Ethical evaluation of medical errors and the patient's safety.

In the offer of health care services, errors may arise that are repeated, so when one has occurred, it is essential to reflect on the elements that could cause it and act on them; however, in general, there is a natural tendency to hide them, mainly due to fear of sanctions or lawsuits. The ethics of clinical safety finds it essential to reveal errors, including almost errors or those without significant consequences, betting on transparent management of them. No error should be filed, since its review in an honest and open manner is not only an ethical obligation, but it can also help to lessen its effects and improve the doctor-patient relationship. Achieving safe medical care requires continuous learning about how the different components of the system interact, this implies putting into practice the behaviors that have shown their effectiveness to reduce the probability of the appearance of faults and errors, increase their detection and reduce their consequences, as well as continuing to investigate the factors that contribute to improving patient safety and the quality of care. In this paper we analyze the incidents related to patient safety, through statistical information from the Comisión Nacional de Arbitraje Médico (CONAMED), referring to complaint files concluded by arbitral award in the 2012-2016 period.

En la prestación de servicios de atención médica pueden surgir errores que se repiten; por ello, cuando se ha producido uno es indispensable reflexionar sobre los elementos que pudieron ocasionarlo y actuar sobre ellos. Sin embargo, de manera general, existe una tendencia natural a ocultar los errores, principalmente por temor a sanciones o demandas. La ética de la seguridad clínica encuentra indispensable revelar los errores, incluso los casi errores o aquellos sin consecuencias significativas, apostando por una gestión transparente de los mismos. Ningún error debe ser archivado, pues su revisión de forma honesta y abierta no solo es una obligación ética, sino que puede contribuir a aminorar sus efectos y mejorar la relación médico-paciente. Lograr una atención médica segura requiere aprendizaje continuo sobre cómo interaccionan los diferentes componentes del sistema; ello implica poner en práctica las conductas que han mostrado su efectividad para reducir la probabilidad de aparición de fallas y errores, aumentar su detección y disminuir sus consecuencias, así como continuar investigando sobre los factores que contribuyen a mejorar la seguridad del paciente y la calidad de la atención. En este trabajo se analizan los incidentes relacionados con la seguridad del paciente, a través de información estadística de la Comisión Nacional de Arbitraje Médico (CONAMED) referente a expedientes de queja concluidos por laudo en el periodo 2012-2016.

[A current perspective of natural orifices transluminal endoscopic surgery (NOTES)]. / Perspectiva actual de la cirugía endoscópica transluminal por orificios naturales (CETON).

Natural orifice transluminal endoscopic surgery (NOTES) represents an alternative in surgical approach, combined with the progress and experience gained from conventional and endoscopic surgery. Bibliographic research in PubMed, Medline database from 2000 to 2015 and analysis of the literature reviews found. NOTES provides vision and natural orifice approach, it has optimized operating times as well as reduced complications and better cosmetic results. Small series of patients have been reported, but there is not a valid clinical multicenter study by evidence-based medicine. NOTES can help to improve the standard operations, complemented with laparoscopic surgery rather than replace it and thus develop tools for the resolution of various diseases that require surgical treatment. This option in current surgery is safe and presents satisfactory results in the reported cases. The development of this new approach of performing surgical procedures requires further study and development of new technology in order to increase the accessibility of these procedures and represent in a practical and sustained way, a better option to approach surgical pathology.

Diverticular disease of the small bowel.

A diverticulum is a bulging sack in any portion of the gastrointestinal tract. The most common site for the formation of diverticula is the large intestine. Small intestine diverticular disease is much less common than colonic diverticular disease. The most common symptom is non-specific epigastric pain and a bloating sensation. Major complications include diverticulitis, gastrointestinal bleeding, acute perforation, pancreatic or biliary (in the case of duodenal diverticula) disease, intestinal obstruction, intestinal perforation, localized abscess, malabsorption, anemia, volvulus and bacterial overgrowth. We describe the clinical case of a 65-year-old female patient with a diagnosis on hospital admittance of acute appendicitis and a intraoperative finding of diverticular disease of the small intestine, accompanied by complications such as intestinal perforation, bleeding and abdominal sepsis. This was surgically treated with intestinal resection and ileostomy and a subsequent re-intervention comprising perforation of the ileostomy and stomal remodeling. The patient remained hospitalized for approximately 1 month with antibiotics and local surgical wound healing, as well as changes in her diet with food supplements and metabolic control. She showed a favorable clinical evolution and was dismissed from the hospital to her home. We include here a discussion on trends in medical and surgical aspects as well as early handling or appropriate management to reduce the risk of fatal complications.

