ABDOMEN AGUDO
La cirugía laparoscópica en las urgencias
abdominales
abdominales
La cirugía laparoscópica (CL) ha demostrado su eficacia
y seguridad en el tratamiento de algunas enfermedades
quirúrgicas, para las que se ha convertido en el tratamiento
de elección. Sin embargo, en otras enfermedades
cuyo tratamiento es posible por vía laparoscópica, ésta
no se ha generalizado, bien por posibles riesgos, como la
diseminación en el caso del cáncer, o porque sus ventajas
frente a la cirugía por vía abierta (CA) no parecen
muy evidentes o no se han demostrado claramente,
como ocurre con algunos aspectos de la CL en el tratamiento
de las enfermedades abdominales urgentes.
VASCULAR PERIFERICO
OPCIONES EN EL TRATAMIENTO DE LAS VARICES DE MIEMBROS INFERIORES
Las venas varicosas se definen como venas tortuosas, contorsionadas, o alargadas. A menos que el agrandamiento sea severo, el tamaño solo no indica anormalidad porque puede variar dependiendo de la temperatura ambiente y, en mujeres, de factores hormonales. Además, las venas superficiales normales pueden parecer agrandadas en sujetos delgados, mientras que las venas varicosas pueden estar ocultas en sujetos obesos.
Las venas varicosas se definen como venas tortuosas, contorsionadas, o alargadas. A menos que el agrandamiento sea severo, el tamaño solo no indica anormalidad porque puede variar dependiendo de la temperatura ambiente y, en mujeres, de factores hormonales. Además, las venas superficiales normales pueden parecer agrandadas en sujetos delgados, mientras que las venas varicosas pueden estar ocultas en sujetos obesos.Pueden ser clasificadas de acuerdo a la forma en troncos varicosos, reticulares o telangiectasias. Las telangiectasias también se las conoce como arañas vasculares, o variculas.
La mayoría de las várices de miembros inferiores son primarias; únicamente una minoría son secundarias a enfermedades como trombosis u oclusión venosa profunda, tumores de localización pelviana, o fístulas arteriovenosas.
Afecta al 17% de los hombres y al 31% de las mujeres entre los 35 y 70 años de edad.
Las venas varicosas se producen por insuficiencia de las válvulas de las venas superficiales de los miembros inferiores que producen reflujo de sangre venosa y dilatación venosa.
Los factores de riesgo incluyen el incremento de la edad, la paridad y las ocupaciones que requieren estar en posición de pie. La obesidad se asocia con venas varicosas en las mujeres pero no en los hombres.
Los síntomas asociados con venas varicosas son pesadez, tensión, dolorimiento y prurito, hormigueos o picazón.
Las complicaciones que se pueden producir son:
1- Hemorragia
2- Tromboflebitis
3- Edema
4- Pigmentación de la piel
5- Atrofia
6- Eczema varicoso
7- Lipodermatoesclerosis
8- Ulceraciones.
El diagnóstico se realiza por la anamnesis y examen físico. Es importante determinar si el paciente tiene antecedentes de trombosis venosa profunda (TVP) o tromboflebitis, o historia familiar de TVP, ya que estos antecedentes incrementan el riesgo de presentar TVP después de la cirugía de várices y puede conducir a la decisión de no realizar la operación. En caso de realizar la corrección quirúrgica se debe administrar heparina subcutánea profiláctica. Esto es importante sobre todo en mujeres que ingieren píldoras anticonceptivas o terapia de reemplazo hormonal. http://www.intermedicina.com/Avances/Clinica/Fotos19.htm
DIABETES
El riesgo de acidosis lactica en pacientes medicados con medformina.
La metformina es una biguanida ampliamente utilizada en el tratamiento de la diabetes mellitus tipo II. Entre los efectos secundarios derivados de su empleo destaca por su baja frecuencia de presentación pero potencial gravedad la acidosis láctica.
El diagnóstico de la misma se basa generalmente en la coexistencia de la acidosis láctica en un paciente en tratamiento con metformina con uno o mas factores de riesgo para la presentación de la misma. El desarrollo de acidosis láctica en relación con el tratamiento con metformina conlleva una mortalidad que oscila entre 50-80%. (Nutr Hosp. 2007;22:124-125)
Metformin lactic acidosis and anaesthesia: myth or reality?
