Cirugía de control de daños: ¿que hay de nuevo? / Damage control surgery: what's new?

Antecedentes. La cirugía de control de daños se ha ganado un espacio en el tratamiento de un pequeño número de enfermos con traumatismos graves. Objetivo. Actualizar los conocimientos que se han aportado para perfeccionar esta táctica clínico-quirúrgica. Lugar de aplicación. C.M.P.F. "Churruca-Visca" Diseño. Análisis de los nuevos conceptos desarrollados en el último decenio. Conclusiones. Este tema ha sido actualizado con la intención de exponer los nuevos avances en la resucitación, el traslado y el sostén del medio interno de estos enfermos. Esta táctica médico-quirúrgica se ha puesto en boga para un selecto grupo de pacientes que reúnen condiciones excepcionales y probables chances de muerte. El control del daño en fase cero obliga a una resucitación más dinámica en el lugar del hecho y durante el traslado. El control del daño resuscitatorio involucra un nuevo concepto basado en un antiguo precepto de la cirugía del aneurisma complicado "la resucitación hipotensiva". El manejo de las lesiones arteriales y venosas son la llave del éxito de este procedimiento. El uso de la arteriografía selectiva las 24 hs permiten rescatar muchos enfermos con lesiones de difícil abordaje.(AU)

[Acute experimental pancreatitis in the opossum. The role of prior truncular vagotomy on the inflammatory response]. / Pancreatitis aguda experimental en el opossum. Rol de la vagotomía troncular previa en la respuesta inflamatoria.

BACKGROUND: Acute pancreatitis (AP) is a common cause of admission to the emergency room. Its etiopathogeny is poorly understood. The pancreatic inflammatory response in this process is unclear. The influence of the autonomic nervous system is a controversial issue. AIMS: To demonstrate the effects of truncular vagotomy on AP due to duodenal distention in the South American opossum. PLACE OF APPLICATION: Department of experimental surgery (Churruca-Visca Hospital) INEUCI (Neuroscience Institute, CONICET, UBA). POPULATION: Male and female South American opossum divided into: a control group (7 animals); group A: truncular vagotomy and pyloroplasty seven days after the onset of AP (7 animals). Group B: truncular vagotomy and pyloroplasty 30 days after provoking AP (7 animals). Group C: truncular vagotomy and pyloroplasty 45 days after the onset of AP (7 animals). METHODS: Acute pancreatitis was caused by duodenal distention of the second portion by inserting a Foley catheter through a gastrostomy. CONCLUSIONS: The method of provoking AP is original. The influence of autonomous nervous system is being underestimated in most of the literature available.

Pancreatitis aguda experimental en el opossum. Rol de la vagotomía troncular previa en la respuesta inflamatoria / Acute experimental pancreatitis in the opossum. The role of prior truncular vagotomy on the inflammatory response

Antecedentes: Las Pancreatitis Agudas (PA) son causa frecuente de consulta en los Servicios de Emergencias. Tanto sus etiopatogenias como la respuesta inflamatoria desencadenada son ejes de controversia, a la luz del desconocimiento actual de muchos de estos aspectos. La influencia del Sistema Nervioso Autónomo dentro de la respuesta a la inflamación es actualmente discutida. Objetivo: Demostrar el efecto de la vagotomía troncular previa sobre la PA por distensión duodenal en el opossum sudamericano. Lugar de aplicación: Instituto de Neurociencias (INEUCI-CONICET-UBA) y Sección Cirugía Experimental del Servicio de Cirugía General del hospital Churruca-Visca. Diseño: Estudio prospectivo randomizado. Población: Opossum sudamericanos de ambos os sexos divididos en cuatro grupos; Grupo control: (7 animales) se les ocasionó PA. Grupo A: (7 animales) se les realizó vagotomía troncular y piloroplastía siete días antes de ocasionar PA. Grupo B: (7 animales) se les realizó vagotomía troncular y piloroplastía 30 días antes de ocasionar PA. Grupo C: (7 animales) se les ocasionó PA después de 45 días de realizarles una vagotomía troncular y piloroplastía. Métodos: Se les realizó PA por distensión de la segunda porción del duodeno, por el insuflado de una sonda Foley frente a la papila. A todos los animales se les determinó Hto, G. Blancos, Calcio, Transaminasas, LDH, CPK, Amilasemia, Lipasemia, Colesterol, Urea en estado basal, a las 2 horas de desencadenada la PA y a las 4 horas de producida la afección. A todos los animales se les realizó estudio anatomopatológico con microscopía óptica del páncreas, hígado, pulmón y riñon. Resultados: Los datos de laboratorio más significativos fueron la interrupción vagal no altera el recuento leucocitario en relación a los grupos control; tanto la amilasa como la lipasa y la LDH, presentan un incremento pos distensión. No existen modificaciones de consideración con el hematocrito, la calcemia, la urea y el colesterol. Conclusiones: El método de desencadenamiento es original. Existe para los autores una subvaloración de la participación del Sistema Nervioso Autónomo en el proceso inflamatorio agudo pancreático. No existe relación entre el tiempo transcurrido de la vagotomía troncular en relación a las lesiones posteriores. La vagotomía troncular no aparenta modificar las lesiones desencadenada por este modelo experimental. En este grupo de animales, en relación a...