Calidad de vida en pacientes operados de plastía inguinal mediante short form 36 (SF-36) / Quality of life in patients subjected to inguinal hernioplasty assessed through the short form 36 (SF-36)

Objetivo: Demostrar la autopercepción de los pacientes en su calidad de vida antes y después de operados de plastía inguinal en un hospital de tercer nivel de atención del sector salud, mediante el cuestionario de salud SF-36. Sede: Hospital General de México. Diseño: Estudio prospectivo, longitudinal, comparativo y observacional. Análisis estadístico: Medidas de tendencia central, prueba de rangos de Wilcoxon y modelo lineal general. Pacientes y métodos: Se incluyeron 67 pacientes a quienes se les realizó plastía inguinal con técnica de Lichtenstein, del día 1 de marzo al 31 de mayo de 2012, aplicando el cuestionario SF-36 un día previo al procedimiento quirúrgico y a los 3 meses posteriores a éste. Resultados: Se conformó el grupo con 64 hombres y 3 mujeres, con edad promedio de 44.73 (DE ± 13.2). Sin importar el tipo de hernia (clasificación de Nyhus), todos los pacientes percibieron una mejoría significativa en su calidad de vida (p <0.05). Los pacientes con menos de un año de síntomas ocasionados por la hernia inguinal no percibieron mejoría en su calidad de vida (p >0.05). Los casos con síntomas por más de 1 año manifestaron una mejoría significativa en su calidad de vida (p <0.05). Conclusiones: Los pacientes con más de un año de evolución de la hernia inguinal fueron los que percibieron mayor mejoría en su calidad de vida (SF-36) después de la cirugía.

Objective: To demonstrate self-perception of patients regarding their quality of life before and after inguinal plasty in a third level health care hospital of the health sector, by means of the SF-36 health questionnaire. Setting: Hospital General de México, Mexico City. Design: Prospective, longitudinal, comparative and observational study. Statistical analysis: Central tendency measures, Wilcoxon ranks tests and general linear model. Patients and methods: We included 67 patients, in whom inguinal plasty was performed with the Lichtenstein technique between March 1st and May 31st 2012, applying the SF-36 questionnaire one day before and 3 months after surgery. Results: The group consisted of 64 men and 3 women, average age of 44.73 (SD ± 13.2). Regardless of the type of hernia (Nythus classification), all patients perceived a significant improvement in their quality of life (p <0.05). Patients with less than 1 year with symptoms caused by the inguinal hernia did not perceive an improvement in the quality of life (p >0.05). Those cases with more than 1 year with symptoms perceived a significant improvement in their quality of life (p <0.05). Conclusions: Those patients with more than one year of evolution with the inguinal hernia were the ones to perceive the best improvement in their quality of life (SF-36) after surgery.

Precisión diagnóstica de la escala RIPASA para el diagnóstico de apendicitis aguda: análisis comparativo con la escala de Alvarado modificada / Diagnostic accuracy of the RIPASA Score for the diagnosis of acute appendicitis: comparative analysis with the modified Alvarado Score

Objetivo: Evaluar en forma comparativa la escala de Alvarado modificada y la escala RIPASA, para conocer su utilidad en el diagnóstico de apendicitis aguda en un hospital de tercer nivel de atención del sector salud. Sede: Hospital General de México. Diseño: Estudio prospectivo, transversal, comparativo y observacional. Análisis estadístico: Medidas de tendencia central, análisis para pruebas diagnósticas (sensibilidad, especificidad, valores predictivos, likelihood ratio o coeficiente de probabilidad) y curva ROC. Pacientes y métodos: De acuerdo al cálculo de tamaño de muestra se estudiaron 70 pacientes, que ingresaron al Servicio de Urgencias del Hospital General de México con síndrome doloroso abdominal sugestivo de apendicitis aguda, se les realizaron estudios de laboratorio y gabinete. Aplicando en forma simultánea las escalas de Alvarado modificada y la RIPASA. Se anotaron hallazgos clínicos, quirúrgicos e histopatológicos del apéndice. Resultados: La escala de Alvarado presentó una sensibilidad de 89.5% y especificidad de 69.2%, la RIPASA presentó una sensibilidad de 91.2% y especificidad de 84.6%. El área bajo la curva ROC de la escala RIPASA fue de 0.93, superior a la de Alvarado de 0.89. Si la decisión quirúrgica se hubiera realizado con base en la escala de Alvarado, las apendicectomías negativas se hubieran presentado en 18.3% pacientes, y con RIPASA disminuirían a 15.7%. Conclusiones: Ambas escalas presentaron buena sensibilidad para el diagnóstico de apendicitis aguda. La escala RIPASA presentó mejor especificidad y valores predictivos, con menor probabilidad de apendicectomías negativas. La escala RIPASA presenta mayor exactitud diagnóstica que la de Alvarado.

