Diagnóstico, manejo y tratamiento de pacientes con peritonitis secundaria en una unidad de cirugía general / Diagnosis, management and treatment of patients with secondary peritonitis in a general surgery unit

La peritonitis es una inflamación aguda o crónica del peritoneo que generalmente tiene un origen infeccioso. Existen varios tipos, siendo la de tipo secundario la más frecuente. El término peritonitis secundaria se define como la inflamación localizada o generalizada de la membrana peritoneal causada por infección polimicrobiana posterior a la ruptura traumática o espontánea de una víscera o secundaria a la dehiscencia de anastomosis intestinales. Esta entidad se caracteriza por la presencia de pus en la cavidad peritoneal o de líquido; que, en el estudio microscópico directo, contiene leucocitos y bacterias. El tratamiento de esta patología constituye una urgencia y puede ser de tipo clínico y/o quirúrgico. El objetivo del manejo operatorio se basa en identificar y eliminar la causa de la infección, recoger muestras microbiológicas, realizar una limpieza peritoneal y prevenir la recidiva. El tratamiento clínico se ocupa de las consecuencias de la infección mediante la reanimación perioperatoria y el tratamiento antibiótico1. A pesar de los avances en diagnóstico, procedimientos quirúrgicos, terapia antimicrobiana y cuidados intensivos, la mortalidad asociada con la peritonitis secundaria grave es aún muy alta. El pronóstico y el manejo oportuno representan la clave para mejorar la sobrevida y reducir la mortalidad asociada a infecciones intraabdominales extensas2. Es importante establecer lineamientos en cuanto al diagnóstico, manejo antibiótico y pautas de tratamiento quirúrgico para disminuir la morbilidad y mortalidad asociada a esta enfermedad. Palabras clave: Peritonitis; Peritoneo; Cavidad Abdominal/cirugía; Cavidad Peritoneal; Líquido Ascítico/patología; Procedimientos Quirúrgicos Operativos.

Peritonitis is an acute or chronic inflammation of the peritoneum that generally has an infectious origin. There are several types, with secondary peritonitis being the most frequent. The term secondary peritonitis is defined as localized or generalized inflammation of the peritoneal membrane caused by polymicrobial infection following traumatic or spontaneous rupture of a viscus or secondary to dehiscence of intestinal anastomoses. This entity is characterized by the presence of pus in the peritoneal cavity or fluid which, on direct microscopic examination, contains leukocytes and bacteria. The treatment of this pathology constitutes an emergency and can be clinical and/or surgical. The aim of operative management is based on identifying and eliminating the cause of the infection, collecting microbiological samples, performing peritoneal cleansing and preventing recurrence. Clinical management deals with the consequences of the infection by perioperative resuscitation and antibiotic treatment1 . Despite advances in diagnosis, surgical procedures, antimicrobial therapy and intensive care, mortality associated with severe secondary peritonitis is still very high. Prognosis and timely management represent the key to improving survival and reducing mortality associated with extensive intra-abdominal infections2. It is important to establish guidelines for diagnosis, antibiotic management and surgical treatment guidelines to reduce the morbidity and mortality associated with this disease.

Presencia de infección de sitio quirúrgico en procedimientos gineco-obstétricos en un hospital de II nivel de atención, Honduras 2017-2018 / Presence of surgical site infection in obstetric-gynecological procedures in a level II care hospital, Honduras 2017-2018

OBJETIVO: Identificar la presencia de infección de sitio quirúrgico y factores de riesgo en pacientes sometidas a cirugías Gineco-Obstétricas de forma programada o de urgencia en un hospital de II nivel de atención en Honduras. METODOLOGÍA: Estudio observacional, descriptivo, retrospectivo; recopilando 226 fichas del registro de infección de sitio quirúrgico recuperadas de los expedientes clínicos brindados por el servicio de estadística del Hospital Mario Catarino Rivas. Captando pacientes sometidas a cirugías Gineco-Obstétricas, durante el 2017 y 2018. RESULTADOS: 99 fichas cumplieron los criterios de inclusión, reportando una edad de 24 años [RIQ, 19,0 - 30,0], peso 82,0 kg [RIQ, 51,7 - 98,25], talla 154 cm [150,0 - 158,0] y el IMC de 25,8 ± 3,6 kg/m2. Un 9,1% presento antecedentes de inmunosupresión. 5,1% presento ISQ. El 55.6% de las cirugías se realizó el mismo día de ingreso del paciente. El tiempo entre la profilaxis antibiótica y el comienzo de la intervención quirúrgica es de 60 minutos [RIQ, 40,0 - 160,0]. La duración de los procedimientos quirúrgicos son de 45 minutos [RIQ, 35,0 - 55,0]. Los microrganismos aislados en los cultivos fueron Cocos gram positivos (2/5), Enterococcus faecalis (1/5), Klebsiella pneumoniae (2/5). CONCLUSIÓN: La presencia de ISQ en cirugías Gineco-Obstétricas del HMCR es del 5.1%, identificando los siguientes factores de riesgo: edad extrema, obesidad, diabetes mellitus, estado inmunitario (VIH), profilaxis antibiótica (temprana); por último, la técnica y el tiempo quirúrgico.

