Assuntos
Fístula Anastomótica/cirurgia , Gastrectomia/métodos , Obstrução Intestinal/cirurgia , Laparoscopia/métodos , Gastropatias/cirurgia , Anastomose em-Y de Roux , Fístula Anastomótica/etiologia , Gastrectomia/efeitos adversos , Humanos , Obstrução Intestinal/etiologia , Masculino , Omento/cirurgia , Gastropatias/etiologia , Adulto JovemRESUMO
BACKGROUND: Recent studies suggest that intraluminal pancreatic enzymes play a major role in the initiation of the inflammatory cascade by the gut after hemorrhagic shock. Previous animal models have shown that the inhibition of enteral pancreatic enzymes with a serine protease inhibitor, nafamostat mesilate (NM), decreases leukocyte activation and transfusion requirements after hemorrhagic shock. The objective of this study was to determine whether enteroclysis with NM would improve the clinical outcomes in swine after hemorrhagic shock and intestinal hypoperfusion. METHODS: Thirty-three male Yucatan minipigs weighing 25 kg to 30 kg underwent a controlled hemorrhage of 25 mL/kg with mesenteric clamp for further gut ischemia. Animals were allocated to three groups: (1) shock only (n = 15), (2) shock + enteroclysis with 100 mL/kg GoLYTELY (GL) as a carrier (n = 11), and (3) shock + enteroclysis with GL + 0.37 mmol/L NM (GL+NM, n = 7). Animals were resuscitated, recovered from anesthesia, observed for 3 days, and graded on a daily 4-point clinical scoring system. A score of 0 indicated a moribund state or early death, and a score of 4 indicated normal behavior. RESULTS: Pigs treated with GL + NM had significantly higher mean postoperative recovery scores (3.8 +/- 0.4, essentially normal behavior with no early deaths) compared with animals within the shock only and shock + GL groups (2.1 +/- 1 with one early death and 2.2 +/- 1.2 with two early deaths, respectively, analysis of variance p < 0.003). CONCLUSION: The inhibition of intraluminal pancreatic enzymes using enteroclysis with the serine protease inhibitor, NM, after hemorrhagic shock significantly improves the clinical outcome.
Assuntos
Guanidinas/uso terapêutico , Pâncreas , Inibidores de Serina Proteinase/uso terapêutico , Choque Hemorrágico/tratamento farmacológico , Análise de Variância , Animais , Benzamidinas , Modelos Animais de Doenças , Avaliação Pré-Clínica de Medicamentos , Duodenostomia , Eletrólitos/uso terapêutico , Nutrição Enteral , Guanidinas/imunologia , Guanidinas/farmacologia , Leucócitos/efeitos dos fármacos , Masculino , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/prevenção & controle , Pâncreas/efeitos dos fármacos , Pâncreas/enzimologia , Polietilenoglicóis/uso terapêutico , Ressuscitação/métodos , Inibidores de Serina Proteinase/imunologia , Inibidores de Serina Proteinase/farmacologia , Choque Hemorrágico/complicações , Choque Hemorrágico/enzimologia , Choque Hemorrágico/imunologia , Choque Hemorrágico/mortalidade , Suínos , Porco Miniatura , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Síndrome de Resposta Inflamatória Sistêmica/prevenção & controle , Resultado do TratamentoRESUMO
The specialty of trauma is at a crossroads. Choosing a career in trauma is associated with concerns related to lifestyle issues and maintenance of adequate operative experience. Trauma and critical care surgeons in the U.S. have reexamined their role based on these concerns and the realization that surgeon resources for the injured patient are in jeopardy. After much work over the past five years, a model of "Acute Care Surgery" has emerged and a training curriculum has been proposed. This article reviews the evolution of a new specialty and identifies some of the challenges and opportunities associated with the implementation of this model.