Análisis de nuestra experiencia en el diagnóstico y tratamiento de la hernia obturatriz en un hospital de tercer nivel / Analysis of our experience in the diagnosis and treatment of obturator hernia in a third level hospital

La patología herniaria supone un porcentaje importante de las intervenciones quirúrgicas urgentes. La hernia obturatriz es una entidad poco frecuente, presentándose generalmente como un cuadro de oclusión intestinal agudo en mujeres adultas. El objetivo del estudio es analizar la experiencia en un hospital de tercer nivel en el diagnóstico y tratamiento de la hernia obturatriz, así como detectar aquellos signos que permitan un diagnóstico precoz. La técnica de imagen de elección para su diagnóstico es la tomografía computarizada. Se trata de un estudio observacional prospectivo, en el que se incluyeron pacientes intervenidos de forma urgente por hernia obturatriz entre los años 2000 y 2016. Para el registro de la morbilidad postoperatoria se empleó la clasificación de Clavien-Dindo. Se identificaron doce pacientes con clínica de obstrucción intestinal secundaria a hernia obturatriz. Todos ellos fueron intervenidos de forma urgente, realizándose laparotomía media urgente en el 59%, laparotomía media infraumbilical en el 33% y abordaje por vía inguinal posterior en un solo paciente (8%). En ocho pacientes (67%) fue necesario realizar una resección intestinal por isquemia intestinal. La técnica quirúrgica empleada fue la reparación mediante malla de polipropileno en seis pacientes (50%), mediante tapón en dos (17%) y cierre con puntos sueltos en cuatro (33%). Cuatro de ellos presentaron complicaciones postoperatorias, registrando un único exitus secundario a perforación por sufrimiento intestinal. Es prioritario establecer un diagnóstico precoz y tratamiento quirúrgico urgente para reducir la morbimortalidad asociada a la hernia obturatriz

Hernia pathology accounts for a large percentage of urgent surgical interventions. Obturator hernia is rare, usually presenting as a picture of acute intestinal occlusion. The aim of the study is to analyze the experience in a third level hospital in the diagnosis and treatment of obturator hernia, as well as to detect those signs that allow an early diagnosis. This is a prospective observational study, which included patients operated on urgently for obturator hernia between 2000 and 2016. For the registration of postoperative morbidity, the Clavien-Dindo classification was used. We identified twelve patients with intestinal obstruction secondary to obturator hernia. All of them were operated on urgently. Urgent midline laparotomy was carried out on 59% of them, infraumbilical laparotomy on 33%, and a posterior inguinal approach was realized on only one patient (8%). In eight patients (67%) it was necessary to perform intestinal resection. Repair was performed by polypropylene mesh in six patients (50%), by plugging in two (17%) and closing with loose stitches in four patients (33%). Four of them presented postoperative complications, recording a single exitus secondary to perforation due to intestinal suffering. Obturator hernia is a rare entity that develops mostly as an occlusive condition in elderly women. The imaging technique of choice for diagnosis is computed tomography. Establishing an early diagnosis and urgent surgical treatment is a priority to reduce associated morbidity and mortality

[Analysis of our experience in the diagnosis and treatment of obturator hernia in a third level hospital]. / Análisis de nuestra experiencia en el diagnóstico y tratamiento de la hernia obturatriz en un hospital de tercer nivel.

Hernia pathology accounts for a large percentage of urgent surgical interventions. Obturator hernia is rare, usually presenting as a picture of acute intestinal occlusion. The aim of the study is to analyze the experience in a third level hospital in the diagnosis and treatment of obturator hernia, as well as to detect those signs that allow an early diagnosis. This is a prospective observational study, which included patients operated on urgently for obturator hernia between 2000 and 2016. For the registration of postoperative morbidity, the Clavien-Dindo classification was used. We identified twelve patients with intestinal obstruction secondary to obturator hernia. All of them were operated on urgently. Urgent midline laparotomy was carried out on 59% of them, infraumbilical laparotomy on 33%, and a posterior inguinal approach was realized on only one patient (8%). In eight patients (67%) it was necessary to perform intestinal resection. Repair was performed by polypropylene mesh in six patients (50%), by plugging in two (17%) and closing with loose stitches in four patients (33%). Four of them presented postoperative complications, recording a single exitus secondary to perforation due to intestinal suffering. Obturator hernia is a rare entity that develops mostly as an occlusive condition in elderly women. The imaging technique of choice for diagnosis is computed tomography. Establishing an early diagnosis and urgent surgical treatment is a priority to reduce associated morbidity and mortality.

Síndrome de Boerhaave secundario a vólvulo gástrico / Boerhaave’s syndrome secondary to gastric volvulus

El síndrome de Boerhaave es una ruptura espontánea del esófago, causada por un aumento de presión intraluminal que se produce en el contexto de una presión negativa intratorácica. Tiene un alto índice de morbimortalidad (14-40%), por lo que precisa un diagnóstico y tratamiento precoces. Debería incluirse en el diagnóstico diferencial del dolor epigástrico en un paciente que ha presentado vómitos. Las hernias de hiato paraesofágicas pueden complicarse con una volvulación gástrica. Esta, a su vez, puede producir necrosis tanto esofágica como gástrica que requiere un manejo quirúrgico precoz. Presentamos el caso de un paciente de 83 años que presentó una volvulación gástrica como complicación de una hernia de hiato, con vómitos asociados que desencadenaron un síndrome de Boerhaave. Se trata del segundo caso publicado en la literatura (AU)

Boerhaave’s syndrome is a spontaneous rupture of the oesophagus, caused by an increase of intraluminal pressure that is produced in the context of negative intrathoracic pressure. It has a high index of morbimortality (14-40%), which is why it requires early diagnosis and treatment. When a patient presents vomiting, the differential diagnosis should include epigastric pain. Para-esophageal hiatal hernias can be complicated by gastric volvulus. In its turn, this can produce both oesophageal and gastric necrosis requiring early surgical treatment. We describe the case of an 83-year-old patient who presented gastric volvulus with complications from a hiatal hernia with associated vomiting, which triggered Boerhaave’s syndrome. This is the second case published in the literatura (AU)

[Boerhaave's syndrome secondary to gastric volvulus]. / Síndrome de Boerhaave secundario a vólvulo gástrico.