Pancreatitis aguda experimental en el opossum. Rol de la vagotomía troncular previa en la respuesta inflamatoria. / [Acute experimental pancreatitis in the opossum. The role of prior truncular vagotomy on the inflammatory response]

BACKGROUND: Acute pancreatitis (AP) is a common cause of admission to the emergency room. Its etiopathogeny is poorly understood. The pancreatic inflammatory response in this process is unclear. The influence of the autonomic nervous system is a controversial issue. AIMS: To demonstrate the effects of truncular vagotomy on AP due to duodenal distention in the South American opossum. PLACE OF APPLICATION: Department of experimental surgery (Churruca-Visca Hospital) INEUCI (Neuroscience Institute, CONICET, UBA). POPULATION: Male and female South American opossum divided into: a control group (7 animals); group A: truncular vagotomy and pyloroplasty seven days after the onset of AP (7 animals). Group B: truncular vagotomy and pyloroplasty 30 days after provoking AP (7 animals). Group C: truncular vagotomy and pyloroplasty 45 days after the onset of AP (7 animals). METHODS: Acute pancreatitis was caused by duodenal distention of the second portion by inserting a Foley catheter through a gastrostomy. CONCLUSIONS: The method of provoking AP is original. The influence of autonomous nervous system is being underestimated in most of the literature available.

Pancreatitis aguda experimental en el opossum. Rol de la vagotomía troncular previa en la respuesta inflamatoria / Acute experimental pancreatitis in the opossum. The role of prior truncular vagotomy on the inflammatory response

Antecedentes: Las Pancreatitis Agudas (PA) son causa frecuente de consulta en los Servicios de Emergencias. Tanto sus etiopatogenias como la respuesta inflamatoria desencadenada son ejes de controversia, a la luz del desconocimiento actual de muchos de estos aspectos. La influencia del Sistema Nervioso Autónomo dentro de la respuesta a la inflamación es actualmente discutida. Objetivo: Demostrar el efecto de la vagotomía troncular previa sobre la PA por distensión duodenal en el opossum sudamericano. Lugar de aplicación: Instituto de Neurociencias (INEUCI-CONICET-UBA) y Sección Cirugía Experimental del Servicio de Cirugía General del hospital Churruca-Visca. Diseño: Estudio prospectivo randomizado. Población: Opossum sudamericanos de ambos os sexos divididos en cuatro grupos; Grupo control: (7 animales) se les ocasionó PA. Grupo A: (7 animales) se les realizó vagotomía troncular y piloroplastía siete días antes de ocasionar PA. Grupo B: (7 animales) se les realizó vagotomía troncular y piloroplastía 30 días antes de ocasionar PA. Grupo C: (7 animales) se les ocasionó PA después de 45 días de realizarles una vagotomía troncular y piloroplastía. Métodos: Se les realizó PA por distensión de la segunda porción del duodeno, por el insuflado de una sonda Foley frente a la papila. A todos los animales se les determinó Hto, G. Blancos, Calcio, Transaminasas, LDH, CPK, Amilasemia, Lipasemia, Colesterol, Urea en estado basal, a las 2 horas de desencadenada la PA y a las 4 horas de producida la afección. A todos los animales se les realizó estudio anatomopatológico con microscopía óptica del páncreas, hígado, pulmón y riñon. Resultados: Los datos de laboratorio más significativos fueron la interrupción vagal no altera el recuento leucocitario en relación a los grupos control; tanto la amilasa como la lipasa y la LDH, presentan un incremento pos distensión. No existen modificaciones de consideración con el hematocrito, la calcemia, la urea y el colesterol. Conclusiones: El método de desencadenamiento es original. Existe para los autores una subvaloración de la participación del Sistema Nervioso Autónomo en el proceso inflamatorio agudo pancreático. No existe relación entre el tiempo transcurrido de la vagotomía troncular en relación a las lesiones posteriores. La vagotomía troncular no aparenta modificar las lesiones desencadenada por este modelo experimental. En este grupo de animales, en relación a... (Au)

[Biliary acute pancreatitis: an etiopathology and evolution review of 148 cases]. / Pancreatitis aguda biliar. Una revisión etiopatogénica y evolutiva de 148 casos.

