[Comparison of two types of surgical gastrostomies, open and laparoscopic in home enteral nutrition]. / Comparación entre dos tipos de gastrostomías quirúrgicas, abierta y laparoscópica, en nutrición enteral domiciliaria.

AIM: Exposing the complications of surgical gastrostomies used as way of home enteral nutritional support (HEN) and detecting the differences between the two techniques used in our environment: Open Surgery vs Laparoscopic Surgery. MATERIAL AND METHODS: Retrospective descriptive observational study of the surgical gastrostomies performed between 1994 and 2009 followed up by our unit. Have been analyzed the complications detected in our practice during the follow-up of patients with HEN performed via open laparotomy vs. laparoscopic tecniques, assessing: leaks of gastric fluid to the exterior, abdominal wall irritation, presence of exudate, presence of exudate with positive culture that required antibiotical treatment, burning or loss of substance of the periostomic zone, breach of balloon, decubitus ulcer caused by the tube and formation of granuloma. RESULTS: Between 1994 and 2009, 57 surgical gastrostomies were performed: 47 using the conventional laparotomic (open) tecnique and 10 laparoscopies. The average age of the patients was 57.51 ± 17.29 years old. The most common cause for the performance of surgical gastrostomy was esophageal cancer (38.6%) followed by neurologic alterations (26.3%) and head and neck tumors (26.3%). 97.9% of the patients who underwent to surgical gastrostomy presented at least one complication, meaning that only 2.1% were free of complications; meanwhile, 50% of the patients were laparoscopic gastrostomy was performed had none of these complications. The most common complications were the presence of leaks of gastric fluid and abdominal wall irritation that appeared on 89.4% and 83% respectively of the laparotomic gastrostomies versus the presence of only 30% of both complications in laparoscopic gastrostomies being the difference statistically significant (p < 0.01). CONCLUSIONS: After the introduction of the laparoscopic technique in the performance of surgical gastrostomies has been observed a decrease of the complications occured during the home enteral nutritional support related to surgical gastrostomies.

Comparación entre dos tipos de gastrostomías quirúrgicas, abierta y laparoscópica, en nutrición enteral domiciliaria / Comparison of two types of surgical gastrostomies, open and laparoscopic in home enteral nutrition

Objetivo: Exponer las complicaciones de las gastrostomías quirúrgicas utilizadas como vía de soporte nutricional enteral domiciliario (SNED) y detectar si existen diferencias entre las dos técnicas usadas en nuestro medio: Cirugía abierta vs laparoscópica. Material y métodos: Estudio observacional descriptivo de carácter retrospectivo de las gastrostomías quirúrgicas realizadas entre los años 1994 y 2009 seguidas por nuestra unidad. Se han analizado las complicaciones detectadas en consulta durante el seguimiento de pacientes con SNED a través de gastrostomía quirúrgica realizada con técnica laparotómica abierta vs laparoscópica, valorando: fuga del contenido gástrico al exterior, irritación de la pared abdominal, presencia de exudado, presencia de exudado con cultivo positivo que requirió tratamiento antibiótico, quemadura o pérdida de sustancia de la zona periostomía, rotura de balón, úlcera de decúbito por la sonda y formación de granuloma. Resultados: Durante los años 1994-2009 se realizaron 57 gastrostomías quirúrgicas: 47 por técnica laparótomica (abierta) convencional y 10 por vía laparoscópica. La edad media de los pacientes fue de 57,51 ± 17,29 años. La causa más frecuente que motivó la realización de la gastrostomía quirúrgica fue el cáncer de esófago (38,6%) seguido de alteraciones neurológicas (26,3%) y tumores de cabeza y cuello (26,3%). El 97,9% de los pacientes a los que se realizó una gastrostomía quirúrgica abierta presentaron al menos una complicación, es decir que solo el 2,1% estuvieron libres de complicaciones; mientras que el 50% de los que se sometieron a una gastrostomía laparoscópica no tuvo ninguna. Las complicaciones más frecuentes fueron la presencia de fuga del contenido gástrico y la irritación de la pared abdominal que se presentaron en el 89,4% y 83% respectivamente de las gastrostomías laparotómicas frente a la aparición de solo el 30% de ambas complicaciones en las gastrostomías laparoscópicas siendo la diferencia estadísticamente significativa (p < 0,01). Conclusiones: Tras la introducción de la técnica laparoscópica en la realización de las gastrostomías quirúrgicas se ha observado una disminución de las complicaciones que se presentan durante la Nutrición Enteral Domiciliaria relacionadas con las gastrostomías quirúrgicas (AU)

