Fast track in colo-rectal surgery. Preliminary experience in a rural hospital.

BACKGROUND: "Fast Track surgery" is a therapeutic program of large application, despite some doubts about its applicability and real validity. Literature review shows that this approach to colo-rectal surgery, particularly video-assisted, can allow a rapid recovery, better performance and a faster postoperative functional autonomy of the work, which can be discharged without cause additional welfare costs; in addition it can be reproducible in different health reality. PURPOSE: To analyze the possibility to apply the Fast Truck protocol in patients undergoing colorectal surgery in a rural hospital and non specialistic Unit of Surgery. PATIENTS AND METHODS: We have conducted a prospective, randomized study on 80 patients subjected to colorectal surgery in the last year. RESULTS: The protocol was observed in 95% of cases, compliance with the Fast Track was high and general morbidity was limited (7.8%). CONCLUSION: This "aggressive" approach, which has fundamentally altered the usual surgical behavior, seems to allow a mean length of stay significantly lower than in controls (p < 0.05) with positive implications for patients and containment of health care costs, even after discharge (no need for home care in 92% of cases, no early re-admittance to the hospital). Homogeneous protocols are desirable, as well as an increased enrollment, to consolidate these rehabilitation programs in order to provide a reference for all hospitals.

Extensive resection in pancreatic cancer: review of the literature and personal experience.

BACKGROUND/AIMS: The surgical treatment of pancreatic carcinoma, and particularly the decision to resect locally advanced non-metastatic cancer is extremely controversial. The aim of this study is to report our experience in extensive pancreatectomy and draw conclusions regarding its effectiveness in treating locally advanced pancreatic cancer. METHODOLOGY: In our Department of Surgery, 12 patients underwent pancreatic resective surgery extended to the portal vein (6 cases), to the superior mesenteric vein (1 case) or to other peripancreatic organs (5 cases). RESULTS: The procedure was considered curative in 7 cases. The mortality rate was 16.6% and the morbidity 25%. Four out of the five patients who had undergone vascular resection and had not died in the postoperative period survived for more than 12 months, while the 5 cases in whom the resection was extended to other organs survived from 9 to 93 months. In all cases, the quality of life was satisfactory until tumor recurrence, which occurred in 8 cases (66.7%). Two of the cases with vascular resection are still alive after 17 and 22 months. CONCLUSIONS: In all of these 12 cases, we were forced to perform "extensive" resective surgery, which was apparently curative, although we were not able to prevent recurrence in a high percentage of cases. Moreover, aggressive surgery seems justified in particular histotypes, such as in the carcinoid case reported in our study; debulking enhances the effectiveness of chemotherapy and permits relief of the endocrine symptoms eventually induced by the tumor.

Tórax móvil traumático / Traumatic flail chest

El tórax móvil es una entidad poco frecuente en niños debido a la mayor elasticidad de la pared costal comparado con adultos. Se presenta una niña de 20 meses que ingresa a la Unidad de Cuidados Intensivos Pediátricos, quien embestida por un automóvil, sufrió un politraumatismo severo con tórax móvil. Se realiza una revisión de esta entidad en la literatura

Tórax móvil traumático / Traumatic flail chest

El tórax móvil es una entidad poco frecuente en niños debido a la mayor elasticidad de la pared costal comparado con adultos. Se presenta una niña de 20 meses que ingresa a la Unidad de Cuidados Intensivos Pediátricos, quien embestida por un automóvil, sufrió un politraumatismo severo con tórax móvil. Se realiza una revisión de esta entidad en la literatura

Formación de recursos humanos para la atención de víctimas pediátricas traumatizadas: cursos A.I.T.P., una experiencia docente / Teaching model in advanced pediatric trauma courses