BACKGROUND: A retrospective analysis of the etiologic factors and physiopathogenic mechanisms underlying an acute biliary pancreatitis episode put in evidence the complexity of the attempt to acquire a clear understanding of the entity. In this presentation the authors try to re-examine the main factors involved in the triggering of the disease. Besides the classic theories and their own approach to the management of an acute pancreatic inflammation episode are discussed. AIMS: The main purpose of this endeavor was to identify and discuss the etiopathogenic mechanisms that were prevalent in a series of 148 patients observed and treated in a 10 years period. Besides, another distinctive aim was to analyze their evolution and somehow to try to assess their probable prognosis. PLACE OF APPLICATION: Close community. POPULATION: The whole group of patients that were admitted with the diagnosis of acute pancreatitis in the time period comprised between 1987-1997. METHODS: The acute pancreatitis subgroups and their respective number of patient included were the following: BILIARY ACUTE PANCREATITIS 140 CASES POST ERCP 8 CASES CONCLUSIONS: As a result of the present reviewing endeavour several observations deserve to be pointed out: a. The pancreatic gland undoubtedly is a neuroendocrine organ, that is subjected to complex neural and hormonal influence. b. Undeniably, the involvement of the autonomic nervous system in the physiopathogenic mechanism of acute pancreatitis has been surprisingly disregarded. c. The biliary acute pancreatitis variant is the most frequent. What we consider a simplification is to accept the Opie's postulation without taking into account the intermediate steps, centered on autonomic reflexes, that ultimately lead to the acute inflammatory lesions. d. Although without an absolute proof, it is undeniable that "stress" is a primary etiology in some cases of acute pancreatitis. e. We favor the idea that the pancreas functional status influences on the extension and intensity degree of the acute pancreatic inflammatory lesions.

Pancreatitis aguda biliar: una revisión eteiopatogénica y evolutiva de 148 casos / Biliary acute pancreatitis: an etiopathology and evolution review of 148 cases

BACKGROUND: A retrospective analysis of de etiologic factors and fisiopathogenic mechanisms underlyng an acute biliar pancreatitis episode put in evidence the complexity of the attempt to acquire a clear understanding of the entity. In this presentation the authors try to re-examine the main factors involved in the triggering of the disease. Beasides the clasic theories and their own approach to the management of an acute pancreatic inflammation episode are discussed. AIMS: The main purpose of this endeavor was to identify and discuss the etiopahogenic machanisms that were prevalent in a series of 148 patients observed and trated in a 10 years period. Besides, another distinctive aim was to analyze their evolution and somehow to try to assess their probable prognosis. PLACE OF APPLICATION: Close comunity. POPULATION: The whole group of patients that were admitted with the diagnosis of acute pancreatitis in the time period comprised between 1987-1997. METHODS: The acute pancreatitis subgroups and their respective number of patient included were the following: BILIARY ACUTE PANCREATITIS 140 CASES POST ERCP 8 CASES CONCLUSIONS: As a result of the present reviewing endeaveur several observations deserve to be pointed out: a. The pancreatic gland undoubtedly is a neuroendocrine organ, that is subjeted to complex neural and hormonal influence. b. Undeniably, the involvement of the autonomic nervous system in the physiopathogenic mechanism of acute pancreatitis has been surprisingly disregarded. c. The biliary acute pancreatitis variant is the most frequent. What we consider a simplification is to accept the Opies postulation without taking into account the intermediate steps, centered on autonomic reflexes, that ultimately lead to the acute inflammatory lesions. d. Although without an absolute proof, it is undeniable that "stress" is a primary etiologie in some cases of acute pancreatitis. e. We favor the idea that the pancreons functional status influences on the extension and intensity degree of the acute pancreatic inflammatory lesions. (Au)

Pancreatitis aguda biliar: una revisión eteiopatogénica y evolutiva de 148 casos / Biliary acute pancreatitis: an etiopathology and evolution review of 148 cases