Aim: Exposing the complications of surgical gastrostomies used as way of home enteral nutritional support (HEN) and detecting the differences between the two techniques used in our environment: Open Surgery vs Laparoscopic Surgery. Material and methods: Retrospective descriptive observational study of the surgical gastrostomies performed between 1994 and 2009 followed up by our unit. Have been analyzed the complications detected in our practice during the follow-up of patients with HEN performed via open laparotomy vs. laparoscopic tecniques, assessing: leaks of gastric fluid to the exterior, abdominal wall irritation, presence of exudate, presence of exudate with positive culture that required antibiotical treatment, burning or loss of substance of the periostomic zone, breach of balloon, decubitus ulcer caused by the tube and formation of granuloma. Results: Between 1994 and 2009, 57 surgical gastrostomies were performed: 47 using the conventional laparotomic (open) tecnique and 10 laparoscopies. The average age of the patients was 57.51 ± 17.29 years old. The most common cause for the performance of surgical gastrostomy was esophageal cancer (38.6%) followed by neurologic alterations (26.3%) and head and neck tumors (26.3%). 97.9% of the patients who underwent to surgical gastrostomy presented at least one complication, meaning that only 2.1% were free of complications; meanwhile, 50% of the patients were laparoscopic gastrostomy was performed had none of these complications. The most common complications were the presence of leaks of gastric fluid and abdominal wall irritation that appeared on 89.4% and 83% respectively of the laparotomic gastrostomies versus the presence of only 30% of both complications in laparoscopic gastrostomies being the difference statistically significant (p < 0.01). Conclusions: After the introduction of the laparoscopic technique in the performance of surgical gastrostomies has been observed a decrease of the complications occured during the home enteral nutritional support related to surgical gastrostomies (AU)

[Hyperammonemic encephalopathy: nutritional assessment and management of a case]. / Encefalopatía hiperamoniémica: valoración y manejo nutricional a propósito de un caso.

OTC deficiency is a disorder of the urea cycle X-linked. It is manifested in men as severe hyperammonemia in the first days of life. In women the disease is milder severity. Various conditions cause decompensation with hyperammonemia. It could be fatal or cause permanent neurological damage. We report a 36 years old woman admitted for surgery, she suffered a decompensation in conjunction with surgical wound infection. Hyperammonemia caused neurological deterioration with decreased level of consciousness, tetraparesis and neurogenic dysphagia. The treatment consisting of low-protein diet, ammonium chelating drugs and dialytic measures, was effective in controlling hyperammonaemia and improving neurological status. This case illustrates the importance of nutritional support of patients with disorders of the urea cycle in the hospital because the descompensations are more frecuent here.

Nutrición y cáncer / Nutrition and cáncer

La expresión máxima de desnutrición en el cáncer es la caquexia tumoral, que será responsable directa o indirecta de la muerte en un tercio de los pacientes con cáncer. En un Consenso Internacional se ha definido la Caquexia cancerosa como un síndrome multifactorial caracterizado por una pérdida de masa muscular esquelética (con o sin pérdida de masa grasa) que no puede ser completamente revertida con un soporte nutricional convencional y que lleva a un deterioro funcional progresivo. La fisiopatología se caracteriza por un balance proteico y energético negativo, debido a una combinación variable de ingesta reducida y un metabolismo alterado. Se clasifica la Caquexia Tumoral dentro de un continuum evolutivo, con tres estadios de relevancia clínica: Precaquexia, Caquexia, y Caquexia Refractaria; y se asocia con una disminución en la tolerancia al tratamiento oncológico, menor respuesta al mismo, y disminución de la calidad de vida y de la supervivencia del paciente. Para el Cribado nutricional del paciente con cáncer y siguiendo la Guía Clínica Multidisciplinar se recomienda el «Malnutrition Screening Toll» (MST) para los pacientes adultos con cáncer por su sencillez, fiabilidad y validez. Como método de valoración nutricional para enfermos con cáncer, debe mencionarse la Valoración Global Subjetiva (VGS), y sobre todo la VSG Generada por el Paciente. Al describir las causas de desnutrición en el paciente neoplásico las podemos concretar en: a) causas de desnutrición relacionadas con el tumor, b) con el paciente o c) con los tratamientos oncológicos, teniendo en cuenta que en muchas ocasiones todas las causas pueden estar presentes en un mismo paciente. La desnutrición en el paciente con cáncer se asocia, además de un aumento de morbilidad-mortalidad y aumento de estancias y de costes, a una peor evolución y tolerancia de los tratamientos oncológicos (quirúrgicos, radio y quimioterápicos). Los objetivos fundamentales de la intervención nutricional en el paciente oncológico son: Evitar la muerte precoz secundaria a la propia desnutrición; Disminuir las complicaciones y Mejorar la calidad de vida de los pacientes. Para lograr estos objetivos, la intervención nutricional engloba varias opciones que deben individualizarse para cada paciente. En todo caso la atención nutricional debe ser precoz y formar parte del tratamiento global de paciente oncológico. Si se clasifica el apoyo nutricional según su agresividad y complejidad, se incluyen las siguientes categorías: Recomendaciones nutricionales o consejo dietético; Nutrición artificial (Nutrición enteral oral o suplementación, Nutrición enteral por sonda, Nutrición parenteral) y Valoración de la posible adición de fármacos relacionados con la estimulación del apetito, la inhibición de citoquinas, con acción anabolizante, y otros (AU)