Introducción: Se presenta la experiencia de 5 años de los Cursos A.I.T.P. Cursos de Atención Inicial en Trauma pediátrico. Los objetivos de este trabajo son: a) presentar la experiencia docente de los cursos avanzados sobre la atención inicial en trauma pediátrico, b) evaluar el desarrollo de los cursos, parte de un programa de formación de recursos humanos, inédito en nuestro medio y original en el campo de la Pediatría, c) evaluar el desempeño y características de los participantes y d) analizar la respuesta de los alumnos sobre los cursos. La experiencia comunicada en este trabajo se basa en el análisis de los cursos Atención Inicial en Trauma Pediátrico o Cursos A.I.T.P. del Programa Categorización y Atención del Paciente Pediátrico Accidentado (Programa C.A.P.P.A.). Método: Se describe la dinámica pedagógica de los Cursos A.I.T.P., y el tipo de datos recogidos en una base de datos sobre el desempeño de los participantes así como sobre la evaluación que hacen los mismos de los cursos. Resultados: Entre 1991 y 1995 se realizaron 15 Cursos A.I.T.P. en los cuales participaron 274 profesionales entre médicos y enfermeras. La edad media para los primeros fue de 30,4 años y la media de años de recibidos fue de 8,4 años. La distribución por sexo en los médicos fue predominante el masculino y en las enfermeras el femenino. El 94,9 por ciento profesionales de distintos puntos del país y un 5,1 por ciento fueron profesionales de países vecinos. El índice de ausentismo fue del 9 por ciento. El índice de aprobados fue del 81 por ciento. La evaluación por parte de los alumnos fue muy favorable en el 97 por ciento de las observaciones y el 100 por ciento recomendaría a sus colegas la participación en los Cursos A.I.T.P. Comentarios: Los Cursos A.I.T.P. son una experiencia docente original en el campo de formación de recursos humanos en el campo de la Pediatría. La presencia de profesionales de diversas especialidades, provenientes de Capital Federal y distintas provincias, revela el interés despertado en los equipos de salud por este tema. La participación de médicos y enfermeras extranjeros es parte de una importante tarea de integración entre países vecinos y de participación de los logros alcanzados en trauma pediátrico...

Formación de recursos humanos para la atención de víctimas pediátricas traumatizadas: cursos A.I.T.P., una experiencia docente / Teaching model in advanced pediatric trauma courses

Introducción: Se presenta la experiencia de 5 años de los Cursos A.I.T.P. Cursos de Atención Inicial en Trauma pediátrico. Los objetivos de este trabajo son: a) presentar la experiencia docente de los cursos avanzados sobre la atención inicial en trauma pediátrico, b) evaluar el desarrollo de los cursos, parte de un programa de formación de recursos humanos, inédito en nuestro medio y original en el campo de la Pediatría, c) evaluar el desempeño y características de los participantes y d) analizar la respuesta de los alumnos sobre los cursos. La experiencia comunicada en este trabajo se basa en el análisis de los cursos Atención Inicial en Trauma Pediátrico o Cursos A.I.T.P. del Programa Categorización y Atención del Paciente Pediátrico Accidentado (Programa C.A.P.P.A.). Método: Se describe la dinámica pedagógica de los Cursos A.I.T.P., y el tipo de datos recogidos en una base de datos sobre el desempeño de los participantes así como sobre la evaluación que hacen los mismos de los cursos. Resultados: Entre 1991 y 1995 se realizaron 15 Cursos A.I.T.P. en los cuales participaron 274 profesionales entre médicos y enfermeras. La edad media para los primeros fue de 30,4 años y la media de años de recibidos fue de 8,4 años. La distribución por sexo en los médicos fue predominante el masculino y en las enfermeras el femenino. El 94,9 por ciento profesionales de distintos puntos del país y un 5,1 por ciento fueron profesionales de países vecinos. El índice de ausentismo fue del 9 por ciento. El índice de aprobados fue del 81 por ciento. La evaluación por parte de los alumnos fue muy favorable en el 97 por ciento de las observaciones y el 100 por ciento recomendaría a sus colegas la participación en los Cursos A.I.T.P. Comentarios: Los Cursos A.I.T.P. son una experiencia docente original en el campo de formación de recursos humanos en el campo de la Pediatría. La presencia de profesionales de diversas especialidades, provenientes de Capital Federal y distintas provincias, revela el interés despertado en los equipos de salud por este tema. La participación de médicos y enfermeras extranjeros es parte de una importante tarea de integración entre países vecinos y de participación de los logros alcanzados en trauma pediátrico...(AU)

Assessment of risk factors for pancreatic resection for cancer.