BACKGROUND: A retrospective analysis of de etiologic factors and fisiopathogenic mechanisms underlyng an acute biliar pancreatitis episode put in evidence the complexity of the attempt to acquire a clear understanding of the entity. In this presentation the authors try to re-examine the main factors involved in the triggering of the disease. Beasides the clasic theories and their own approach to the management of an acute pancreatic inflammation episode are discussed. AIMS: The main purpose of this endeavor was to identify and discuss the etiopahogenic machanisms that were prevalent in a series of 148 patients observed and trated in a 10 years period. Besides, another distinctive aim was to analyze their evolution and somehow to try to assess their probable prognosis. PLACE OF APPLICATION: Close comunity. POPULATION: The whole group of patients that were admitted with the diagnosis of acute pancreatitis in the time period comprised between 1987-1997. METHODS: The acute pancreatitis subgroups and their respective number of patient included were the following: BILIARY ACUTE PANCREATITIS 140 CASES POST ERCP 8 CASES CONCLUSIONS: As a result of the present reviewing endeaveur several observations deserve to be pointed out: a. The pancreatic gland undoubtedly is a neuroendocrine organ, that is subjeted to complex neural and hormonal influence. b. Undeniably, the involvement of the autonomic nervous system in the physiopathogenic mechanism of acute pancreatitis has been surprisingly disregarded. c. The biliary acute pancreatitis variant is the most frequent. What we consider a simplification is to accept the Opie's postulation without taking into account the intermediate steps, centered on autonomic reflexes, that ultimately lead to the acute inflammatory lesions. d. Although without an absolute proof, it is undeniable that "stress" is a primary etiologie in some cases of acute pancreatitis. e. We favor the idea that the pancreon's functional status influences on the extension and intensity degree of the acute pancreatic inflammatory lesions.

Pancreatitis aguda biliar. Una revisión etiopatogénica y evolutiva de 148 casos. / [Biliary acute pancreatitis: an etiopathology and evolution review of 148 cases]

BACKGROUND: A retrospective analysis of the etiologic factors and physiopathogenic mechanisms underlying an acute biliary pancreatitis episode put in evidence the complexity of the attempt to acquire a clear understanding of the entity. In this presentation the authors try to re-examine the main factors involved in the triggering of the disease. Besides the classic theories and their own approach to the management of an acute pancreatic inflammation episode are discussed. AIMS: The main purpose of this endeavor was to identify and discuss the etiopathogenic mechanisms that were prevalent in a series of 148 patients observed and treated in a 10 years period. Besides, another distinctive aim was to analyze their evolution and somehow to try to assess their probable prognosis. PLACE OF APPLICATION: Close community. POPULATION: The whole group of patients that were admitted with the diagnosis of acute pancreatitis in the time period comprised between 1987-1997. METHODS: The acute pancreatitis subgroups and their respective number of patient included were the following: BILIARY ACUTE PANCREATITIS 140 CASES POST ERCP 8 CASES CONCLUSIONS: As a result of the present reviewing endeavour several observations deserve to be pointed out: a. The pancreatic gland undoubtedly is a neuroendocrine organ, that is subjected to complex neural and hormonal influence. b. Undeniably, the involvement of the autonomic nervous system in the physiopathogenic mechanism of acute pancreatitis has been surprisingly disregarded. c. The biliary acute pancreatitis variant is the most frequent. What we consider a simplification is to accept the Opies postulation without taking into account the intermediate steps, centered on autonomic reflexes, that ultimately lead to the acute inflammatory lesions. d. Although without an absolute proof, it is undeniable that [quot ]stress[quot ] is a primary etiology in some cases of acute pancreatitis. e. We favor the idea that the pancreas functional status influences on the extension and intensity degree of the acute pancreatic inflammatory lesions.

[Acute pancreatitis of uncommon etiology: a physiopathologic approach]. / Pancreatitis agudas de etiologías poco frecuentes: una aproximación fisiopatogénica.

A review of 73 cases of acute pancreatitis (A.P.) of *A in frequent etiology is critically analyzed. The patients were allocated to the following categories: post ingestion of a large meal, dyslipemic, post ERCP, post operative, pregnancy, and puerperium linked., post urlian parotiditis, post stress, idiopathic, drug associated, post traumatic. In each of the above groups those hypotheses that are currently primarily accepted as been mainly concerned with the etiopathogenesis of the inflammatory episode were given preference. One factor upon which the authors has put special emphasis is that of frequent involvement of the nervous system through different types of autonomic are reflexes. This pathogenic mechanism is surprisingly disregarded in the literature. The interrelation ship between the severity of an AP episode and the background provided by the "pancreon" secretory activity is also emphasized. The mortality rate of the whole series was of 7 cases (9.6%). The groups that disclosed the highest rates were related to abdominal surgery (50%) and to dyslipemia (17%).

