53 [0.31, 0.92], p = 0.03), but this difference did not hold at the 1-year survey (OR 1.37 [0.48, 3.92], p = 0.55). Similarly, patients who underwent robotic repair were more likely to have a higher (worse) 30-day QoL score (OR 2.01 [1.18, 3.42], p = 0.01), but no evidence of a difference at 1 year (OR 0.83 [0.3, 2.26] p = 0.71). CONCLUSIONS: Our study did not reveal significant post-operative outcomes between open, laparoscopic, and robotic approaches for large medial inguinal hernias. Surgeons should continue to tailor operative approach based on patient needs and their own surgical expertise.

Differential phosphorylation of a regulatory subunit of protein kinase CK2 by target of rapamycin complex 1 signaling and the Cdc-like kinase Kns1.

Transcriptional regulation of ribosome and tRNA synthesis plays a central role in determining protein synthetic capacity and is tightly controlled in response to nutrient availability and cellular stress. In Saccharomyces cerevisiae, the regulation of ribosome and tRNA synthesis was recently shown to involve the Cdc-like kinase Kns1 and the GSK-3 kinase Mck1. In this study, we explored additional roles for these conserved kinases in processes connected to the target of rapamycin complex 1 (TORC1). We conducted a synthetic chemical-genetic screen in a kns1Δ mck1Δ strain and identified many novel rapamycin-hypersensitive genes. Gene ontology analysis showed enrichment for TORC1-regulated processes (vesicle-mediated transport, autophagy, and regulation of cell size) and identified new connections to protein complexes including the protein kinase CK2. CK2 is considered to be a constitutively active kinase and in budding yeast, the holoenzyme comprises two regulatory subunits, Ckb1 and Ckb2, and two catalytic subunits, Cka1 and Cka2. We show that Ckb1 is differentially phosphorylated in vivo and that Kns1 mediates this phosphorylation when nutrients are limiting and under all tested stress conditions. We determined that the phosphorylation of Ckb1 does not detectably affect the stability of the CK2 holoenzyme but correlates with the reduced occupancy of Ckb1 on tRNA genes after rapamycin treatment. Thus, the differential occupancy of tRNA genes by CK2 is likely to modulate its activation of RNA polymerase III transcription. Our data suggest that TORC1, via its effector kinase Kns1, may regulate the association of CK2 with some of its substrates by phosphorylating Ckb1.

Gastric Bypass Versus Sleeve Gastrectomy: Comparison of Patient Outcomes, Satisfaction, and Quality of Life in a Single-Center Experience.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most common primary bariatric operation performed in the United States. Its relative technical ease, combined with a decreased risk for anatomic and malabsorptive complications make LSG an attractive option compared to laparoscopic gastric bypass (LGB) for many patients and surgeons. However, emerging evidence for progressive gastroesophageal reflux disease (GERD) after LSG, and the inferior weight loss in many studies, suggests that the enthusiasm for LSG requires reassessment. We hypothesized that patient satisfaction and quality of life (QoL) may be lower after LSG compared to LGB because of these differences. Methods: We distributed a survey querying weight-loss outcomes, complications, foregut symptoms, QoL, and overall satisfaction to patients who underwent bariatric operations at our institution between 2000 and 2020 and who had electronic mail contact information available. Mean follow-up was 2.75 ± 2.41 years for LGB patients and 3.37 ± 2.18 (P = .021) years for LSG patients. We compared these groups for weight-loss outcomes, changes in foregut symptoms, gastrointestinal QoL, postbariatric QoL, and overall satisfaction using appropriate statistical tests. Results: Among 323 respondents, 126 underwent LGB and 197 underwent LSG. LGB patients had larger body mass index (BMI) reduction than LSG patients (-17.16 ± 9.07 kg/m2 versus -14.87 ± 7.4 kg/m2, P = .023). LGB patients reported less reflux (P = .003), with decreased heartburn (P < .0001) and regurgitation (P = .0027). However, a greater proportion of LGB patients reported at least one complication (P = .025). Despite this, more LGB patients reported satisfaction (92.86%) than LSG patients (73.6%). Conclusion: LGB patients are significantly more likely to be satisfied than LSG patients. Factors contributing to the higher level of satisfaction include less GERD and better BMI decrease.

"Orphaned" Stomach-An Infrequent Complication of Gastric Bypass Revision.