A series of 101 consecutive patients undergoing pancreatic resection for cancer was retrospectively analyzed to define factors that may affect the immediate postoperative outcome. Overall morbidity and mortality were 28.7% and 10.9%, respectively, although these figures were greatly reduced during the last years; the complication rate dropped from 55.6% (1981-1987) to 20.0% (1993-1995) and the mortality from 16.7% to 6.7%. At univariate statistical analysis the patient characteristics (sex, age, American Society of Anesthesiologists [ASA] class, nutritional status, jaundice), tumor characteristics (site, size, TNM stage, and grading), and type of surgery were found not to affect postoperative morbidity and mortality. In contrast, a significantly lower rate of complications was observed in patients not undergoing gastric resection, in those who received 3 units or less of blood intraoperatively, and in subjects operated more recently (after 1990). At multivariate analysis the period when the operation was performed was the only independent variable that affected the immediate postoperative outcome. Among the examined factors, only the experience acquired over time regarding the intra- and perioperative treatment of these patients seems able to lower the rate of postoperative complications.

Análisis comparativo de la mortalidad por trauma en pediatría / Mortality in pediatric trauma

Introducción: Los aspectos epidemiológicos de las lesiones por trauma y en particular el análisis de la morbi-mortalidad por esta causa, constituyen temas en estudio de interés general. En este marco y a modo de hipótesis se puede asumir que mediante un adecuado nivel de capacitación, se pueden modificar actitudes y acciones en la atención inicial, lo cual disminuiría la mortalidad de las víctimas traumatizadas. El objetivo de este trabajo es mostrar la variación de letalidad en trauma pediátrico. Material y método: Durante la Fase I del Registro de Trauma Pediátrico (RTP) ingresaron 5013 pacientes. Esta fase se desarrolló entre Enero 1990 y Diciembre 1994 e intervinieron en la recopilación centros que integran la red del programa C.A.P.P.A. Para el presente trabajo se tomaron dos subperíodos del RTP de 15 meses cada uno. Denominados en adelante S-90 y S-94. El S-90 comprendido entre el 1/1/1990 y el 31/3/1991. El S-94, comprendido entre 1/10/93 y el 31/12/94. Estos subperíodos permiten tener una clara separación de tiempo entre ambas series. Los lugares del muestreo habían participado del programa docente. Para evaluar la gravedad de las lesiones se usó el indice de Traumatismo Pediátrico (ITP). Para el análisis que se realiza en el presente trabajo se incluyen los pacientes con ITP entre 2 a 8. Se analizan las variables edad, número de días de internación, ITP para el total de pacientes de ambos períodos considerados y para los que tuvieron condición de egreso fallecidos. Resultados: Para las variables relativas al total de traumatizados y al total de muertos de ambas series, no se observan diferencias significativas en cuanto a los promedios de edad, ITP y días de internación. En el grupo de pacientes con ITP entre 2 y 8 se observó que los tres cuartiles del ITP en el rango considerado resultaron iguales para los dos períodos comparados (p25 = 5; Mediana = 7; P75 = 8). Al comparar la mortalidad registrada, en los primeros 15 meses del RTP con la registrada en los últimos 15 meses, se observó una diferencia entre las mismas, resultando mayor en la S-90 (14,1 por ciento) que en la S-94 (5,9 por ciento) (X² = 9,51; p = 0,002; Odds Ratio = 2,6; Límite Confianza Cornfield al 0,95: 1,34 < OR < 5,09). Comentarios: En Argentina se dispone del Registro de Trauma Pediátrico, (RTP), su información posibilita evaluar las características de las víctimas y de los accidentes...