Objective: To assess comparatively the Modified Alvarado and the RIPASA scores, to know their usefulness in the diagnosis of acute appendicitis in a third level health care hospital. Setting: General Hospital of Mexico. Design: Prospective, cross-sectional, comparative, and observational study. Statistical analysis: Central Tendency Measures, analyses for diagnostic tests (specificity, sensitivity, predictive values, likelihood ratio) and ROC curve. Patients and methods: According to the established sample size, we studied 70 patients that were admitted at the Emergency Ward of the General Hospital of Mexico, with abdominal pain syndrome suggestive of acute appendicitis. Laboratory and imaging studies were performed. The modified Alvarado and RIPASA scores were applied simultaneously. Clinical, surgical, and histopathological findings were recorded. Results: The Alvarado score presented a sensitivity of 89.5% and a specificity of 69.2%, whereas RIPASA presented a sensitivity of 91.2% and specificity of 84.6%. The area under the ROC curve for the RIPASA score was 0.93, higher than that of the Alvarado with 0.89. If surgical decision had been based on the Alvarado score, negative appendicectomies would have been encountered in 18.3% of patients, and with RIPASA they would have diminished to 15.7%. Conclusions: Both scores presented a good sensitivity for the diagnosis of acute appendicitis. RIPASA presented better specificity and predictive values, with a lower likelihood of negative appendicectomies. The RIPASA score had a better diagnostic accuracy than the Alvarado score.

Influencia de la inmunonutrición sobre el estado general, nutricional y estancia hospitalaria en pacientes postoperados de sepsis abdominal / Influence of immunonutrition on the general and nutritional state, and on the in-hospital stay, of patients operated secondary to abdominal sepsis

Objetivo: Valorar el efecto del uso de glutamina con alimentación temprana, en pacientes con sepsis abdominal resuelta quirúrgicamente, sobre el estado general de salud (Apache II), el catabolismo proteico (nitrógeno ureico urinario), las complicaciones y la duración de la estancia hospitalaria. Sede: Hospital General de México. Diseño: Ensayo clínico controlado. Analisis estadístico: Prueba t de Student. Método: Se seleccionaron 24 pacientes con sepsis abdominal que requirieron resolución quirúrgica en la Unidad de Urgencias en el Hospital General de México. Luego de 24 a 72 h del evento quirúrgico, se inició la alimentación enteral en dos grupos: el primero con glutamina más alimentación estándar y el segundo con alimentación estándar. El día 1 y en el 3ro del postoperatorio se midieron niveles de laboratorio y nitrógeno ureico urinario, para determinar la clasificación Apache II, las complicaciones infecciosas y las no infecciosas, el balance nitrogenado y la duración de la estancia hospitalaria. Resultados: No se encontró diferencia significativa en ninguno de los parámetros medidos entre el grupo de glutamina y el control; sin embargo, sí lo hubo en el valor de Apache II en el grupo de glutamina comparando intragrupo entre el primer día y el tercero (P < 0.05). Conclusiones: La alimentación enteral temprana suplementada con glutamina no presenta diferencia temprana en cuanto a la respuesta metabólica al trauma, estado nutricional ni utilización proteica.

Objective: To assess the effect of glutamine, together with early enteral nutrition in patients with surgically resolved abdominal sepsis, on the general health status (Apache II), protein catabolism (urinary urea nitrogen test), complications, and duration of in-hospital stay. Setting: General Hospital of Mexico. Design: Controlled clinical trial. Statistical analysis: Student's t test. Method: We chose 24 patients with abdominal sepsis from the Emergency Ward in the General Hospital of Mexico, who required surgical resolution. After 24 to 72 h of the surgery, enteral nutrition was started in two groups: the first with glutamine plus standard nutrition and the second with standard nutrition. On days 1 and 3 of the postoperative period, laboratory tests were performed and urinary urea nitrogen was measured to determine Apache II classification, infectious and non-infectious complications, the nitrogen balance, and duration of in-hospital stay. Results: No statistically significant difference was found in any of the measured parameters between the two groups (glutamine and control); however, a significant difference was found in the value of the Apache II in the glutamine group when compared intragroup on the first and third days (p < 0.05). Conclusions: Early enteral nutrition supplemented with glutamine does not reveal an early difference in terms of the metabolic response to trauma, nutritional state, or protein utilization.