Acta Anaesthesiol Belg;56(3):297-302
AIMS: To determine whether a causal or coincidental relationship is indicated in the literature between metaformin and lactic acidosis and to recommend clinicalguidelines for the withdrawal of metformin prior to surgery. METHOD: A broadreview of the literature related to metformin associated acidosis was carriedout. (There are few publications specifically related to metformin treatment and anaesthesiology). RESULTS: When metformin-associated lactic acidosis occurs, aconcurrent pathology or contraindication to the use of metformin is often found. Anaesthesia and surgery can generate or aggravate concurrent pathologies.CONCLUSION: Although no association has been shown between metformin and lacticacidosis under usual conditions of use, vigilance is required when metformin isused prior to surgery. The following clinical guideline is proposed: to withdraw (when possible) metformin 48 hours prior to surgery and to wait until thepatient's biological and clinical parameters return to normal beforereintroducing it.
Metformin-associated lactic acidosis
Ann Fr Anesth Reanim2006;25(10):1046-52
OBJECTIVE: The aims of this review are to precise the pathophysiologicalmechanisms leading to biguanide-associated lactic acidosis, to give elements ofdiagnosis, and to underline the precautionary conditions for prescribing thesedrugs by an improvement in physicians and patient's education. DATA SOURCES: APubMed database research in English and French language reports published untilDecember 2005. The keywords were: lactic acidosis, metformin, biguanide, diabetesmellitus. DATA EXTRACTION: Data in selected articles were reviewed, clinical and basic science research relevant informations were extracted. DATA SYNTHESIS:Metformin, which is an oral antidiabetic agent, is the only one biguanideavailable in France. It acts by enhancing the sensitivity to insulin by adecrease in the hepatic glucose production and an increase in its peripheral use.In term of glycemic control, it has the same efficiency than the otherhypoglycemic agents. It represents the treatment of choice for overweight type 2 diabetic patients because of its beneficial effects on the weight loss and on thecardiovascular complications. The incidence of metformin-associated lacticacidosis is very low when contra-indications and appropriate rules forprescribing this drug are respected. The relationship between metformin andlactic acidosis remains largely controversial. In practical, we can distinguishthree situations which have different prognosis. In the first case, metforminseems to be responsible for lactic acidosis because of self-poisoning oraccidental overdose, and prognosis is good. In the second case, the associationbetween metformin and lactic acidosis is coincidental rather than causal, and maybe induced by an underlying organ failure. In the last case there is a cause oflactic acidosis which is worsened by a precipitating factor leading to metformin accumulation. The 2 latter situations are very severe as mortality rate is about 50%. Symptomatic treatments and renal replacement therapy which allows metformin removal are the curative treatment. Prevention is essential. It requires therespect of metformin contraindications and a better education of physicians andpatients for a safe prescription. CONCLUSION: Due to its beneficial effects,metformin is the gold standard treatment for overweight type 2 diabetic patients.The essential precautionary conditions for prescribing metformin as well as therespect of its contra-indications permit largely to prevent lactic acidosis. Thiscomplication is serious when it is associated with intercurrent illnesses andmetformin accumulation. The curative treatment is based on renal replacementtherapy. Prevention only rests on the respect of the contra-indications.Education of physicians and patients concerning the rules of prescription remainsessential.
CIRUGIA ENDOSCOPICA
Endoscopic retrieval devices are used for the removal 
of resected polyps, foreign bodies, and esophageal food
impactions. Various forceps, graspers, baskets, snares,
and nets are available, and selection depends mainly on
the size and shape of the target being retrieved. Some devices
are designed specifically for retrieval, whereas some
are designed for other interventions but can also be used
for the purpose of retrieval.
The success of retrieval seems to be a function of the
endoscopist’s experience.2 Proper retrieval device selection
may be an important factor along with more skillful
endoscope manipulation.3 Guidelines for the management
of ingested foreign bodies have been issued by the
ASGE4; this review focuses on available devices.
of resected polyps, foreign bodies, and esophageal food
impactions. Various forceps, graspers, baskets, snares,
and nets are available, and selection depends mainly on
the size and shape of the target being retrieved. Some devices
are designed specifically for retrieval, whereas some
are designed for other interventions but can also be used
for the purpose of retrieval.
The success of retrieval seems to be a function of the
endoscopist’s experience.2 Proper retrieval device selection
may be an important factor along with more skillful
endoscope manipulation.3 Guidelines for the management
of ingested foreign bodies have been issued by the
ASGE4; this review focuses on available devices.
FLUIDOTERAPIA Y ALTERACIONES ELECTROLÍTICAS
CONCEPTO DE SUEROTERAPIA - FLUIDOTERAPIA La fluidoterapia es la parte de la terapéutica que tiene por objeto mantener el equilibrio interno o restaurarlo mediante la administración de líquidos y o de diversos componentes electrolíticos, bien sea por vía oral o parenteral. El balance hídrico habitualmente se considera en términos del balance externo de agua y electrólitos entre el organismo y el entorno, por lo que conviene repasar los aspectos básicos del equilibrio normal de los mismos.