Análisis comparativo de la mortalidad por trauma en pediatría / Mortality in pediatric trauma

Introducción: Los aspectos epidemiológicos de las lesiones por trauma y en particular el análisis de la morbi-mortalidad por esta causa, constituyen temas en estudio de interés general. En este marco y a modo de hipótesis se puede asumir que mediante un adecuado nivel de capacitación, se pueden modificar actitudes y acciones en la atención inicial, lo cual disminuiría la mortalidad de las víctimas traumatizadas. El objetivo de este trabajo es mostrar la variación de letalidad en trauma pediátrico. Material y método: Durante la Fase I del Registro de Trauma Pediátrico (RTP) ingresaron 5013 pacientes. Esta fase se desarrolló entre Enero 1990 y Diciembre 1994 e intervinieron en la recopilación centros que integran la red del programa C.A.P.P.A. Para el presente trabajo se tomaron dos subperíodos del RTP de 15 meses cada uno. Denominados en adelante S-90 y S-94. El S-90 comprendido entre el 1/1/1990 y el 31/3/1991. El S-94, comprendido entre 1/10/93 y el 31/12/94. Estos subperíodos permiten tener una clara separación de tiempo entre ambas series. Los lugares del muestreo habían participado del programa docente. Para evaluar la gravedad de las lesiones se usó el indice de Traumatismo Pediátrico (ITP). Para el análisis que se realiza en el presente trabajo se incluyen los pacientes con ITP entre 2 a 8. Se analizan las variables edad, número de días de internación, ITP para el total de pacientes de ambos períodos considerados y para los que tuvieron condición de egreso fallecidos. Resultados: Para las variables relativas al total de traumatizados y al total de muertos de ambas series, no se observan diferencias significativas en cuanto a los promedios de edad, ITP y días de internación. En el grupo de pacientes con ITP entre 2 y 8 se observó que los tres cuartiles del ITP en el rango considerado resultaron iguales para los dos períodos comparados (p25 = 5; Mediana = 7; P75 = 8). Al comparar la mortalidad registrada, en los primeros 15 meses del RTP con la registrada en los últimos 15 meses, se observó una diferencia entre las mismas, resultando mayor en la S-90 (14,1 por ciento) que en la S-94 (5,9 por ciento) (X² = 9,51; p = 0,002; Odds Ratio = 2,6; Límite Confianza Cornfield al 0,95: 1,34 < OR < 5,09). Comentarios: En Argentina se dispone del Registro de Trauma Pediátrico, (RTP), su información posibilita evaluar las características de las víctimas y de los accidentes...(AU)

Integrated radiosurgical treatment of resectable pancreatic head carcinoma.

Thirty-six patients with pancreatic head carcinoma entered a protocol, but only 20 were suitable for resection and evaluation of long-term survival. They were nine males and 11 females, with a mean age of 64.3 years. Following surgical resection, 10 Gy was delivered to the tumor bed intraoperatively. Postoperative radiotherapy was performed 4-6 weeks after surgery: patients were treated with 50.4 Gy (1.8 Gy/day, 5 days/week) to the tumor and nodal bed. Since 1991, 10 patients have also received preoperative short-course radiotherapy (5 Gy) of the liver and pancreas. Postoperative morbidity was 25%; two postoperative deaths were observed in patients with locally advanced neoplasms, in whom a vascular resection was also performed. Only 14 patients started postoperative radiotherapy, which was interrupted in two cases. At present, 14 patients are dead and four are alive and disease free. The local recurrence rate was 11.1% and distant metastases were observed in 66.7% of cases. The median actuarial survival was 11.9 months, but it was 18.5 months in patients with disease-free resection margins. A significantly better survival was also observed in patients submitted to short-course preoperative radiotherapy. These preliminary results show that intraoperative and perioperative radiotherapy is feasible and may improve local control of disease. Unfortunately, these results are not matched by a significant improvement in survival due to the high incidence of intraabdominal metastases. Thus, new therapeutic modalities, including preoperative radiotherapy (with or without chemotherapy), should be tested.

