Management of non-surgical pneumoperitoneum.

Percutaneous endoscopic gastrostomy (PEG) is the best approach to feeding patients not eligible for oral nutrition who have a functioning digestive system. Pneumoperitoneum after PEG is a relatively common complication. As regards management, the most important decision is whether conservative therapy or an exploratory laparotomy should be indicated. We report the case of a patient with giant pneumoperitoneum following PEG, who was successfully managed with percutaneous air drainage.

[Non-obstructive enterolithiasis: report of two cases]. / Enterolitiasis no obstructiva: presentación de 2 casos.

Enterolithiasis, or coprolithiasis, stones formed mainly in the intestine, is uncommon in humans and is generally associated with intestinal stasis. This entity is highly common in some animals, such as horses. Enterolithiasis is usually asymptomatic but may lead to intestinal occlusion and should be considered as a possible cause of this event. We report two cases of enterolithiasis, in which the diagnosis was established by simple abdominal radiography and computed tomography. Although both patients had factors favoring the development of enterolithiasis, a genetic substrate predisposing them to this uncommon clinical entity cannot be excluded.

[Laparoscopic cholecystectomy in a patient with situs inversus totalis]. / Colecistectomía laparoscópica en una paciente con situs inversus totalis.

OBJECTIVE: To report a case with situs inversus totalis (SIT) and chronic cholelithiasis solved by laparoscopic surgery, outlining the utility of minimal invasive surgery and specific considerations in patients with anatomic variations. CASE REPORT: A case of a 46 year-old female who presented with a six-month history of abdominal colic pain at the left hypochondrium, accompanied with nausea and vomiting, is presented. On examination she had epigastric tenderness. Blood tests, including liver function tests, were normal. Electrocardiogram showed right axis deviation and right ventricular hypertrophy, in keeping with dextrocardia. Chest-X-Ray confirmed the diagnosis of dextrocardia. An ultrasound scan of the upper abdomen identified the gallbladder containing stones in the left upper quadrant. A CT scan visualized the spleen and the gastric camera in the right upper quadrant. Barium gastrointestinal transit, barium enema and abdominal-X-Ray were used as complementary diagnostic studies. A magnetic resonance cholangiography was not performed because the patient suffered from claustrophobia. Cholecystectomy and transcystic cholangiography were performed by laparoscopic route, taking care to set-up the operating theatre in the mirror image of the normal set-up for cholecystectomy. The patient completed a successful procedure without complications and was discharged 48 hours after the procedure. Histological exam diagnosed a chronic lithiasic cholecystitis. CONCLUSIONS: Laparoscopic cholecystectomy is an adequate surgical procedure for patients with total situs inversus and cholelithiasis, having a high security range. Detailed clinical examination is important for the diagnosis of previously unknown anatomic variations. Transcystic cholangiography is mandatory when a magnetic resonance cholangiography can not be performed. Furthermore, perhaps in this situation a left-handed surgeon is better prepared than a right-handed one to comfortably carry out the procedure.

[Pneumoperitoneum due to splenic abscess: a diagnostic challenge. Case Report]. / Neumoperitoneo por absceso esplénico: un reto diagnóstico. Reporte de un caso.

BACKGROUND: Splenic abscess is a rare clinic entity, its incidence has increased due to the rising number of clinical conditions involving immunosuppression. Endocarditis is the most frequent cause, and gram-positive aerobes are the main causal agents. Its clinical presentation is non-specific and delays diagnosis. Computed tomography scan is the method of choice, and the treatment is based on antibiotics and drainage, radiological or surgical, involving splenectomy in special cases that require it. CLINICAL CASE: A 55-year-old man with abdominal pain and fever. The analysis revealed leukocytosis 14,000/mm3, prothrombin activity 53%, and metabolic acidosis. Computed tomography scan showed a peri-hepatic pneumoperitoneum, liquid fluid, and peri-splenic bubbles, and slight trabeculation of fat around the duodenal bulb with pneumoperitoneum in this area. Patient underwent a median laparotomy, finding a purulent peritonitis due to a ruptured abscess in the spleen, splenectomy was performed. Fluid culture showed polymorphonuclears, with no microorganisms identified. The patient progressed and was discharged on the 5th post-operative day. CONCLUSIONS: Splenic abscess is an uncommon condition, in which the diagnosis is delayed and mortality, in untreated patients, is high. Its association with pneumoperitoneum may confuse the diagnosis towards viscera perforation. Thus it must be suspected in the finding of unknown cause of pneumoperitoneum by complementary examinations. The treatment of choice is splenectomy, because the capsular rupture is the norm in all of them.