OBJECTIVE: To identify the presence of surgical site infection and risk factors in patients undergoing Gynecological-Obstetric surgeries on a scheduled or emergency basis in a 2nd level of care hospital in Honduras. METHODOLOGY: Observational, descriptive, retrospective study, compiling 226 data sheets of the surgical site infection record recovered from the clinical records provided by the statistics service of the "Hospital Mario Catarino Rivas". Recruiting patients undergoing Gynecological-Obstetric surgeries, during 2017 and 2018. RESULTS: 99 tabs met the inclusion criteria, reporting an age of 24 [RIQ, 19.0 - 30.0], weight 82.0 kg [RIQ, 51.7 - 98.25], size 154 cm [150.0 - 158.0] and BMI of 25.8 ± 3.6 kg/m2. 9.1% have a history of immunosuppression. 5.1% present ISQ. 55.6% of surgeries were performed on the same day as the patient's admission. The time between antibiotic prophylaxis and the onset of surgery 60 minutes [RIQ, 40.0 - 160.0]. Duration of surgical procedures 45 minutes [RIQ, 35.0 - 55.0]. Isolated micro-morphisms in crops were Cocos gram positives (2/5), Enterococcus faecalis (1/5), Klebsiella pneumoniae (2/5). CONCLUSION: The presence of ISQ in HMCR Gynecological-Obstetric surgeries is 5.1%, identifying the following risk factors: extreme age, obesity, diabetes mellitus, immune status (HIV), early antibiotic prophylaxis; finally, technique and surgical time.

Relação entre orientação em saúde e complicações no pós-operatório de cirurgias torácicas e abdominais altas / Correlation between the healthcare guidance and thoracic and upper abdominal post-operative care / Relación entre orientación en salud y complicaciones en el postoperatorio de cirugías torácicas y abdominales alta

Objetivo: avaliar a influência das orientações em saúde nas complicações no pós-operatório de cirurgias torácicas e abdominais altas. Método: estudo quantitativo transversal realizado com 266 indivíduos. Os dados foram coletados por um questionário sociodemográfico, clínico e assistencial. Foram incluídos sujeitos de ambos os sexos, com faixa etária de 18 a 80 anos, que estivessem na enfermaria em pós-operatório de cirurgias torácicas e ou abdominais altas. Resultados: 82 (30%) dos indivíduos receberam orientações no período de pós-operatório e 184 (70%) não receberam nenhum tipo de orientação. Quatro dos sujeitos que receberam orientações desenvolveram algum tipo de complicação e 16 dos que não receberam tiveram complicações; não apresentando resultados estatisticamente significativos quanto aos pesquisados que tiveram orientação e os que não tiveram orientações (p=0,4). Conclusão: em relação ao número de complicações, ao comparar os indivíduos que receberam orientações com os que não receberam não houve resultado estatisticamente significativo

Objective: to evaluate correlation between health guidelines and complications in the postoperative period after thoracic and upper abdominal surgeries. Method: a cross-sectional quantitative study with 266 individuals. Data were collected by a sociodemographic, clinical and care questionnaire. We included subjects of both sexes, with ages ranging from 18 to 80 years, who were in the postoperative ward after thoracic and/ or upper abdominal surgeries. Results: 82 (30%) of the subjects received guidance in the postoperative period and 184 (70%) received no guidance. Four of the subjects who received guidelines developed some type of complication while 16 of those who did not receive guidance developed complications; therefore, the results were not statistically significant (p=0,4). Conclusion: in relation to the number of complications, when comparing individuals who received guidelines with those who did not receive, there was no statistically significant result

Objetivo: evaluar la influencia de las orientaciones en salud en las complicaciones en el postoperatorio de cirugías torácicas y abdominales altas. Metodo: estudio cuantitativo transversal realizado con 266 individuos. Los datos fueron recolectados por un cuestionario sociodemográfico, clínico y asistencial. Se incluyeron sujetos de ambos sexos, con rango de edad de 18 a 80 años, que estuvieran en la enfermería en postoperatorio de cirugías torácicas y / o abdominales alta. Resultados: 82 (30%) de los individuos recibieron orientaciones en el período de postoperatorio y 184 (70%) no recibieron ningún tipo de orientación. Cuatro de los sujetos que recibieron orientaciones, desarrollaron algún tipo de complicación y 16 de los que no recibieron tuvieron complicaciones; no presentando resultados estadísticamente significativos en cuanto a los encuestados que tuvieron orientación y los que no tuvieron orientaciones (p=0,4). Conclusión: en relación al número de complicaciones, al comparar a los individuos que recibieron orientaciones con los que no recibieron no hubo resultado estadísticamente significativo

Reconstrução de parede abdominal: série de casos / Reconstruction of the abdominal wall: a case series