Tension-free hernioplasty: technical remarks and personal experience.

The authors report their experience with 463 tension free hernioplasty procedures for inguinal and femoral hernias. The surgical technique included the insertion of both a polypropylene plug and a polypropylene mesh, and was carried out mostly in local anesthesia (84.2%) using bupivacaine 0.25% for ileoinguinal and ileohypogastric blockage and mepivacaine 0.5% for local infiltration. There was no major intraoperative complication; local postoperative complications were rare (10%) and easily managed; postoperative pain was frequently observed (66%), though mild and transient; resumption of working activity occurred within a month in 96.6% of cases; there were only 3 post-operative recurrences (respectively, at 1, 6 and 12 months). The authors conclude that the tension free hernioplasty is a simple, rapid, low-cost and effective technique, easily performed under local anesthesia.

Cystic neoplasm mistaken for pancreatic pseudocyst.

The authors report a case of cystic neoplasm of the pancreas treated by cystojejunostomy two years and half earlier. On that occasion, a false diagnosis of pancreatic pseudocyst had been suggested. Cystic neoplasm of the pancreas has a far better prognosis than adenocarcinoma. However, early detection is difficult and erroneous initial diagnosis may lead to delayed treatment and poor long-term results. In our case, though surgical treatment was aggressive and apparently radical, early recurrence of neoplasm was observed. Only early accurate diagnosis of pancreatic cystadenocarcinoma might improve the results of surgical treatment.

[Aorto-iliac aneurysms and associated gastrointestinal neoplasms. Treatment problems]. / Aneurismi aorto-iliaci e neoplasie gastrointestinali associate. Problemi di trattamento.

In patients affected by aortoiliac aneurysm the concurrent presence of a gastrointestinal tumor is a not infrequent occurrence which poses problems of therapeutic approach (one step operation or prior treatment of one of the two diseases; in the latter case definition of timing and sequence of the surgical treatment). Three cases are reported where an eclectic therapeutic approach has enabled satisfactory results. A patient with an isolated aneurysm of right hypogastric artery associated with rectal cancer was treated with percutaneous embolization of the aneurysm and subsequent excision of the tumor. In a patient with a neoplasm of the left colon and aortic aneurysm, the aneurysm was treated first and after about a month the tumor was resected. In a patient with gastric cancer and aortic aneurysm subtotal gastrectomy was first performed and subsequently, after about 3 months, the aneurysm was treated by extraperitoneal route. Even if an unidirectional approach cannot be defined, it is thought that the two-step treatment of the associated diseases is preferable. In the presence of non stenosed non bleeding colorectal tumors it seems more suitable to treat the aneurysm first (increased postoperative risk for rupture of the aneurysm; more difficult preparation of subrenal aorta in the presence of cicatricial outcomes of colonic surgery; persistence of perianastomotic infections after colonic resection). Gastric tumors should be treated first for their higher biological aggressiveness and unfeasible correct preoperative staging. In particular cases (single unilateral aneurysm of a hypogastric artery associated with gastrointestinal cancer), non surgical treatment of the vascular lesion (embolization during angiography) is the treatment of choice.

Carcinoma of the pancreatic head area: follow-up.

Preliminary results of a planned follow-up schedule based on periodic clinicoinstrumental controls applied to a population of 73 patients with pancreatic cancer undergoing combined modality treatments modulated according to the different prognosis, are reported. The following considerations are stressed: 1) the feasibility of scheduled controls is confirmed by the low rate (1.4%) of patients lost to follow-up in spite of the rapidly fatal course of the disease, characterized by the deteriorating performance status in most patients; 2) radiologic exams should be performed in the same center where the patients were initially staged by a team experienced in the natural history of this disease and aware of the difficulties in assessing the treatment, surgery in particular; 3) supportive care plays a major role in patients followed-up for the frequent onset of symptoms which impact on the quality of life; 4) the interdisciplinary collaboration between surgeons, oncologists, radiotherapists, endoscopists and experts in nutrition and pain relief plays a major role.