Low-risk papillary thyroid cancer recurrence in patients treated with total thyroidectomy and adjuvant therapy vs. patients treated with partial thyroidectomy.

BACKGROUND: Surgical extension for treatment of patients with low-risk papillary thyroid carcinoma is still controversial. We undertook this study to assess if there is a difference in recurrence between patients undergoing total thyroidectomy plus adjuvant therapy and patients treated with only partial thyroidectomy. METHODS: We conducted a longitudinal, observational, analytical study in patients with histopathological diagnosis of low-risk papillary thyroid carcinoma followed for at least 10 years. Patients were divided into two groups: Group 1: Patients treated with total thyroidectomy plus adjuvant therapy (TT) and Group 2: Patients treated with only partial thyroidectomy without adjuvant therapy (HT). Descriptive and inferential statistical methods were used. RESULTS: AMES: 184 patients, recurrence in 5/23 HT and 7/161 TT (p = 0.0016); MACIS: 170 patients, recurrence in 5/24 HT and 5/146 TT (p = 0.0008); DeGroot: 92 patients, recurrence in 3/19 HT and 2/73 TT (p = 0.0254); TNM: 150 patients, recurrence in 5/22 HT and 7/128 TT (p = 0.0058). The time interval for local recurrences was higher in comparison to regional recurrences (p <0.05). In all classifications, recurrences occur mainly with regional metastatic disease (60%). Multifocality, bilateral disease and extracapsular disease showed no statistical difference. There was one incidental injury to a recurrent laryngeal nerve and this was repaired during the same surgical procedure. There was no morbidity due to hypoparathyroidism. CONCLUSIONS: Patients classified as low risk according to any of the studied classifications have a higher risk for recurrence when treated with hemithyroidectomy than when treated with total thyroidectomy plus adjuvant therapy.

Prevalence of thyroid nodules in the Valley of Mexico.

BACKGROUND: There are no open population epidemiological studies to determine the true prevalence of thyroid nodules in the Valley of Mexico. The aim of this investigation was to determine prevalence. METHODS: We carried out a cross-sectional, observational, descriptive study in 2401 open population subjects in the Valley of Mexico. All subjects were at least 18 years of age with no clinical history of thyroid disease. Variables analyzed were age, gender, thyroid nodule identified by neck palpation or neck ultrasound, TSH levels, cytological diagnosis and histopathological diagnosis in case of clinical thyroid nodule detection. Percentages as a summary measure for qualitative variables and proportions and chi-square for independent variables were used for statistical analysis. RESULTS: Included were 2401 subjects with a mean age of 39 years (82.4% female, 17.6% male). Thirty-four (1.4%) thyroid nodules were detected by palpation and 471 (19.6%) by ultrasound. The 34 palpable thyroid nodules corresponded to 16 (47.2%) colloid goiters, 8 (23.5%) follicular adenomas, 7 (20.5%) Hashimoto's thyroiditis, 2 (5.9%) papillary carcinomas and 1 (2.9%) oxiphilic cell adenoma. Nonpalpable thyroid nodules detected by ultrasound did not develop illness at 2-year follow-up. TSH was normal in 1620 (67.4%), high in 515 (21.5%) and low in 266 (11.1%) patients. There was no relationship between TSH levels and final diagnosis of the 34 palpable nodules (p >0.05). CONCLUSIONS: Prevalence of palpable thyroid nodule in the Valley of Mexico is 1.4%; 5.9% of these are due to papillary thyroid cancer. TSH levels do not correlate with the presence or cause of the thyroid nodule.

Factors associated with postoperative complications and mortality in perforated peptic ulcer.