Introdução: Os pacientes com defeitos de parede abdominal chegam ao consultório do cirurgião plástico em situações muitas vezes complexas, necessitando de abordagem cirúrgica avançada. Métodos: Estudo primário, retrospectivo e descritivo de pacientes submetidos a procedimentos cirúrgicos de reconstrução de parede abdominal pelo Serviço de Cirurgia Plástica do Hospital das Clínicas da Universidade Federal de Pernambuco (HC-UFPE). Resultados: Foram revisados e incluídos os prontuários de 18 pacientes, 15 (83,3%) do sexo feminino e 3 (16,7%) do masculino, com idade variando de 16 a 79 anos (média de 41 anos). Dezessete pacientes possuíam histórico de cirurgia prévia (94,4%), sendo a cesárea presente em 8 dos casos (44,4%), seguida de cirurgia oncológica com 6 (33,3%), cirurgia do trauma com 2 (11,1%) e bariátrica com 2 (11,1%). Em relação à etiologia do defeito, 8 (44,4%) eram decorrentes de fasciite necrosante, 4 (22,2%) de hérnia incisional, 2 (11,1%) por trauma, 2 (11,1%) por infecção de ferida operatória e 2 (11,1%) por neoplasia de parede abdominal, sendo somente um (5,5%) paciente com defeito de espessura total. A técnica cirúrgica de separação dos componentes foi realizada em 7 dos casos (38,9%), seguida de retalho de avanço simples em 6 (33,3%), fechamento com tela associado à abdominoplastia em 3 (16,7%), e expansor tecidual em 2 (11,1%). Quanto às complicações, houve 4 casos (22,2%). Conclusões: Defeitos de parede abdominal são casos desafiadores para o cirurgião plástico, seu tratamento se mostra árduo, porém com resultados satisfatórios mesmo nos casos mais severos.

Introduction: Patients with abdominal wall defects present challenging complications that require the use of advanced surgical approaches. Methods: This primary, retrospective, and descriptive study evaluated patients who underwent abdominal wall reconstruction at the Plastic Surgery Service of the Clinics Hospital of the Federal University of Pernambuco. Results: The medical records of 18 patients were reviewed, including 15 women (83.3%) and 3 men (16.7%), with a mean age of 41 years (range, 16-79 years). Seventeen patients (94.4%) had a history of previous surgery. The causes of abdominal injury were cesarean section in eight cases (44.4%), oncologic surgery in six (33.3%), trauma surgery in two (11.1%), and bariatric surgery in two (11.1%). The etiology of the defect was necrotizing fasciitis in eight cases (44.4%), incisional hernia in four (22.2%), trauma in two (11.1%), surgical wound dehiscence in two (11.1%), abdominal wall neoplasia in two (11.1%), and total thickness defect in one (5.5%). The surgical interventions included the component separation technique in seven cases (38.9%), simple VY advancement flap in six (33.3%), closure with abdominoplasty in three (16.7%), and tissue expander in two (11.1%). Four patients (22.2%) presented complications. Conclusions: Abdominal wall defects are challenging cases for plastic surgeons, as their treatment is difficult, but the results are satisfactory even in the most severe cases.

Perfil de pacientes con ostomía abdominal de evacuación del hospital central del instituto de previsión social, año 2017 / Profile of patients with abdominal ostomy of evacuation of the central hospital of the social security institute, year 2017

Introducción: La confección de estomas intestinales han permitido el tratamiento quirúrgico de variadas patologías abdominales ya sea de forma temporal o permanente. La persona ostomizada es aquella que fue sometida a una cirugía donde el lumen de un órgano hueco fue abocado al exterior y fijado en piel. En el Paraguay el Hospital Central del Instituto de Previsión Social (HCIPS) es un centro quirúrgico de referencia por tal motivo estudiar el perfil de los pacientes con estomas abdominales de dicho centro aportó información de la situación actual. Objetivo: Describir el perfil de los pacientes con ostomias abdominales de evacuación que acuden al Hospital Central del Instituto de Previsión Social durante el año 2017. Material y métodos: Se realizó un estudio observacional, de tipo descriptivo, de corte transversal. Fueron incluidos la totalidad de los pacientes con ostomia abdominal de evacuación del Hospital Central del Instituto de Previsión Social de enero a diciembre del 2017. Resultados: Ingresaron al estudio 125 pacientes. La mediana de edad fue de 64 años, el rango etario más frecuente fue entre 27 a 86 años; el sexo masculino tuvo una frecuencia de 52% de los ostomizados; el 44% acudió a consultar por dolor abdominal; la neoplasia en un 52% fue el motivo que llevó a la confección de una ostomía; el órgano con mayor número de intervenciones fue el colon en un 65%. El 88,80% no tuvo complicaciones. Conclusión: El estudio incorpora datos relevantes que demuestra el perfil actual de los pacientes que acuden al Centro de Ostomizados que posibilitará la asistencia directiva en la planificación de la asistencia especializada multiprofesional y de las políticas públicas

Experiencia en la reparación de hernia incisional por vía laparoscópica en una Unidad de Cirugía Ambulatoria / Experience in the Repair of Incisional Hernia by Laparoscopic Route in an Ambulatory Surgery Unit