Boerhaave's syndrome is a spontaneous rupture of the oesophagus, caused by an increase of intraluminal pressure that is produced in the context of negative intrathoracic pressure. It has a high index of morbimortality (14-40%), which is why it requires early diagnosis and treatment. When a patient presents vomiting, the differential diagnosis should include epigastric pain. Para-esophageal hiatal hernias can be complicated by gastric volvulus. In its turn, this can produce both oesophageal and gastric necrosis requiring early surgical treatment. We describe the case of an 83-year-old patient who presented gastric volvulus with complications from a hiatal hernia with associated vomiting, which triggered Boerhaave´s syndrome. This is the second case published in the literature. Key words. Boerhaave´s syndrome. Gastric volvulus. Surgical treatment.

Qué no hacer en la EPOC. Análisis metodológico / No disponible

Objetivo: Identificar en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) prácticas diagnósticas, terapéuticas y de autocuidado que resultan inadecuadas, de dudosa efectividad o que no son coste-efectivas, tanto en fase estable como durante una agudización. Material y método: El estudio se ha organizado en 3 fases y diseñado para identificar prácticas que no aportan valor o que deben desaconsejarse en el manejo de la EPOC estable y agudizada, y en los autocuidados llevados a cabo por estos pacientes. La primera fase se realizó mediante la técnica Metaplan en la que se puntuaron y seleccionaron las prácticas que con más frecuencia claramente debían desaconsejarse. La segunda fase se hizo a través de la web mediante una técnica de conferencia de consenso que permitió la valoración y la selección jerarquizada de las recomendaciones en función de la frecuencia en que ocurren y la intensidad en el que esa práctica resultaba inútil o perjudicial. En la tercera fase se elaboró una ficha descriptiva de cada una de las recomendaciones finales, que incluye la descripción de la práctica a erradicar, el nivel de evidencia y grado de recomendación y los indicadores de la medida en que se ha logrado un cambio en la práctica. Resultados: Los resultados se mostrarán en una tabla que recogerá las prácticas ‘no hacer’ en la EPOC, con la frecuencia con que se produce la práctica que se desaconseja y la intensidad con que la práctica resulta inadecuada, tanto en la EPOC estable como en la EPOC agudizada y en las prácticas realizadas por los pacientes. Además, se desarrollará en una ficha técnica para cada recomendación en el que se expondrá la denominación, la justificación y el nivel de evidencia de la recomendación. También se elaborarán indicadores que permitan evaluar los datos recogidos y que se haya logrado cambiar la práctica inadecuada, ineficaz o no coste-efectiva. Conclusiones: Las recomendaciones 'Qué no hacer en la EPOC' mejorarán el manejo de esta patología al reducir las prácticas diagnósticas, terapéuticas o de cuidados que sean inadecuadas o no coste-efectivas

Objective: To identify diagnostic, therapeutic and self-care practices in chronic obstructive pulmonary disease (COPD) patients which are inadequate, of dubious effectiveness or non cost-effective, both in stable phase and during an exacerbation. Material and Methods: The study was performed in 3 phases and designed to identify practices which do not add value or must be discouraged in the management of stable COPD and its exacerbations, and also in self-care carried out by the patients. The first phase was carried out by the Metaplan technique in which the most frequent practices which had to be clearly discouraged were rated and selected . The second phase was made through the web by a consensus conference technique that allowed to evaluate and select hierarchically recommendations based on the frequency of occurrence and intensity of the practices which were found useless or harmful. In the third phase a technical file on each of the final recommendations was created. It includes the description of the practices which must be eradicated, evidence levels and recommendation degrees, as well as indicators of the measure achieved thanks to the change in practice. Results: The results are shown in a table that summarizes ‘do not do’ practices in COPD, the frequency with which the practice is discouraged and the intensity with which the practice is inadequate, both in stable and exacerbated COPD and in practices carried out by patients. In addition, there will be a technical file developed for each recommendation with denomination, justification and evidence level of the recommendation. Indicators, permitting to evaluate collected data and the improvements reached by decreasing inadequate, ineffective or non cost-effective practices, will also be developed. Conclusions: 'Do not do' recommendations in COPD will improve the management of this patology by reducing inadequate or non cost-effective diagnostic, therapeutic or care practices

Amiloidosis traqueobronquial y nodular múltiple / Tracheobronchial and mulitple nodular amyloidosis

Resumen. La amiloidosis pulmonar primaria o localizada es una patología poco frecuente que aparece en adultos a partir de la quinta década de vida. Se describen 5 formas de presentación. Describimos el caso de una mujer de 35 años que cursa de forma excepcional con una doble presentación de amiloidosis pulmonar traqueobronquial y nodular múltiple (AU)

Abstract: Primary or localized pulmonary amyloidosis is an uncommon condition that appears in adults after 50 years of age. Five presentation forms have been described. We describe the case of a 35-year old woman who had a rare form with double presentation of tracheobronchial pulmonary amyloidosis and multiple nodular amyloidosis (AU)