BACKGROUND: Elective surgery for uncomplicated peptic ulcer has shown a significant decrease; however, complications such as perforation and obstruction persist and require urgent surgical management. The aim of this study was to identify factors associated with early postoperative complications and mortality of patients admitted to the emergency department with perforated peptic ulcer. METHODS: We performed a clinical, retrospective, cross-sectional and descriptive study of patients who were treated at the General Hospital of Mexico with a diagnosis of perforated peptic ulcer from January 2006 to December 2008. Thirty patients were included in the study. We studied several clinical findings upon admission to the emergency department and intraoperative patient findings in order to determine the association of those with early postoperative complications and mortality. RESULTS: We studied 30 patients with an average age of 57.07 years (± 14.2 years). The male:female ratio was 2:1. We found that the risk of developing postoperative complications was 66.7% and is significantly influenced by time of onset of abdominal pain prior to admission, bloating, septic shock and blood type O positive. Mortality was 16.7% and was correlated with the presence of septic shock on admission. The surgical procedure performed was primary closure with Graham patch in 86.6%. Average hospital stay was 12.8 days. CONCLUSIONS: The presence of early postoperative complications is associated with time of onset of abdominal pain before admission, abdominal distension, blood type O positive and the presence of septic shock on admission.

Prevalencia de diabetes mellitus secundaria a necrosectomía pancreática / Prevalence of diabetes mellitus secondary to pancreatic necrosectomy

Objetivo: Reportar la prevalencia de diabetes mellitus secundaria a necrosectomía por complicaciones sépticas de la pancreatitis aguda severa. Sede: Hospital General de México, OD Diseño: Estudio clínico comparativo, observacional, longitudinal, transversal y retrospectivo. Análisis estadístico: Medidas de tendencia central, prueba de Chi cuadrada (χ²) y prueba t de Student. Material y métodos: Se analizaron todos los pacientes consecutivos con diagnóstico de diabetes mellitus secundaria (DMS) a necrosectomía por complicación séptica de pancreatitis aguda severa (PAS) atendido entre el 1 de enero de 1999 al 31 de diciembre de 2009, mayores de 18 años, tanto hombres como mujeres, vivos al momento del seguimiento, con seguimiento hasta 12 meses. Las variables evaluadas fueron: edad, género, etiología, grado de necrosis, número de desbridamientos pancreáticos, días de internamiento, días de estancia en Unidad de Cuidados Intensivos, Calificaciones de Ranson, APACHE II y Balthazar preoperatorias, glicemia en ayuno subsecuentes a los 1, 6 y 12 meses posteriores a la última cirugía para detección de paciente con DMS. Resultados: De un total de 137 pacientes con complicaciones sépticas de PAS y necrosectomía, 67 se excluyeron, 33 por fallecimiento (24%), 26 por seguimiento incompleto (18.9%) y 8 por DM previa al evento de pancreatitis aguda (5.8%); quedaron 70 pacientes, de los cuales 46 (65.7%) desarrollaron DMS; la etiología fue alcohólica en 36 (51.4%), biliar en 31 (44.3%) y por otras causas en 3 (4.3%). En la evaluación por tomografía se detectó en 10 casos con Balthazar C (14.3%), 20 con D (28.6%) y 40 con E (57.1%). Desbridamientos pancreáticos realizados: 1 en 18 pacientes (25.8%), 2 en 12 (17.1%), 3 en 12 (17.1%), 4 en 13 (18.6%) y 5 o más en 15 casos (21.4%). El promedio de estancia hospitalaria y en la Unidad de Cuidados Intensivos fue de 21.6 (rango 10-48) y 14.2 días (rango 5-28), respectivamente. La calificación Ranson promedio fue de 2.8 (rango de 2-6) y APACHE II preoperatoria promedio fue de 12 puntos (rango 8-28). La DMS se detectó en la mayoría de los pacientes poco tiempo después de su egreso; en el 82.6% a las 4 semanas, en el 17.4% a los 6 meses y ningún otro a los 12 meses posteriores a la última necrosectomía. El resultado de TC demostró mayor frecuencia de DM en aquellos pacientes clasificados con E (P < 0.0001), así como la realización de más de 4 desbridaciones con una P < 0.001. Conclusiones: La prevalencia de diabetes mellitus secundaria en pacientes con necrosis pancreática infectada, postoperados de necrosectomía pancreática fue del 65.7%, se relaciona con clasificación por TAC de Balthazar E y con 4 o más desbridaciones.