Manejo del neumoperitoneo no quirúrgico / Management of non-surgical pneumoperitoneum

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[Quality assessment and improvement in the indication and management of parenteral nutrition in a general surgery unit]. / Evaluación y mejora de la calidad en la indicación y el manejo de la nutrición parenteral en un servicio de cirugía general.

OBJECTIVE: To analyze the degree of compliance with a variety of internationally accepted standards defined for Total Parenteral Nutrition (TPN) quality control in our Surgery Department. PATIENTS AND METHOD: Prospective study of patients treated with TPN over two years in the department of surgery of a university teaching hospital (n = 72). Assessment of quality was performed by measurements of compliance using 19 criteria. The criteria were divided into three groups according to characteristics of TPN standardisation: this must be "appropriate" to the nutritional requirements of the patient, "safe" in order to prevent complications and "accurate" in its daily programming. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria over six months, paying particular attention to those criteria which had the highest percentage of errors in the study carried out using a Pareto analysis. During a third period of six months the information on all 19 criteria was gathered again and the improvement with regard to the standard values and to the compliance in the first period (using the value of z) was evaluated. RESULTS: The compliance with seven criteria was significantly below standard values: all those of the "appropriate" group, except the criteria "type of diet" and "composition of the diet", and the criteria "absence of complications" of the "safe" group, which was also the one with the highest number of grouped non-compliances. In the second period all the below standard criteria improved with compared to the first period. The criteria "time of fasting", "concordance" and "duration" were significantly improved. The criteria "time of fasting", "duration" and "latency" reached the standard. The rest of criteria that reached their standard in the first evaluation maintained the same results. CONCLUSIONS: Corrective measures introduced were effective since all the below standard criteria improved, including metabolic complications. Notwithstanding, it is necessary to continue in this line to improve the criteria still below standard.

Enterolitiasis no obstructiva: presentación de 2 casos / Non-obstructive enterolithiasis: Report of two cases

La enterolitiasis o coprolitiasis, cálculos formados primariamente en el intestino, es una rara enfermedad en humanos asociada, generalmente, con estasis intestinal. Es sin embargo muy frecuente en algunos animales como los caballos. Suele cursar sin síntomas en la mayoría de los casos, pero puede presentar oclusión intestinal y debe ser tenida en cuenta como posible causa de la misma. Presentamos 2 casos de enterolitiasis cuyo diagnóstico fue establecido por imágenes de radiografía simple de abdomen y tomografia computarizada (TC). Aunque ambos pacientes presentaban factores favorecedores para enterolitiasis, no se puede descartar un sustrato genético que predisponga al desarrollo de esta infrecuente entidad clínica (AU)

Abstract Enterolithiasis, or coprolithiasis, stones formed mainly in the intestine, is uncommon in humans and is generally associated with intestinal stasis. This entity is highly common in some animals, such as horses. Enterolithiasis is usually asymptomatic but may lead to intestinal occlusion and should be considered as a possible cause of this event. We report two cases of enterolithiasis, in which the diagnosis was established by simple abdominal radiography and computed tomography. Although both patients had factors favoring the development of enterolithiasis, a genetic substrate predisposing them to this uncommon clinical entity cannot be excluded (AU)

Evaluación y mejora de la calidad en la indicación y el manejo de la nutrición parenteral en un servicio de cirugía general / Quality assessment and improvement in the indication and management of parenteral nutrition in a general surgery unit