Introducción. La hernia Incisional es una complicación frecuente de la cirugía abdominal sobre todo en pacientes que presentan factores de riesgo para desarrollar la misma. El sistema de salud pública no cuenta con suficiente encamamiento para estos pacientes para la realización de una cirugía electiva. La reparación laparoscópica y su aplicación en una unidad de cirugía ambulatoria se ha convertido en una opción para estos pacientes. El presente estudio busca evaluar los resultados de la reparación de la hernia incisional por vía laparoscópica y su aplicación en cirugía ambulatoria. Métodos. Se realizó un estudio retrospectvo de pacientes a quienes se le realizo reparación laparoscópica del año 2010 al año 2016, evaluando los factores de riesgo para la hernia incisional, el tamaño, su localización más frecuente, cierre del defecto, estancia hospitalaria, tiempo quirúrgico, malla utilizada, que tipo de analgésico se utilizaron a su egreso, sus complicaciones, su manejo y el seguimiento a los 8 días, 30 días y cada 2 meses durante un año. Resultados. Se incluyeron un total de 50 pacientes, siendo más frecuente en el sexo femenino. El principal factor de riesgo para el aparecimiento de la hernia incisional fue cirugías múltiples de origen obstétrico. La localización más frecuente fue la línea media infra umbilical. En 80% de los casos se realizó cierre por afrontación del defecto. En 100% de los casos se colocó malla separadora de tejido. El tiempo operatorio promedio fue de 70 minutos. El 75% de los pacientes fueron dados de alta el mismo día de la cirugía, el resto se ingresó al hospital, por condiciones de dolor post operatorio, complicaciones transoperatorias (2 casos) o reparación de un defecto grande (mayor de 15 centímetros). La mayor parte de los pacientes respondieron adecuadamente al uso de analgésicos por vía oral (75%), el resto se utilizó una combinación de dos analgésicos. Conclusiones. La técnica laparoscópica es una técnica adecuada y segura para la reparación de la hernia incisional aplicada en cirugía ambulatoria. Además, permite tratar a los pacientes que la sufren sin recargar la capacidad hospitalaria.

Introduction. Incisional hernia is a common abdominal surgical complication in patents with risk factors. Public hospitals don´t have enough beds to admit patents and perform the repair in an elecitve way, so ambulatory laparoscopic technique became a feasible alternative. The aim of the study is to evaluate our experience with ambulatory laparoscopic incisional hernioplasty. Methods. This retrospective study includes all the patents that presented an incisional hernia and were repaired by ambulatory laparoscopic hernioplasty between 2010 and 2016. We evaluated the presence of risk factors, the size of the hernia defect and location, the type of closure, operative time, type of mesh, length of hospitalization, analgesic treatment and management of complications. Results. We treated 50 patents. The main risk factor for incisional hernia was multiple gynecological surgeries. The most common site was at the infraumbilical medial line. In 80% of the patents we performed a complete defect closure. In all patents we used a two layer mesh. The mean operative time was 70 minutes. 75% of patents were discharged the same day and the rest of the patents were hospitalized because of uncontrolled pain, perioperative complications (2 cases) or extensive defects (above 15 centimeters in diameter). 75% of patents needed one analgesic and the rest a combination of two. Conclusions. Laparoscopic incisional hernioplasty can be safely performed in an ambulatory program and reduce the need of hospitalization.

Respiratory status of adult patients in the postoperative period of thoracic or upper abdominal surgeries / Estado respiratório de pacientes adultos no período pós-operatório de cirurgias torácicas ou abdominal superior / Estado respiratorio de pacientes adultos en el postoperatorio de cirugías torácicas o de abdomen superior

ABSTRACT Objective: to evaluate the respiratory status of postoperative adult patients by assessing the nursing outcome Respiratory Status. Method: descriptive, cross-sectional study developed with 312 patients. Eighteen NOC indicators were assessed and rated using a Likert-scale questionnaire and definitions. Descriptive and correlative analysis were conducted. Results: the most compromised clinical indicators were coughing (65.5%), auscultated breath sounds (55%), and respiratory rate (51.3%). Factors associated with worse NOC ratings in specific clinical indicators were sex, age, pain, and general anesthesia. Conclusions: certain clinical indicators of respiratory status were more compromised than others in postoperative patients. Patient and context-related variables can affect the level of respiratory compromise.

RESUMO Objetivo: avaliar o estado respiratório de pacientes adultos no pós-operatório por meio da análise do resultado de enfermagem Estado Respiratório. Método: estudo descritivo e transversal desenvolvido com 312 pacientes. Dezoito indicadores da Classificação dos Resultados de Enfermagem (Nursing Outcomes Classification - NOC) foram avaliados e classificados utilizando um questionário contendo escalas Likert e definições. Foram realizadas análises descritivas e de correlações. Resultados: os indicadores clínicos mais comprometidos foram tosse (65,5%), ausculta de sons respiratórios (55%) e frequência respiratória (51,3%). Fatores associados com escores NOC comprometidos para indicadores clínicos específicos foram gênero, idade, dor e anestesia geral. Conclusões: certos indicadores clínicos do estado respiratório foram mais comprometidos do que outros em pacientes no pós-operatório. O paciente e as variáveis relacionadas aos pacientes e ao contexto podem afetar o nível de comprometimento respiratório.

RESUMEN Objetivo: evaluar el estado respiratorio de pacientes adultos en postoperatorio por la evaluación del resultado de enfermería Estado Respiratorio. Método: estudio descriptivo transversal realizado con 312 pacientes. Dieciocho indicadores de la Clasificación de Resultados en Enfermería (Nursing Outcomes Classification - NOC) fueron evaluados y calificados utilizando un cuestionario conteniendo escalas Likert y definiciones. Análisis descriptivos y de correlaciones fueron realizados. Resultados: los indicadores clínicos más comprometidos fueron tos (65,5%), auscultación de sonidos respiratorios (55%) y frecuencia respiratoria (51,3%). Factores asociados con puntuaciones NOC comprometidas en indicadores clínicos específicos fueron género, edad, dolor y anestesia general. Conclusiones: ciertos indicadores clínicos de estado respiratorio fueron más comprometidos que otros en pacientes postoperatorios. El paciente y las variables relacionadas con el paciente y el contexto pueden afectar el nivel de compromiso respiratorio.