Objective: To report on the prevalence of diabetes mellitus secondary to necrosectomy due to septic complication of severe acute pancreatitis. Setting: General Hospital of Mexico. Design: Clinical comparative, observational, longitudinal, transversal, retrospective study. Statistical analysis: Central tendency measures, Chi square (χ2) and Student's t tests. Material and methods: We evaluated all consecutive patients with a diagnosis of diabetes mellitus secondary (DMS) to a necrosectomy due to septic complication of severe acute pancreatitis (SAP) cared for between January 1st 1999 and December 31st 2009, older than 18 years, of either sex, alive at the time of follow-up, and a follow-up of 12 months. Assessed variables were: age, gender, etiology, degree of necrosis, number of pancreatic debridements, in-hospital stay days, days of Intensive Care Unit stay, scores of preoperative Ranson, APACHE II, and Balthazar, fasting glycemia at 1, 6, and 12 months after the last surgery to detect patients with DMS. Results: From a total of 137 patients with septic complications of SAP and necrosectomy, 67 were excluded: 33 (24%) due to death, 26 (18.9%) because of incomplete follow up, and 8 (5.8%) because of DM before the acute pancreatitis event, this left 70 patients of which 46 (65.7 %) developed DMS; etiology was alcoholic in 36 (51.4%), biliary in 31 (44.3%), and other causes in 3 (4.3%). Tomography evaluation revealed 10 (14.3%) cases with Balthazar C, 20 (28.6%) with D, and 40 (57.1%) with E. Pancreatic debridements performed were: 1 in 18 patients (25.8%), 2 in 12 (17.1%), 3 in 12 (17.1%), 4 in 13 (18.6%), and 5 or more in 15 cases (21.4%). Average in-hospital stay and in the Intensive Care Unit was 21.6 (range 10-48) days and 14.2 (range 5-28) days, respectively. The average Ranson score was of 2.8 (range 2-6) and average preoperative APACHE II was of 12 (range 8-28). DMS was detected in most patients shortly after their hospital ...

¿Hay factores clínicos y/o bioquímicos con los que se pueda presumir diagnóstico preoperatorio de perforación de vesícula biliar? / Are there clinical or biochemical factors that would allow assuming a preoperatory diagnosis of gallbladder perforation?

Objetivo: Conocer la prevalencia e identificar cuáles datos clínicos y/o bioquímicos detectan la perforación vesicular en forma preoperatoria en pacientes con colecistitis aguda. Sede: Hospital General de México, O.D. Diseño: Estudio de casos y controles. Análisis estadístico: Razón de momios, Chi cuadrada (χ²) y t de Student. Material y métodos: Se estudiaron los expedientes de pacientes operados por el servicio de urgencias del Hospital General de México en el periodo de diciembre 2007 a septiembre del 2009. Se revisaron todos los pacientes operados de colecistectomía, seleccionando, de éstos, a los pacientes con reporte de perforación de vesícula biliar (correspondiendo a casos) y se comparó con controles pareados (una perforación por dos no perforados), es decir, pacientes con las mismas características pero sin perforación vesicular. La variables analizadas fueron edad, género, tipo de perforación, signo de Murphy, signos de irritación peritoneal, fiebre, comorbilidades, consumo de tabaco, alcohol o drogas, tiempo de evolución, de ingreso a quirófano, diagnóstico preoperatorio clínico y paraclínico, tipo de abordaje, sitio de perforación, complicaciones y mortalidad. Resultados: Las comparaciones entre cada una de las variables estudiadas y la presencia o no de perforación indica la fiebre (temperatura > 38°C) antes de cirugía como único factor con significancia estadística RM de 1.15 (IC 95% de 0.51 a 2.6) P = 0.001. Conclusiones: La prevalencia de perforación de vesícula biliar en pacientes con colecistitis aguda es de 9.7%. El único dato clínico relacionado a esta complicación y que pudiera hacer sospechar su diagnostico es la fiebre.

Objective: To know the prevalence and to identify which clinical and/or biochemical data can lead to detect gallbladder perforation preoperatively in patients with acute cholecystitis. Setting: General Hospital of Mexico City (Ministry of Health). Design: Study of cases and controls. Statistical analysis: Odds ratio, Chi square (χ²), and Student's t test. Material and methods: We examined the clinical files of patients operated at the Emergency Ward of the General Hospital of Mexico City in the period between December 2007 and September 2009. We reviewed all patients subjected to cholecystectomy, choosing from them those patients with perforation of the gallbladder (cases) and compared them with paired controls (one perforation with two non-perforated), that is, patients of the same characteristics but without gallbladder perforation. Analyzed variables were age, gender, type of perforation, Murphy's sign, sign of peritoneal irritation, fever, comorbidities, alcohol or drug consumption, smoking, time of evolution, time of operating room admittance, clinical and paraclinical preoperative diagnosis, type of approach, perforation site, complications, and mortality. Results: Comparison between each studied variable and the presence or not of perforation reveals fever (temperature > 38°C) as the sole factor with statistical significance, odds ratio of 1.15 (IC 95% from 0.51 to 2.6) P = 0.001. Conclusions: Prevalence of gallbladder perforation in patients with acute cholecystitis is of 9.7%. The only clinical data related to this complication and that could lead to suspect its diagnosis was fever.