[Nutritional status of surgical patients without apparent nutritional compromise]. / Estado nutricional de pacientes quirúrgicos sin aparente compromiso nutricional.

Nutritional status of 80 preoperative patients from programmed surgeries of hernias and lithiasis was studied by anthropometric and biochemical parameters. Nutritional deficiencies related to pathology were not expected in these patients. Results were as follows: 77% of the population showed overweight, being 15% obese. Prevalent protein intake, evaluated by the urea nitrogen/creatinine ratio, was adequate in 87.5% of the patients; however, patients presented 72% of albumin, 52% of prealbumin and 50% of RBP below reference values. Transferrin, ceruloplasmin, alpha 2-macroglobulin and haptoglobin were not decreased. Assessment of vitamin A, carotenes and vitamin C showed plasmatic levels below reference values in 16% of the patients for vitamin A, 5% for carotenes and 27% for vitamin C. Respect to calcium status, data of calcium/creatinine ratio show deficiency in 45% of the population. Respect to iron, the nutritional status was in general adequate, patients at risk being 5% by Htc, 11% by Hb, 5% by TS% and 12.5% by FEP, women showed over twice abnormal values than men. Although some isolated relations were observed, in this population sex, age and pathology were variable that did not affect in a relevant way the nutritional status. In spite of the individual analysis of each nutrient did not show important deficiencies, the analysis by patient showed that only a few of them (7%) presented an optimal biochemical profile with all the studied parameters within the reference values.

Pancreatitis agudas de etiologías poco frecuentes: una aproximación fisiopatogénica / Acute pancreatitis of uncommon etiology: a physiopathologic approach

Los autores presentan 73 casos de pancreatitis agudas (P.A.) de causas poco frecuentes. Ellas fueron divididas en ingestión copiosa, displémicas, postcolangioretrógrada endoscópica, postoperatorias, tercer trimestre de embarazo, puerperio inmediato, parotídica, por stress e idiopáticas, medicamentosa y por trauma. Se evalúan las teorías etiopatogénicas probables haciendo hincapié en la importancia del Sistema Nervioso Autónomo (S.N.A.) como responsables de las lesiones glandulares. El estado funcional del páncreas, previo al ataque agudo, es uno de los factores predisponentes de mayor envergadura. La mortalidad de la serie fue de 7 casos (9.58 por ciento) siendo las postoperatorias (50 por ciento) y las dislipémicas (16.6 por ciento) las de mayor índice de mortalidad.

Pancreatitis agudas de etiologías poco frecuentes: una aproximación fisiopatogénica. / [Acute pancreatitis of uncommon etiology: a physiopathologic approach]

A review of 73 cases of acute pancreatitis (A.P.) of *A in frequent etiology is critically analyzed. The patients were allocated to the following categories: post ingestion of a large meal, dyslipemic, post ERCP, post operative, pregnancy, and puerperium linked., post urlian parotiditis, post stress, idiopathic, drug associated, post traumatic. In each of the above groups those hypotheses that are currently primarily accepted as been mainly concerned with the etiopathogenesis of the inflammatory episode were given preference. One factor upon which the authors has put special emphasis is that of frequent involvement of the nervous system through different types of autonomic are reflexes. This pathogenic mechanism is surprisingly disregarded in the literature. The interrelation ship between the severity of an AP episode and the background provided by the [quot ]pancreon[quot ] secretory activity is also emphasized. The mortality rate of the whole series was of 7 cases (9.6

). The groups that disclosed the highest rates were related to abdominal surgery (50

) and to dyslipemia (17

).

Pancreatitis agudas de etiologías poco frecuentes: una aproximación fisiopatogénica / Acute pancreatitis of uncommon etiology: a physiopathologic approach

Los autores presentan 73 casos de pancreatitis agudas (P.A.) de causas poco frecuentes. Ellas fueron divididas en ingestión copiosa, displémicas, postcolangioretrógrada endoscópica, postoperatorias, tercer trimestre de embarazo, puerperio inmediato, parotídica, por stress e idiopáticas, medicamentosa y por trauma. Se evalúan las teorías etiopatogénicas probables haciendo hincapié en la importancia del Sistema Nervioso Autónomo (S.N.A.) como responsables de las lesiones glandulares. El estado funcional del páncreas, previo al ataque agudo, es uno de los factores predisponentes de mayor envergadura. La mortalidad de la serie fue de 7 casos (9.58 por ciento) siendo las postoperatorias (50 por ciento) y las dislipémicas (16.6 por ciento) las de mayor índice de mortalidad. (AU)