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.

Treatment of aortic dissecting aneurysm involving visceral arteries with multi-layer bare stents

SUMMARY OBJECTIVE: Aortic dissecting aneurysms involving visceral arteries are difficult for clinical treatment. This study aimed to explore the clinical efficacy and safety of multi-layer bare stents technique in the treatment of aortic dissecting aneurysms involving visceral arteries. METHOD: The clinical data of 16 patients of aortic dissecting aneurysm involving visceral artery treated with multi-layer bare stents technique from March 2013 to March 2017 in Tianjin Medical University General Hospital were retrospectively analyzed. To explore the clinical efficacy, the number of stents applied, postoperative aortic dissecting thrombosis and postoperative cumulative branch arterial patency of the16 patients. RESULTS: The operations of the 16 patients were successfully completed without peri-operative death cases. The 16 patients were implanted with 39 bare stents with an average of 2.44 per person. There were 2 cases with 1 stent, 8 cases with 2 stents and 7 cases with 3 stents. One month after the operation, CTA showed complete thrombosis in the arterial dissection in 4 cases (25.0%), partial thrombosis in 12 cases (75.0%); CTA showed that celiac artery, left and right renal arteries, and superior mesenteric artery were all unobstructed. There were 4 cases (25.0%) of dissecting artery with reduced diameter, 12 patients (75.0%) without changes in the diameter, and no diameter expanding cases. CONCLUSION: The treatment for aortic dissecting aneurysm involving the visceral arteries using multi-layer bare stents technique is safe and reliable with a higher patency rate of postoperative accumulated branch arteries.

RESUMO Objetivo: Aneurismas dissecantes da aorta envolvendo artérias viscerais são de difícil tratamento clínico. O objetivo deste estudo foi explorar a eficácia e segurança clínica da técnica de stents multicamadas não farmacológicos para o tratamento de aneurismas dissecantes da aorta envolvendo artérias viscerais. Métodos: Foi feito um estudo retrospectivo usando os dados de 16 pacientes com aneurisma dissecante da aorta envolvendo artérias viscerais e tratados com stents multicamadas não farmacológicos de março de 2013 a março de 2017, do Hospital da Escola de Medicina da Universidade de Tianjin. Foram analisados nos 167 pacientes: a eficácia clínica, o número de stents aplicados, trombose dissecante da aorta no pós-operatório e patência cumulativa pós-operatória do ramo arterial. Resultados: As operações dos 16 pacientes foram concluídas com sucesso sem nenhum óbito perioperatório. Os 16 pacientes receberam 39 stents não farmacológicos, com uma média de 2,44 por indivíduo. Houve 2 casos com 1 stent, 8 com 2 stents, e 7 com 3. Um mês após a operação, a ATC mostrou trombose completa da dissecção arterial em 4 casos (25,0%) e trombose parcial em 12 casos (75%). Também mostrou que a artéria celíaca, as artérias renais direita e esquerda e a artéria mesentérica superior estavam todas desobstruídas. Houve 4 casos (25,0%) de artéria dissecante com diâmetro reduzido, 12 (75,0%) pacientes sem alteração no diâmetro, e nenhum caso de aumento de diâmetro. Conclusão: O tratamento para aneurisma dissecante da aorta envolvendo artérias viscerais com a técnica de stents não farmacológicos multicamadas é seguro e confiável, com uma taxa mais alta de patência de ramos arteriais acumulados no pós-operatório.

Prognostic factors affecting outcomes in multivisceral en bloc resection for colorectal cancer

OBJECTIVES: This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer. METHODS: Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155. RESULTS: The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement. CONCLUSIONS: Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes.

Effect of the 5-HT4 receptor and serotonin transporter on visceral hypersensitivity in rats