Impact of prior abdominal surgery on the outcomes after robotic - assisted laparoscopic radical prostatectomy: single center experience

ABSTRACT Purpose: To evaluate the influence of prior abdominal surgery on the outcomes after robotic-assisted laparoscopic radical prostatectomy (RALP). Materials and Methods: We retrospectively analyzed patients with prostate cancer who underwent RALP between June 2012 and February 2015 at our institution. Patients with prior abdominal surgery were compared with those without prior surgery while considering the mean total operating, console, and port-insertion times; mean estimated blood loss; positive surgical margin rate; mean duration of catheterization; and rate of complications. Results: A total of 203 patients who underwent RALP during the study period were included in this study. In all, 65 patients (32%) had a prior history of abdominal surgery, whereas 138 patients (68%) had no prior history. The total operating, console, and port-insertion times were 328 and 308 (P=0.06), 252 and 242 (P=0.28), and 22 and 17 minutes (P=0.01), respectively, for patients with prior and no prior surgery. The estimated blood losses, positive surgical margin rates, mean durations of catheterization, and complication rates were 197 and 170 mL (P=0.29), 26.2% and 20.2% (P=0.32), 7.1 and 6.8 days (P=0.74), and 12.3% and 8.7% (P=0.42), respectively. Furthermore, whether prior abdominal surgery was performed above or below the umbilicus or whether single or multiple surgeries were performed did not further affect the perioperative outcomes. Conclusions: Our results suggest that RALP can be performed safely in patients with prior abdominal surgery, without increasing the risk of complications.

Bloqueos paravertebrales torácicos ecoguiados en pediatría. Estudio de series de casos / Thoracic paravertebral loops echoguided in pediatrics. Case series study

La analgesia epidural es la técnica analgésica tradicionalmente utilizada para el manejo del dolor postoperatorio en cirugía torácica y abdominal alta, tanto en adultos como en pediatría. En la población pediátrica además de los riesgos inherentes a la colocación de un catéter peridural torácico, existen otro tipo de problemas, como la mayor dificultad técnica, y que el procedimiento debe realizarse con el paciente anestesiado. Los bloqueos analgésicos paravertebrales consisten en inyectar una dosis de anestésico local, o colocar un catéter, en el espacio paravertebral torácico y se extendieron gracias a la aparición de la ecografía.

The epidural analgesia is the analgesic technique traditionally used for the management of postoperative pain in upper thoracic and abdominal surgery in both adults and pediatrics. In the pediatric population in addition to the risks inherent in the placement of a thoracic epidural catheter, there are other problems, such as greater technical difficulty, and that the procedure should be performed with the anesthetized patient. Analgesics paravertebral blocks consist of injecting a dose of local anesthetic, or placing a catheter in the thoracic paravertebral space They were extended by the appearance of ultrasound.

Correlation between intra-abdominal pressure and pulmonary volumes after superior and inferior abdominal surgery

OBJECTIVE: Patients undergoing abdominal surgery are at risk for pulmonary complications. The principal cause of postoperative pulmonary complications is a significant reduction in pulmonary volumes (FEV1 and FVC) to approximately 65-70% of the predicted value. Another frequent occurrence after abdominal surgery is increased intra-abdominal pressure. The aim of this study was to correlate changes in pulmonary volumes with the values of intra-abdominal pressure after abdominal surgery, according to the surgical incision in the abdomen (superior or inferior). METHODS: We prospectively evaluated 60 patients who underwent elective open abdominal surgery with a surgical time greater than 240 minutes. Patients were evaluated before surgery and on the 3rd postoperative day. Spirometry was assessed by maximal respiratory maneuvers and flow-volume curves. Intra-abdominal pressure was measured in the postoperative period using the bladder technique. RESULTS: The mean age of the patients was 56±13 years, and 41.6% 25 were female; 50 patients (83.3%) had malignant disease. The patients were divided into two groups according to the surgical incision (superior or inferior). The lung volumes in the preoperative period showed no abnormalities. After surgery, there was a significant reduction in both FEV1 (1.6±0.6 L) and FVC (2.0±0.7 L) with maintenance of FEV1/FVC of 0.8±0.2 in both groups. The maximum intra-abdominal pressure values were similar (p = 0.59) for the two groups. There was no association between pulmonary volumes and intra-abdominal pressure measured in any of the groups analyzed. CONCLUSIONS: Our results show that superior and inferior abdominal surgery determines hypoventilation, unrelated to increased intra-abdominal pressure. Patients at high risk of pulmonary complications should receive respiratory care even if undergoing inferior abdominal surgery. .