While generally safe, bariatric operations have a variety of possible complications. We present an uncommon complication after gastric bypass revision, namely the creation of an "orphaned" segment of remnant stomach that was left inadvertently in discontinuity, leading to recurrent intra-abdominal abscesses. Sinogram ultimately proved the diagnosis, and the issue was successfully treated using a combination of surgical and endoscopic methods to control the abscess and to allow internal drainage.

Laparoscopic Posterior Partial Fundoplication for Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a common condition that greatly impacts quality of life. Management options include medical and surgical therapies. Nonoperative management typically relies on longitudinal use of acid-suppressive medications such as proton pump inhibitors, which is associated with a significant financial burden and an increasing number of recognized side effects. The surgical management of GERD is focused on correction of the lower esophageal sphincter dysfunction by means of a fundoplication, thus limiting acid and nonacid gastroesophageal reflux. Multiple techniques have been described, including use of complete (360°) fundoplication or partial fundoplication in either an anterior (180°) or posterior (220-270°) position. Recent studies have shown that the total and the partial fundoplications are similarly effective in controlling GERD. A partial fundoplication may also be advantageous when treating patients with GERD and poor esophageal motility. This article focuses on the posterior partial (modified Toupet) fundoplication, with attention to the key elements of the preoperative workup, appropriate patient selection, and important technical steps that are associated with the best outcomes.

Aneurismas ilíacos / Iliac aneurysms

Los aneurismas ilíacos puros constituyen una patología poco frecuente y muchas veces oculta por su sintomatología variada y su difícil palpación. Se presentan 6 aneurismas ilíacos puros operados en 4 pacientes, entre los años 1974 y 1988, encontrándose una incidencia del 3 por ciento sobre el total de aneurismas intraabdominales operados en el mismo período. Se trataba de aneurismas de ilíaca primitiva bilateral en 2 pacientes y unilateral en los restantes. El diámetro varió entre 3,5 y 9 cm, presentándose el más grande de ellos con ruptura y shock hipovolémico. Se considera la tomografía axial computada como procedimiento ideal no sólo para el diagnóstico sino también para planificar la cirugía electiva. En todos los casos los pacientes fueron tratados mediante reemplazo endoaneurismático o exclusión con prótesis de Dacron tratando de conservar la permeabilidad del sistema hipogástrico-ilíaca externa-femoral profunda homolateral

Relación flujo-diámetro en las prótesis vasculares / Flow-diameter relation in vascular prosthesis

Se implantó un complejo protésico (injertos de 10,8 y 6 mm) entre la aorta torácica y abdominal en 5 perros mestizos. Los valores de flujo obtenidos en 50 oportunidades fueron: a) 185,84 + ou - 46 ml/min (complejo protésico); b) 181 + ou - 43 ml/min (tubo de 10 mm); c) 175,26 + ou - 50,11 ml/min (tubo de 8 mm); d) 175,16 + ou - 47,38 ml/min (tubo de 6 mm) y e) 178,86 + ou - 50,47 ml/min (complejo protésico control). Se analizaron los resultados por el método de varianza. Si bien hay diferencia estadísticamente significativa (3%) entre el injerto de 10 y el de 6 mm, en la práctica es despreciable. Por lo tanto el uso de menores calibres produce un aumento de la velocidad circulatoria que se convierte en un factor importante para el logro de la permeabilidad del puente

Evaluación de los parámetros electrofisiológicos durante la estimulación epidural / Evaluation of electrophysiologic parameters with spinal cord stimulation

Se evalúan los resultados electrofisiológicos obtenidos durante la estimulación eléctrica epidural en 25 pacientes con dolor de reposo y lesión trófica en los miembros de diferentes etiologías, Se define como umbral básico al mínimo estímulo capaz de producir respuesta y con umbral efectivo a aquel localizado en la zona de dolor o lesiones. El voltaje umbral básico fue similar al efectivo cuando la ubicación de electrodo correspondiente a la salida de las raices de la zona enferma. La estimulación eléctrica epidural actuaría activando las vías inhibitorias del dolor y del sistema simpático ingresando el estímulo a través de las raíces posteriores.