Carcinoma of the pancreatic head area. Therapy: resectability and surgical management of resectable tumors.

Surgical resection is being increasingly performed for carcinomas of the area of the head of the pancreas with curative intent. Pre-and intraoperative assessment of the site of origin and the stage of the lesion is of the utmost importance for a more favorable prognosis of non pancreatic forms and for a better evaluation of long term results of treatment adopted. Staging of non pancreatic periampullary tumors is usually very precise since they are most often shown to be resectable on laparotomy. Surgical resection by pancreaticoduodenectomy is the treatment of election based on good long term results. To the contrary, problems involved in the carcinoma of the head of the pancreas are non negligible. Some aspects related to the criteria of resectability of these tumors (diameter of primary lesion, infiltration of adjacent organs and large vessels, lymph node involvement) are discussed. How extensive pancreatic resection (subtotal, total or regional pancreatectomy) should be, is still a debated subject. In fact, it is not directly proportional to an improvement in prognosis. Complementary treatments directed to the improvement of the disappointing results at present achieved with surgery alone, are desirable.

Digestive and nutritional consequences of pancreatic resections. The classical vs the pylorus-sparing procedure.

Digestive and nutritional alterations are a common occurrence after pancreatic resections. The authors report the results of a multiparametric evaluation performed in a group of 26 patients submitted to total or cephalic pancreatectomy. Patients were divided into two groups according to the surgical procedure; group A (n = 13) included gastroresected patients and group B (n = 13) included those submitted to pylorus-sparing pancreatic resection. Subclinical digestive and absorptive impairment has been found in 61.5% of group A patients; the nutritional status was clinically poor in four cases from the same group. Digestive alterations have also been found in 69.2% of group B cases, but nutritional status was always satisfactory in the whole group. The more positive results obtained with the pylorus-sparing technique encourage wider adoption of this procedure.

Duodenal malignant somatostatinoma.

The authors report a case of hormonally silent duodenal somatostatinoma. The main clinical features, the natural history and the currently available therapies of these rare neoplasms are described on the basis of this case and of the scientific literature. Although the antiblastic therapies are still debated, the patient showed a surprising outcome following chemotherapy.

[Diagnostic and therapeutic integration in ductal carcinoma of the head of the pancreas. Preliminary note]. / Esperienza di integrazione diagnostica e terapeutica del carcinoma duttale della testa del pancreas. Nota preliminare.

The diagnosis and treatment of pancreatic ductal carcinoma are managed, in our hospital, by a team of radiologist, surgeons, radiotherapists and pathologists. In periodic meetings they discuss the clinical cases before and after clinico-radiologic staging. Patients are entered one of three different treatment routes, based on their general status, on disease stage, tumor size and its arrangement around common bile duct and main pancreatic duct. Thirty-eight patients were studied: 23 of them, considered as resectable on the basis of imaging (CT, US) findings, were submitted to radical surgery and intraoperative radiotherapy (route I); of 11 unresectable cases, 8 had a bilio-digestive bypass and interstitial brachitherapy with 125I seeds (tumor size < 3 cm). Eleven patients unresectable by imaging and 1 by surgery followed treatment route II, characterized by radio-chemotherapy followed by intraluminal radiotherapy with 192Ir wires, relative to residual tumor size and to lesion arrangement around access ways. Four patients with metastases and "adequate" tumor size entered treatment route III-i.e., merely palliative luminal radiotherapy. This preliminary note stresses the importance of polyspecialistic team work in the diagnosis and treatment of pancreatic ductal carcinomas.