Repercusión de la cirugía torácica y abdómino-pélvica en el estado funcional del anciano / Impact of thoracic and abdominopelvic surgery on the functional status in the elderly

La calidad de vida de los ancianos está determinada por su capacidad funcional, más que por el número o tipo de enfermedades que padecen. Se analizaron 43 pacientes mayores de 65 años sometidos a cirugías mayores. Se siguió longitudinalmente la evolución del estado funcional mediante el análisis de 6 variables, las actividades de la vida diaria (AVD), actividades instrumentales de la vida diaria (AIVD), la prueba de levántate y anda, prueba del alcance funcional del brazo, fuerza de prensión de la mano y velocidad de la marcha, medidas previas a la cirugía (medición basal) y a los 1, 2, 3 y 4 meses posteriores al alta. Los objetivos fueron: estimar la repercusión que la cirugía tiene en el estado funcional de ancianos, determinar el tiempo que cada una de las mediciones regresa a los valores del preoperatorio en el seguimiento a 4 meses, comparar las curvas de recuperación de los valores basales de AIVD, fuerza de prensión de la mano y velocidad en la marcha, entre 2 grupos definidos por la velocidad de la marcha basal, en lentos ( 0.8 m/s). La repercusión de la cirugía en la aptitud física presentó una disminución estadísticamente significativa en AVD, AIVD, la prueba de levántate y anda y velocidad en la marcha con recuperación en tiempo variable, más allá de la convalecencia. La evaluación del estado funcional permite planear estrategias tendientes a cubrir limitaciones y necesidades del paciente y su familia en el post operatorio mediato.

The quality of life of older people is determined by their functional capacity, rather than by the number or type of disease suffered. We analyzed 43 patients over 65 years undergoing major surgery. Longitudinally continued evolution of functional status by analyzing six variables, activities of daily living (ADLs), instrumental activities of daily living (IADL), the get up and walk test, functional reach test of arm, strength of handgrip and walking speed, measured before surgery (baseline measurement) and at 1, 2, 3 and 4 months after discharge. The objectives were to estimate the impact that surgery has on functional status in the elderly, determine how long each of the measurements returned to preoperative values at 4 months follow-up. Recovery curves compared the baseline AIVD, grip strength and hand speed on the fly, between two groups defined by baseline walking speed in slow ( 0.8 m/s). The impact of surgery on physical fitness showed a statistically significant decrease in ADL, IADL, and the get up and walk test and walking speed, with variable time recovery beyond convalescence. All return to baseline at 4 months except test walking speed that exceeded the baseline. Functional status can be evaluated quickly and should be included in the preoperative evaluation, since it allows planning strategies to meet the needs and limitations of patients and their families, in the immediate postoperative period.

Surgical risk tests related to cardiopulmonary postoperative complications: comparison between upper abdominal and thoracic surgery

PURPOSE: To investigate if tests used in the preoperative period of upper abdominal or thoracic surgeries are able to differentiate the patients that presented cardiopulmonary postoperative complications. METHODS: Seventy eight patients, 30 submitted to upper abdominal surgery and 48 to thoracic surgery were evaluated. Spirometry, respirometry, manovacuometry, six-minute walk test and stair-climbing test were performed. Complications from immediate postoperative to discharge from hospital were registered. RESULTS: The postoperative complications rate was 17% in upper abdominal surgery and 10% in thoracic surgery. In the univariate regression, the only variable that kept the correlation with postoperative complications in the upper abdominal surgery was maximal expiratory pressure. In thoracic surgery, the maximal voluntary ventilation, six-minute walk test and time in stair-climbing test presented correlation with postoperative complications. After multiple regression only stair-climbing test continued as an important risk predictor in thoracic surgery. CONCLUSION: The respiratory pressure could differentiate patients with complications in upper abdominal surgery, whereas in thoracic surgery, only spirometric values and exercise tests could differentiate them.

High prevalence of chronic pelvic pain in women in Ribeirão Preto, Brazil and direct association with abdominal surgery

INTRODUCTION: Chronic pelvic pain is a disease that directly affects the social and professional lives of women. OBJECTIVE: To estimate the prevalence of this clinical condition and to identify independent factors associated with it in women living in Ribeirão Preto, Brazil. METHODS: A one-year cross-sectional study was conducted in a population sample of 1,278 women over the age of 1,278 women over the age of 14 years. The target population was predominantly composed of women who are treated by the public health system. The questionnaire was administered by interviewers who were not linked to the city health care programs. The prevalence of the morbidity was estimated. First, we identified the significant variables associated with pelvic pain (p<0.10) and then we attributed values of 0 or 1 to the absence or presence of these variables. Logistic regression analysis was used to identify and estimate the simultaneous impact of the independent variables. The results were expressed by odds ratio and their 95 percent confidence interval with p<0.05. RESULTS: The disease was found in 11.5 percent (147/1,278) of the sample. The independent predictors were dyspareunia, previous abdominal surgery, depression, dysmenorrhea, anxiety, current sexual activity, low back pain, constipation, urinary symptoms, and low educational level. CONCLUSION: The prevalence of chronic pelvic pain in Ribeirão Preto is high and is associated with conditions that can usually be prevented, controlled, or resolved by improvement of public health policies and public education.

Full-thickness abdominal skin graft for long-segment urethral stricture reconstruction

Multiple tissue sources have been used for urethral reconstruction in adults. Patients with lichen sclerosis (LS), long segment strictures, or prior oral graft use have less available tissue for urethroplasty. We describe a technique for the use of a full-thickness skin graft of hairless abdominal skin for long segment urethroplasty.