Puentes cruzados femorofemorales / Crossover femorofemoral grafts

Fueron operados 53 pacientes que presentaban una estenosis significativa u oclusión ilíaca unilateral de los cuales el 87% tenía patología distal femoropoplítea. Se obtuvo una permeabilidad acumulativa a los 9 años del 70% y del 84% cuando se incluyeron reoperaciones. Observamos 13 fracasos, de los cuales 5 fueron corregidos con éxito. La mortabilidad relacionada con el procedimiento fue del 3,7%. No se observó ningún fenómeno isquémico contralateral

Tumor del corpúsculo carotídeo / Carotid body tumor

La infrecuente patología tumoral del corpúsculo carotideo motiva la presentación de un caso detectado en un paciente de 29 años. Se comentan las características anatomoclínicas. Se destaca la utilidad de la arteriografía y del tratamiento quirúrgico temprano

Isquemia crítica por oclusión aortoilíaca: puentes aorto y axilofemorales / Critical ischemia by aortoiliac occlusion: aorto and axilofemoral by pass

Se realizó un análisis retrospectivo de los resultados del tratamiento quirúrgico de pacientes con isquemia crítica de miembros inferiores. Sólo se incluyeron aquellos casos en que se utilizaron puentes aortofemorales (Aof) y axilofemorales (Axf). Se revisaron los registros de 139 pacientes (59 puentes Aof y 97 Axf). Se excluyeron los pacientes con aneurismas, con cirugía vascular previa y los infectados. La decisión táctica se basó en las condiciones clínicas que suponían un riesgo operatorio elevado. La femoral superficial estaba ocluída en 129 casos (83 por ciento). Se utilizó siempre prótesis de dacron. La supervivencia global Aof: 68,02 por ciento (ES: 8,20); Axf: 43,07 por ciento (ES: 8,12); Permeabilidad primaria, Aof: 65,11 por ciento (ES: 9,32); Axf: 52,67 por ciento (ES: 9,32). Permeabilidad secundaria, Aof: 80,55 por ciento (ES: 7,57); Axf: 71,71 por ciento (ES: 8,75). Conservación miembro, Aof: 76,16 por ciento (ES: 8,11); Axf: 75,69 por ciento (ES: 8,56). Dentro de los primeros 90 días se realizaron puentes distales en el 5 por ciento de los casos por insuficiencia hemodinámica (3/59 Aof) y en el 6,18 por ciento por trombosis del injerto (6/97 Axf). Cuando no es factible realizar un estudio prospectivo por razones éticas, es posible utilizar controles históricos, aunque la información puede estar sometida a diferentes sesgos. Nuestra experiencia sugiere que: a) la permeabilidad secundaria de los puentes Axf obtenida mediante múltiples reoperaciones tiende a ser comparable a la permeabilidad primaria de los puentes aórticos y b) ambas tasas de conservación del miembro son similares

Revascularización extraanatomica del sector aortoilíaco / Revascularization extraanatomic of the sector aortoiliac

Se presenta la experiencia de 10 años con el tratamiento de la oclusión aortoilíaca mediante procedimientos de alternativa. Se operaron 137 pacientes a los que se les revascularizaron 172 miembros. Se realizaron 74 puentes axilofemorales (35 con injerto cruzado) y 63 puentes femorofemorales. con los primeros se obtuvo 51% de permeabilidad primaria y 75% cuando se agregaron procedimientos para corregir las trombosis acaecidas. Para los puentes femorofemorales estos valores fueron 70 y 81% respectivamente. La permeabilidad comparada a los 5 años entre puentes axilo, uni o bifemorales fue 44 y 54%. La mortalidad operatoria fue del 7% y la infección periprotésica 5%. No se observaron fenómenos clínicos de "robo" en los segmentos arteriales dadores, teniendo este hecho una clara correlación con los valores de flujo registrados. La evaluación de estos resultados avalian el criterio de corrección extraanatómica empleado

Evaluación flujométrica de puentes axilofemorales y femoropoplíteos ante la compresión externa y la flexión / Flow evaluation of axillary femoral and femoropopliteal bypasses in external compression and flexion

Se evalúan los efectos que tienen las compresiones externas (peso corporal, cinturones, flexión de la pierna) sobre el comportamiento del flujo distal en un "bypass" axilofemoral o femoropoplíteo. Se estudiaron 10 puentes axilofemorales y 15 femoropolíteos (con diferentes materiales protésicos) no observándose variaciones estadísticamente significativas antes y después de las compresiones, concluyendose que la presión externa habitual no determina caída del flujo

Ulcera isquémica hipertensiva: un nuevo enfoque terapéutico / Hypertensive ischemic ular: a new therapeutic approach

Se presenta el caso de um paciente con una úlcera isquémica hipertensiva de 20 meses de evolución refractaria al tratamiento medicamentoso empleado. El éxito terapéutico se logró con la aplicación de la estimulación epidural permanente, procedimiento éste que se empleó por primera vez en la patología descripta por Martorell hace 40 años