The highest expression of malnutrition in cancer is tumour cachexia, which directly or indirectly accounts for the deaths of one third of all the patients with cancer. In a formal international consensus process cancer cachexia was defined as a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. Its pathophysiology is characterised by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism. Tumour cachexia can be classified in three evolutionary stages of clinical relevance: precachexia, cachexia, and refractory cachexia, and it is associated with a decrease in treatment tolerance and responsiveness, and impairment of quality of life and survival in cancer patients. According to the Multidisciplinary Clinical Guide, the Malnutrition Screening Toll (MST) is a simple, reliable and valid instrument which can be useful for nutritional screening of adult patients with cancer. As a method of nutritional assessment for patients with cancer, the Subjective Global Assessment (SGA), and especially the Patient-Generated Subjective Global Assessment (PGSGA) should be also mentioned. The causes of malnutrition in cancer can be related to type of tumour, patient features or cancer treatment, taking into account that in many cases all causes may be present in the same patient. Malnutrition in patients with cancer is also associated to increased morbidity and mortality; longer hospital stays and higher medical care costs, and a worse outcome and tolerance of cancer treatments (surgery, radio- and chemotherapy). Key objectives of nutritional intervention in cancer patients include preventing early death secondary to underlying malnutrition, reducing complications and improving the quality of life of patients with cancer. To achieve these goals, nutritional intervention includes several options that should be individualized for each patient. In any case, nutritional care should be started early and be part of the overall treatment of cancer patients. Based on its aggressiveness and complexity nutritional support can be classified into the following categories: nutrition recommendations or dietary counseling; artificial nutrition (oral supplements, enteral and parenteral nutrition), and evaluation of possible addiction to appetite stimulants, anabolic agents, cytokine inhibitors and other drugs (AU)

Encefalopatía hiperamoniémica; valoración y manejo nutricional a propósito de un caso / Hyperammonemic encephalopathy; nutritional assessment and management of a case

El déficit de Ornitintranscarbamilasa (OTC) es un trastorno del ciclo de la urea ligado al cromosoma X. Se manifiesta en el varón como hiperamoniemia severa en los primeros días de vida. En la mujer la enfermedad esmás leve. Diversas situaciones pueden provocar una descompensación con hiperamoniemia que puede ser letal o provocar daños neurológicos permanentes. Presentamos una mujer de 36 años que ingresó para cirugía y que sufrió una descompensación coincidiendo con infección de la herida quirúrgica. La hiperamoniemia provocó un deterioro neurológico con disminución del nivel de conciencia, tetraparesia y disfagia neurógena. Con tratamiento, que consistió en dieta hipoproteica, quelantes de amonio y medidas dialíticas, se consiguió controlar la hiperamoniemia y mejorar el estado neurológico. Este caso ilustra la importancia del soporte nutricional especializado de los pacientes con trastornos del ciclo de laurea en el ámbito hospitalario por darse frecuentemente situaciones que favorecen las descompensaciones (AU)

OTC deficiency is a disorder of the urea cycle X-linked. It is manifested in men as severe hyperammonemia in the first days of life. In women the disease is milder severity. Various conditions cause de compensation with hyperammonemia. It could be fatal or cause permanent neurological damage. We report a 36 years old woman admitted forsurgery, she suffered a de compensation in conjunction with surgical wound infection. Hyperammonemia caused neurological deterioration with decreased level of consciousness, tetraparesis and neurogenic dysphagia. The treatment consisting of low-protein diet, ammonium chelating drugs and dialytic measures, was effective incontrolling hyperammonaemia and improving neurological status. This case illustrates the importance of nutritional support of patients with disorders of the urea cyclein the hospital because the descompensations are more frecuent here (AU)

[Maternal and fetal outcomes in pregnancy following bariatric surgery]. / Resultados materno-fetales de la gestación tras cirugía bariátrica.