Infección del sitio operatorio en cirugía abdominal no traumática / Surgical site infection in non-traumatic surgery

BACKGROUND: Risk factors of surgical site infection (SSI) have been widely studied, such as abdominal surgery, surgical time >2 h, contaminated or dirty surgery, three or more diagnoses at discharge, and ASA classification >II. METHODS: A prospective risk factor study was carried out for SSI in patients who underwent non-traumatic abdominal surgery, comparing an institutional (Secretary of Health) and a private third-level hospital during the period from October 2001 to May 2002. RESULTS: We studied 527 patients with 21 cases (3.98%) of SSI and four deaths due to this cause, 0.75% of the total population and 19% of patients with SSI. The mean age was 47.5 +/- 19.1 years, and there were 195 (37%) males and 332 (63%) females. The incidence of SSI in the private hospital was 2.1% and in the institutional hospital 5%, without statistical significance (p = 0.09). Within the infected group we found 14 superficial infections, 5 deep infections, and 2 infections in the organ or surgical field. Variables included in the models of logistic regression were smoke, blood transfusion, trichotomy, and wound type. CONCLUSIONS: Observed infection incidence was within the expected range. In our study there were no differences between facilities, and SSI incidence is similar to what has previously been reported.

Prognostic factors for perioperative pulmonary events among patients undergoing upper abdominal surgery

CONTEXT AND OBJECTIVE: The significant relationship between upper abdominal surgery and early (perioperative) pulmonary events was investigated among patients with preoperative pulmonary conditions undergoing general anesthesia. DESIGN AND SETTING: Retrospective study for which data were obtained prospectively from 1999 to 2004, at a tertiary university hospital. METHODS: We retrospectively studied 3107 patients over 11 years old presenting American Society of Anesthesiologists (ASA) status I, II or III who underwent upper abdominal surgery under general anesthesia and were discharged to the recovery room. The preoperative conditions analyzed using logistic regression were: age, sex, ASA physical status, congestive heart failure, asthma, chronic obstructive pulmonary disease (COPD), respiratory failure and smoking. The outcomes or dependent variables included intraoperative and postoperative events: bronchospasm, hypoxemia, hypercapnia, prolonged intubation and airway secretion. RESULTS: Among these patients (1500 males, 1607 females, mean age 48 years, 1088 ASA I, 1402 ASA II and 617 ASA III), there were 80 congestive heart failures, 82 asthmatics, 122 with COPD, 21 respiratory failures and 428 smokers. Logistic regression analysis showed that female sex (p < 0.001), age over 70 years (p < 0.01), smoking (p < 0.001) and COPD (p < 0.02) significantly influenced pulmonary event development, particularly hypoxemia and bronchospasm, at both times but not in the same patients. Asthma and congestive heart failure cases did not present pulmonary events in the recovery room. CONCLUSION: In upper abdominal surgery under general anesthesia, female sex, age over 70, smoking and COPD were independent risk factors for intra and postoperative pulmonary events.

CONTEXTO E OBJETIVO: Associações significativas entre cirurgia do abdome superior e eventos pulmonares do período perioperatório foram investigadas em pacientes com condições pulmonares pré-operatórias submetidos a anestesia geral. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo cujos dados foram retirados de banco de dados obtidos prospectivamente de forma protocolada, de 1 de janeiro de 1999 a 31 de dezembro de 2004, em hospital universitário terciário. MÉTODOS: Estudados 3107 pacientes com mais de 11 anos, American Society of Anesthesiologists (ASA) I, II, III, com cirurgia de abdome superior sob anestesia geral, enviados à sala de recuperação. Condições pré-operatórias analisadas por regressão logística foram: idade, sexo, estado físico ASA, insuficiência cardíaca congestiva, asma, doença pulmonar obstrutiva crônica, insuficiência respiratória e hábito de fumar. Os resultados estudados, ou variáveis dependentes, incluíram eventos intra- e pós-operatórios: broncoespasmo, hipoxemia, hipercapnia, intubação prolongada e secreção de vias aéreas. RESULTADOS: Dos 3.107 pacientes: 1.540 eram homens, 1.649 mulheres, tinham média de 48 anos, 1088 ASA I, 1402 ASA II, 617 ASA III, com insuficiência cardíaca havia 80, asma, 82, doença pulmonar obstrutiva, 122, insuficiência respiratória, 21, hábito de fumar, 428. Pela regressão logística, sexo feminino (p < 0.001), idade maior que 70 anos (p < 0.01), hábito de fumar (p < 0.001) e doença pulmonar obstrutiva crônica (p < 0.02) influenciaram significativamente o desenvolvimento de eventos pulmonares, principalmente hipoxemia e broncospasmo, em ambos os períodos, mas não nos mesmos pacientes. Asma e insuficiência cardíaca não se associaram com eventos pulmonares na sala de recuperação. CONCLUSÃO: Em cirurgia do abdome superior sob anestesia geral, sexo feminino, idade maior que 70 anos, hábito de fumar e doença pulmonar obstrutiva crônica foram fatores de risco independentes para a ocorrência de eventos...