Visceral hypersensitivity plays an important role in motor and sensory abnormalities associated with irritable bowel syndrome, but the underlying mechanisms are not fully understood. The present study was designed to evaluate the expression of the 5-HT4 receptor and the serotonin transporter (SERT) as well as their roles in chronic visceral hypersensitivity using a rat model. Neonatal male Sprague-Dawley rats received intracolonic injections of 0.5% acetic acid (0.3-0.5 mL at different times) between postnatal days 8 and 21 to establish an animal model of visceral hypersensitivity. On day 43, the threshold intensity for a visually identifiable contraction of the abdominal wall and body arching were recorded during rectal distention. Histological evaluation and the myeloperoxidase activity assay were performed to determine the severity of inflammation. The 5-HT4 receptor and SERT expression of the ascending colon were monitored using immunohistochemistry and Western blot analyses; the plasma 5-HT levels were measured using an ELISA method. As expected, transient colonic irritation at the neonatal stage led to visceral hypersensitivity, but no mucosal inflammation was later detected during adulthood. Using this model, we found reduced SERT expression (0.298 ± 0.038 vs 0.634 ± 0.200, P < 0.05) and increased 5-HT4 receptor expression (0.308 ± 0.017 vs 0.298 ± 0.021, P < 0.05). Treatment with fluoxetine (10 mg·kg-1·day-1, days 36-42), tegaserod (1 mg·kg-1·day-1, day 43), or the combination of both, reduced visceral hypersensitivity and plasma 5-HT levels. Fluoxetine treatment increased 5-HT4 receptor expression (0.322 ± 0.020 vs 0.308 ± 0.017, P < 0.01) but not SERT expression (0.219 ± 0.039 vs 0.298 ± 0.038, P = 0.654). These results indicate that both the 5-HT4 receptor and SERT play a role in the pathogenesis of visceral hypersensitivity, and its mechanism may be involved in the local 5-HT level.

Morbilidad y mortalidad por traumatismo con lesión visceral / Morbidity and Mortality due to Trauma with visceral injury

Se efectuó un estudio descriptivo y transversal de los pacientes con traumatismos abdominales ingresados en el Hospital Provincial Docente Dr Joaquín Castillo Duany de Santiago de Cuba, desde enero del 2002 hasta diciembre del 2009, para evaluar la morbilidad y mortalidad por traumas abdominales con lesión visceral. En la serie predominaron el sexo masculino, el grupo etario de 20-29 años, los traumas abdominales abiertos y la agresión con arma blanca. El intestino delgado y el hígado fueron las vísceras más lesionadas, en tanto que para el diagnóstico resultaron ser más útiles los elementos clínicos: dolor abdominal, reacción peritoneal y taquicardia. Entre las principales complicaciones prevalecieron la infección de la herida quirúrgica y el choque hipovolémico

A descriptive and cross-sectional study including patients with abdominal traumas admitted at Dr Joaquín Castillo Duany Teaching Provincial Hospital in Santiago de Cuba from January, 2002 to December, 2009 was carried out to assess the morbidity and mortality due to abdominal traumas with visceral injuries. In the series, male sex, age group from 20-29 years, open abdominal traumas and attacks using stabs were predominant. Small intestine and liver were the most affected viscera; while clinical aspects, such as abdominal pain, peritoneal reaction and tachycardia were more useful for the diagnosis. Among the main complications, the infection of surgical wound and the hypovolemic shock were predominant

Mielotomia punctiforme no tratamento da dor oncológica visceral: análise de três casos / Punctate midline myelotomy for the treatment of oncologic visceral pain: analysis of three cases

INTRODUÇÃO: Uma nova via relacionada com a dor visceral foi recentemente descrita. Esta via localiza-se na linha média da coluna dorsal na medula espinhal, sendo o alvo da técnica cirúrgica aqui descrita. OBJETIVO: Apresentar os resultados de três pacientes submetidos ao tratamento da dor visceral oncológica por mielotomia punctiforme. MÉTODO: Três pacientes, com dor abdominal oncológica refratária ao tratamento clínico, foram submetidos à mielotomia punctiforme por meio de de pequena laminectomia torácica. RESULTADOS: Dois pacientes obtiveram controle completo da dor, sendo que um deles não mais necessitou de opióides. O terceiro paciente, que era intolerante aos opióides, obteve melhora de 80 por cento da dor. Nenhum dos pacientes apresentou déficit neurológico no pós-operatório. CONCLUSÃO: Ratificamos a existência de uma via, localizada na linha média da coluna dorsal, relacionada com a dor visceral em humanos, cuja ablação está relacionada à melhora da dor abdominal visceral de origem oncológica.

Dor pelviperineal / Pelviperineal pain

Dor pelviperineal cronica e condicao comum especialmente nos individuos do sexo feminino. Muito frequentemente, anormalidades viscerais eventualmente identificadas aos exames complementares nao...