Evolution of surgical treatment of amebiasis-associated colon perforation.

BACKGROUND: Amebiasis is a worldwide health problem that mainly affects developing countries. Invasive amebiasis tends to develop complications, and among these, perforation of the colon, although infrequent (1.9-9.1%), is the most lethal. Surgical treatment in these cases should be carried out in a timely fashion prior to the presentation of systemic repercussions or death. In the present study, we analyzed a total of 122 cases of invasive amebiasis-associated colon perforation. METHODS AND STUDY DESIGN: We conducted a clinical, retrospective, and observational study and presented cases of colonic perforation observed over the past 30 years at the Medical-Surgical Emergency Service of the Mexico City-based Hospital General de México OD during the 1970-1999 period. RESULTS: During this time, a total of 19,916 emergency abdominal surgeries were performed. One hundred twenty-two of these procedures corresponded to cases of colon perforation by ameba, which represents 0.6%; 80 patients were men (65.6%) and 42 were women (34.4%), with an average age of 48 years. Multiple colon perforation was 74%, with right colon the most affected (90.5%). Depending on the perforation's extension and localization, right hemicolectomy with ileostomy were performed in 53 patients (43.45%), subtotal colectomy with ileostomy in 43 (35.25%), left hemicolectomy with transverse colostomy in 12 (9.83%), exteriorization of perforated left colon (stoma) in 13 (10.65%), and primary closure with exteriorization in one patient (0.8%). Post-operative complications were present in 48 patients (39.3%), and 20 cases were related with the creation of a stoma. Eighteen of these cases were due to persistent abdominal sepsis and ten due to toxic colon; the latter correspond solely to patients with initial nonresective treatment. General mortality was 40%, with 32% (17 of 53 cases) of mortality in those submitted to right hemicolestomy, 16.7% (two of 12) of left hemicolestomy, 44.2% (19 of 43) in those in whom a subtotal colectomy was performed, with 76.9% (ten of 13) patients with exteriorization of the perforated right colon, and with 100% (one of one patient) mortality with primary closure. CONCLUSIONS: Perforation is the most frequent surgical complication of invasive amebiasis of the colon, occurring principally in masculine gender and in the fourth decade of life. Resection and stoma creation is the procedure of choice that can resolve the septic focus from the first surgical procedure, depending on the general status of the patient. However, morbidity and mortality are high, and there is a tendency for these to be lower on comparing initial cases with those with recently conducted surgical procedures.

Gallstone ileus: clinical presentation of a benign mechanical intestinal obstruction.

Gallstone ileus is a rare cause of small bowel obstruction which usually presents in elderly female patients and which has been associated with high morbidity and mortality rates. We present the case of a 63-year-old man who presented at our institution with symptoms of bowel obstruction. Abdominal X-ray and exploratory laparotomy revealed a large gallstone in the terminal ileus.

Propuesta de una escala práctica para el diagnóstico temprano de apendicitis aguda / Proposal of a practical scale for the early diagnosis of acute appendicitis

Objetivo. Propuesta de una escala práctica, confiable y dinámica para el diagnóstico temprano de apendicitis aguda. Diseño. Estudio longitudinal, prospectivo. Sede. Servicio de Urgencias Médico Quirúrgicas. Hospital de tercer nivel de atención. Pacientes y Método. Se evaluaron 281 casos con dolor abdominal agudo de julio de 1995 a junio de 1996. Ciento cincuenta y seis hombres y 125 mujeres, con edad promedio de 28.4 años. Doscientos treinta presentaron apendicitis con confirmación histopatológica. Análisis estadístico. Prueba F y T. Resultados. Se realizó una escala para el diagnóstico temprano de la pendicitis aguda, basada en 3 signos (dolor a la palpación en cuadrante inferior derecho, rebote en fosa iliaca derecha, McBurney), 3 síntomas (dolor migratorio a fosa iliaca derecha, anorexia, náusea/vómito) y 2 hallazgos de laboratorio (leucocitosis < 10,000 células/mm3, neutrofilia < 7,500 células/mm3) a cada uno de los cuales se les asignó un valor para un total de 10 puntos. Siete puntos o más se consideró como candidato a cirugía por probable apendicitis. Los puntos promedio con la escala en pacientes con apendicitis fue de 8.9 y de 7.1 sin la enfermedad. Existen diferencias estadísticamente significativas (p<0.05) entre los pacientes con y sin apendicitis. Conclusión. La escala propuesta demostró ser útil en el diagnóstico temprano de la apendicitis aguda, puede ser de ayuda cuando exista discrepancia en el tratamiento oportuno