Estudio comparativo entre ropivacaína epidural y diclofenac intravenoso para la analgesia continua en las primeras 24 horas del período postoperatorio: investigación clínica en intervenciones ginecológicas de hemiabdomen inferior / Comparative study between epidural ropivacaine and intravenous diclofenac for continuous analgesia during the first 24 hours posoperatively

Introducción: La ropivacaína, un nuevo anestésico local, presenta menos cardiotoxicidad y bloqueo motor que la bupivacaína en dosis equipotentes. Esto la convierte en un fármaco apropiado para administración epidural para analgesia postoperatoria. El objetivo de la presente investigación fue determinar si la ropivacaína epidural es mejor que la infusión intravenosa continua de diclofenac para el alivio del dolor postoperatorio. Material y métodos: El estudio fue abierto, prospectivo y randomizado con dos grupos paralelos. Veinte pacientes ASA I-III, elegidas para cirugía en hemiabdomen inferior bajo anestesia general, completaron el estudio: nueve en el grupo ropivacaína y once en el grupo diclofenac. Los dos grupos recibieron tratamiento durante las primeras 24 horas del postoperatorio. El grupo ropivacaína recibió una infusión epidural de ropivacaína 2 mg/ml (10 ml/h) y el grupo diclofenac, una infusión intravenosa continua de diclofenac a razón de 2 mg/kg/día. La medicación de rescate en ambos grupos consistió en dosis de morfina de 2 mg, administradas según demanda de las pacientes ante la presencia de dolor a nivel de la pared abdominal. Resultados: El grupo ropivacaína consumió significativamente menos morfina que el grupo diclofenac durante las 24 horas del período de estudio (medianas: grupo ropivacaína, 2 mg; grupo diclofenac, 10 mg; p < 0.05). La evaluación del dolor mediante la Escala Visual Analógica en reposo fue significativamente inferior en el grupo ropivacaína, durante las primeras 10 horas de infusión, que en el grupo diclofenac (p < 0.05). Las náuseas y vómitos tuvieron una incidencia similar en ambos grupos. La mayoría de los efectos fueron de pequeña a moderada magnitud. Conclusiones: este estudio demuestra que la infusión epidural de ropivacaína al 0,2 por ciento permite una mejor analgesia que la obtenida con una infusión de diclofenac intravenoso.

Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery

OBJECTIVE: To investigate associations between preoperative variables and postoperative pulmonary complications (PPC) in elective upper abdominal surgery. DESIGN: Prospective clinical trial. SETTING: A tertiary university hospital. PATIENTS: 408 patients were prospectively analyzed during the preoperative period and followed up postoperatively for pulmonary complications. MEASUREMENTS: Patient characteristics, with clinical and physical evaluation, related diseases, smoking habits, and duration of surgery. Preoperative pulmonary function tests (PFT) were performed on 247 patients. RESULTS: The postoperative pulmonary complication rate was 14 percent. The significant predictors in univariate analyses of postoperative pulmonary complications were: age >50, smoking habits, presence of chronic pulmonary disease or respiratory symptoms at the time of evaluation, duration of surgery >210 minutes and comorbidity (p <0.04). In a logistic regression analysis, the statistically significant predictors were: presence of chronic pulmonary disease, surgery lasting >210 and comorbidity (p <0.009). CONCLUSIONS: There were three major clinical risk factors for pulmonary complications following upper abdominal surgery: chronic pulmonary disease, comorbidity, and surgery lasting more than 210 minutes. Those patients with three risk factors were three times more likely to develop a PPC compared to patients without any of these risk factors (p <0.001). PFT is indicated when there are uncertainties regarding the patientÆs pulmonary status

Paracoccidioidomicosis cutanea asociada a seminoma / Paracoccidiodomycosis cutaneous associated with seminoms

Paciente de 35 años, oriundo de Paraguay, con una masa palpable indolente en el hemiabdomen derecho, que fue extirpada con diagnóstico de seminoma. Además, presentaba una lesión ulcerosa en la región escápulovertebral izquierda, cuyo examen micológico directo y cultivo fueron compatibles con Paracoccidioides brasiliens. No se hallaron otras manifestaciones cutáneomucosas relevantes radiografía de torax normal. Desde el punto de vista dermatológico recibió itraconazol con evolución favorable de la lesión. Se interpretó como paracoccidioidomicosis crónica, clinicamente unifocal cutánea, asociada a seminoma clásico

Factores de riesgo de mortalidad en cirugía abdominal de emergencia en pacientes geriátricos: Hospital Edgardo Rebagliati M. Instituto Peruano de Seguridad social 1996 - 1997

Se realiza un estudio retrospectivo, analíitco, comparativo y observacional de 330 operaciones de cirugía abdominal de emergencia en 318 pacientes geriátricos, con el objetivo de determinar los Factores de Riesgo de Mortalidad y con ellos establecer un Indice pronóstico, a la vez que establecer una curva de expectativa de vida. Se estudiaron 62 variables entre antecedentes, riesgo preoperatorio, tiempos preoperatorios y operatorio, hallazgos intraoperatorios y procedimientos quirúrgicos. Luego de un análisis multivariado se encontraron como factores de riesgo para la mortalidad en pacientes geriátricos en cirugía abdominal de emergencia los antecedentes de cirugía biliar o de medicación con corticoides o inmunosupresores, la valoración preoperatoria según ASA, el intervalo entre la admisión a emergencia y el ingreso a sala de operaciones, la presencia de líquido libre en cavidad mayor de 500 cc, los procedimientos quirúrgicos de resección intestinal, colectomía e esplenectomía y la reopeación. Se establece un índice pronóstico de expectativa de vida y se proyecta de expectativa de vida según los hallazgos operatorios. Palabras claves: Cirugía, abdominal, emergencia, geriatría, factores de riesgo, expectativa de vida, mortalidad.