Objetivo. Aplicar un ciclo de evaluación y mejora del cumplimiento de diversos criterios de calidad en la indicación y manejo de la nutrición parenteral total (NPT) en un servicio quirúrgico. Pacientes y método. Estudio prospectivo en 72 pacientes tratados con NPT durante 2 años en el Servicio de Cirugía General del Hospital General Universitario Reina Sofía de Murcia. El ciclo de mejora se realizó en dos períodos: en el primero, de 1 año de duración, se analizó el cumplimiento (porcentaje e intervalo de confianza [IC] del 95%) de 19 criterios respecto a sus estándares internacionalmente aceptados (significación estadística según valor de z para el modelo de una cola) en todas las dietas de NPT prescritas en nuestro servicio de cirugía general. Dichos estándares estaban divididos en tres grupos, “ajustada” (indicación correcta de la nutrición), “segura” (ausencia de complicaciones) y “exacta” (correspondencia de la dieta administrada con la prescrita). Durante los 6 meses siguientes, tras analizar las posibles causas de los incumplimientos, se aplicaron las medidas oportunas para intentar solucionarlos. En un segundo periodo de 6 meses se recogieron nuevamente los datos de los 19 criterios y se evaluó la mejora tanto respecto al estándar como respecto al cumplimiento del primer período (mediante el valor de z para una cola). Resultados. Siete criterios se encontraban significativamente por debajo del estándar: todos los del grupo “ajustada”, salvo los criterios “tipo de dieta” y “composición de la dieta”, y el criterio “ausencia de complicaciones” del grupo “segura”, que era además el que mayor número de incumplimientos agrupaba. En el segundo período, todos los criterios por debajo de su estándar mejoraron respecto al primero y en especial los criterios “tiempo de ayuno”, “concordancia” y “duración” mejoraron de forma estadísticamente significativa. Alcanzaron su estándar los criterios “tiempo de ayuno”, “duración” y “latencia”. El resto de los criterios, que alcanzaron su estándar en la primera evaluación, continuaban con los mismos resultados. Conclusiones. Las medidas correctoras introducidas fueron eficaces, ya que se mejoró en todos los criterios por debajo de sus estándares, incluidas las complicaciones metabólicas. A pesar de ello es necesario continuar en la línea de actuación para mejorar los criterios aún por debajo de su estándar The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Objective. To analyze the degree of compliance with a variety of internationally accepted standards defined for Total Parenteral Nutrition (TPN) quality control in our Surgery Department. Patients and method. Prospective study of patients treated with TPN over two years in the department of surgery of a university teaching hospital (n = 72). Assessment of quality was performed by measurements of compliance using 19 criteria. The criteria were divided into three groups according to characteristics of TPN standardisation: this must be “appropriate” to the nutritional requirements of the patient, “safe” in order to prevent complications and “accurate” in its daily programming. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria over six months, paying particular attention to those criteria which had the highest percentage of errors in the study carried out using a Pareto analysis. During a third period of six months the information on all 19 criteria was gathered again and the improvement with regard to the standard values and to the compliance in the first period (using the value of z) was evaluated. Results. The compliance with seven criteria was significantly below standard values: all those of the “appropriate” group, except the criteria “type of diet” and “composition of the diet”, and the criteria “absence of complications” of the “safe” group, which was also the one with the highest numer of grouped non-complinces. In the second period all the below standard criteria improved with compared to the first period. The criteria “time of fasting”, “concordance” and “duration” were significantly improved. The criteria “time of fasting”, “duration” and “latency” reached the standard. The rest of criteria that reached their standard in the first evaluation maintained the same results. Conclusions. Corrective measures introduced were effective since all the below standard criteria improved, including metabolic complications. Notwithstanding, it is necessary to continue in this line to improve the criteria still below standard The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Evaluación y mejora del cumplimiento de la normativa sobre consentimiento informado para la transfusión de hemoderivados en un servicio de cirugía general / Assessment of improvements in compliance with the guidelines on informed consent for the transfusion of blood derivatives in a general surgery department

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