BACKGROUND: Obesity is the most frequent metabolic disease in the World, and is associated with several comorbidities. Bariatric procedures arise as a promising treatment when classical approach is ineffective. Half of the operated patients are reproductive-aged women and there is evidence that obesity is related to worse maternal and fetal outcomes. Because nutritional status is affected by bariatric surgery and is a vital component during pregnancy, the aim of our study is to asses the impact of bariatric surgery on pregnancy in these patients. MATERIAL AND METHODS: We studied 10 women and 15 pregnancies following bariatric surgery between 2003 and 2009. The visits took place every three months by an obstetrician and an endocrinologist with experience in nutrition, recording clinical features and lab work. RESULTS: We found iron deficiency in 80% of the pregnancies, vitamin D in 46,7%, vitamin A in 20%, vitamin E in 13,3% and vitamin B12 in 26,7%. There were no complications during pregnancy, except one case of gravidic hiperemesis. There were nine deliveries without malformations, three of them were small for gestational age newborns and one suffered aspiration pneumonia. There were three stillbirths and one preterm delivery with fetal death. CONCLUSIONS: our results show fewer complications during pregnancy in these women than obese women and similar to general population.

Resultados materno-fetales de la gestación tras cirugía bariátrica / Maternal and fetal outcomes in pregnancy following bariatric surgery

Introducción: La obesidad es la enfermedad metabólica más frecuente en el mundo y conlleva múltiples comorbilidades,siendo la cirugía bariátrica (CB) una opción terapéutica cuando fallan las medidas clásicas. La mitad de los pacientes intervenidos son mujeres en edad fértil y está demostrado que la obesidad se asocia a peores resultados obstétricos y fetales. Dado que el estado nutricional se ve afectado por la CB y es un factor esencial para el adecuado desarrollo del embarazo, el objetivo de nuestro trabajo es valorar los efectos de la CB sobre la gestación en mujeres obesas intervenidas. Material y métodos: Seguimiento de 10 mujeres y 15 gestaciones tras CB durante el periodo 2003-2009. Se realizaron visitas trimestrales en consultas de Nutrición y Obstetricia, con evaluación clínica y de laboratorio en cada una.Resultados: Se evidenció deficiencia de hierro en el80% de las gestaciones, de vitamina D en el 46,7%, de vitaminaA en el 20%, de vitamina E en el 13,3% y de vitamina B12 en el 26,7%. No hubo complicaciones durante la gestación salvo un caso de hiperémesis gravídica. Hubo9 partos de recién nacidos vivos sin malformaciones de los cuales 3 fueron recién nacidos pequeños para la edad gestacional (RNPEG) y uno presentó neumonía por aspiración de meconio. Hubo 3 abortos y un parto prematuro con feto muerto. Conclusiones: En nuestro grupo de estudio hubo menos complicaciones durante la gestación comparado con lo descrito en obesas no operadas y similares a la población general (AU)

Background: Obesity is the most frecuent metabolic disease in the World, and is associated with several comorbidities. Bariatric procedures a rise as a promising treatment when classical approach is in effective. Half of the operated patients are reproductive-aged women and there is evidence that obesity is related to worse maternal and fetal outcomes. Because nutritional status is affected by bariatric surgery and is a vital component during pregnancy, the aim of our study is to asses the impact of bariatric surgery on pregnancy in these pacients. Material and methods: We studied 10 women and 15 pregnancies following bariatric surgery between 2003 and 2009. The visits took place every three months by an obstetrician and an endocrinologist with experience innutrition, recording clinical features and lab work. Results:We found iron deficiency in 80% of the pregnancies,vitamin D in 46,7%, vitamin A in 20%, vitamin E in13,3% and vitamin B12 in 26,7%. There were no complications during pregnancy, except one case of gravidic hiperemesis. There were nine deliveries without malformations, three of them were small for gestational age newborns and one suffered aspiration pneumonia. There were three stillbirths and one preterm delivery with fetal death. Conclusions: our results show fewer complications during pregnancy in these women than obese women and similar to general population (AU)