Sensibilidad, especificidad y valores predictivos de la radiografía simple de abdomen en apendicitis / Sensibility, specificity and predictive value of the plain radiography of the abdomen in appendicitis

El objetivo de este trabajo es conocer la utilidad diagnóstica de la radiografía simple de abdomen en apendicitis. En un período de dos años se evaluaron 137 pacientes (51 por ciento masculinos y 49 por ciento femenino); se incluyeron aquellos pacientes a los que se les practicó una placa simple de abdomen en posiciones de pie y decúbito, con diagnóstico presuntivo de apendicitis. Todos fueron intervenidos quirúrgicamente comparando la placa simple de abdomen como la prueba diagnóstica a evaluar contra el diagnóstico definitivo. La sensibilidad del estudio fue de 85 por ciento, la especificidad 50 por ciento, el valor previdictivo posotivo 92 por ciento y el valor predictivo negativo 34 por ciento. Los signos radiológicos encontrados con mayor frecuencia fueron: asa centinela en 65 por ciento y borramiento del psoas derecho en 58 por ciento; los signos observados en absceso apendicular fueron: imagen en "panal de abeja" ciego con nivel hidroaéreo. La prueba diagnóstica mostró su capacidad para detectar la apendicitis en más de ocho de cada diez pacientes, pero muy poca para descartarla

La primera esplenectomía por laparoscopia en México / The first laparoscopic splenectomy in Mexico

Se informa sobre la realización de la primera esplenectomía en México por vía laparoscópica en una mujer de 32 años de edad con enfermedad de base anemia hemolítica autoinmune así como colecistectomía laparoscópica incidental en octubre de 1992 en el Hospital General de México, S.S.A. Su evolución fue satisfactoria al utilizar menos sangre para transfusión, el dolor postoperatorio mínimo, dándose de alta a la paciente a la 72 hrs. estando en la actualidad asintomática y bajo seguimiento por el Servicio de Hematología

La urgencia abdominal en el divertículo de Meckel del adulto / The abdominal emergency in the adult Meckel's diverticulum

Se analiza la patología del divertículo de Meckel del adulto, ocupando un 0.28% de 8,538 intervenciones quirúrgicas abdominales en un período de 15 años. Asimismo se revisan 17,884 autopsias del propio hospital en 17 años ocupando el 0.27% de casos asintomáticos. Es más frecuente en el sexo masculino entre los 14 y 30 años, siendo el síndrome de oclusión intestinal el que predomina. En ninguno se hizo el diagnóstico preoperatorio, habiéndose perforado el 45%, sangrado de tubo digestivo bajo en el 8% y tejido heterotópico gástrico en el 4%. La resección intestinal y anastomosis término-terminal fue el procedimiento quirúrgico de elección, dejando la ileostomía para aquellos con peritonitis purulenta severa. La morbilidad fue del 17% y la mortalidad del 8%. Debido a las complicaciones de esta patología recomendamos la resección y cierre transversal del divertículo de Meckel ante el hallazgo o diagnóstico preoperatorio, cuando tiene más de 2 cm. de largo, variedad fija y sin antecedentes de diverticulitis. Cuando hay sangrado de tubo digestivo bajo, o cuadros de diverticulitis, la indicación es resección del íleon incluyendo el divertículo de Meckel y anastomosis término-terminal. Se debe revisar rutinariamente, el último metro del íleon, en cirugía electiva, en sintomatología no comprobada de cuadrantes inferiores del abdomen, durante el transoperatorio.

Vólvulus gástrico. Presentación de dos casos / Gastric volvulus. Report of two cases

Se presentan dos casos de vólvulus gástricos, uno de ellos asociado a hernia diafragmática; se diagnosticaron por medio de un estudio endoscópico, corroborándose con estudios radiológicos baritados. Los dos casos fueron manejados quirúrgicamente con éxito .