Fluidoterapia: Método terapéutico destinado a mantener o a restaurar por vía endovenosa el volumen y la composición normal de los fluidos corporales.
Suero: Nombre genérico de determinadas soluciones de electrolitos empleadas en terapéutica para restablecer el equilibrio hidroelectrolítico.
Objetivo de la Sueroterapia-Fluidoterapia:
Recuperación y mantenimiento del equilibrio hidroelectrolítico alterado.
Indicaciones principales de la Sueroterapia-Fluidoterapia:
- Hipovolemia
- Depleción de fluído extracelular
- Depleción acuosa
- Depleción salina
- Hipernatremia
ACCEDER A LOS ARCHIVOS.... http://www.4shared.com/dir/11066692/7bc11710/FLUIDOTERAPIA.html
TRAUMA
Hernia diafragmatica traumatica y su tratamiento laparoscopico.A proposito de un caso y revision de la literatura.
LINK HACIA LOS ARCHIVOS Y EL CASO.
Psoas abscess
| Psoas abscess rarely requires surgical intervention |
| Yacoub, W.N.; Sohn, H.J.; Chan, S.; Petrosyan, M.; Vermaire, H.M.; Kelso, R.L.; Towfigh, S.; Mason, R.J. |
| American Journal of Surgery Vol: 196 Nro: 2 Págs: 223 - 227 Fecha: 01/08/2008 |
| |
| BACKGROUND: Surgeons are increasingly, encountering psoas abscesses. METHODS: We performed a review of 41 adults diagnosed and treated for psoas abscess at a county hospital. Treatment modalities and outcomes were evaluated to develop a contemporary algorithm. RESULTS: Eighteen patients had a primary psoas abscess, and 23 had a secondary psoas abscess. Patient characteristics were similar in both groups. Intravenous drug abuse was the leading cause of primary abscesses. Secondary abscesses developed most commonly after abdominal surgery. Treatment was via open drainage (3%), computed tomography-guided percutaneous drainage (63%), or antibiotics alone (34%). Four recurrences occurred in the percutaneous group. Statistical analysis showed that the median size of psoas abscesses in the percutaneous group was significantly larger than in the antibiotics group (6 vs 2 cm; P <.001). The mortality rate was 3%. CONCLUSIONS: Initial management of psoas abscesses should be nonsurgical (90% success). Small abscesses may be treated with antibiotics alone, and surgery can be reserved for occasional complicated recurrences. (c) 2008 Elsevier Inc. All rights reserved |
COLON, RECTO Y ANO
Objective: To determine the value of anastomotic leaktesting of left-sided colorectal anastomoses.
Design: Cohort analysis.
Setting: Subspecialty practice at a tertiary care facility.
Patients: Consecutive subjects were selected from a
prospective colorectal database of 2627 patients
treated between January l, 2001, and December 31,
2007.
Intervention: Creation of left-sided colorectal anastomoses
and air leak testing per surgeon preference.
Main Outcomes Measures: Anastomosis type, method
(handsewn vs stapled), performance of air leak testing,
repair method of anastomoses after air leak tests yielding
positive results, and development of postoperative
clinical leak.
Results: A total of 998 left-sided colorectal anastomoses
were performed without proximal diversion; 90.1% were
stapled and 9.9% were handsewn. Intraoperative air leaks
were noted in 65 of 825 tested anastomoses (7.9%), that is,
7.8% of stapled anastomoses and 9.5% of handsewn anastomoses.
Aclinicalleakdevelopedin48patients(4.8%).Clinical
leaks were noted in 7.7% of anastomoses with positive
air leak test resultscomparedwith3.8%ofanastomoseswith
negative air leak test results and 8.1% of all untested anastomoses
(P.03). If air leak testing yielded positive results,
suture repair alone was associated with the highest rate of
postoperative clinical leak compared with diversion or reanastomosis,
12.2% vs 0% vs 0%, respectively (P=.19).
Conclusions: Our data indicate a high rate of air leaks
at air leak testing of left-sided colorectal anastomoses. In
addition, the high rate of clinical leaks in untested anastomoses
leads us to recommend air leak testing of all leftsided
anastomoses, whether stapled or handsewn.
Arch Surg. 2009;144(5):407-411
Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of RadiologyIn the United States, colorectal cancer (CRC) is the third most common cancer diagnosed among men and women and the second leading cause of death from cancer. CRC largely can be prevented by the detection and removal of adenomatous polyps, and survival is significantly better when CRC is diagnosed while still localized. In 2006 to 2007, the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology came together to develop consensus guidelines for the detection of adenomatous polyps and CRC in asymptomatic average-risk adults. In this update of each organization's guidelines, screening tests are grouped into those that primarily detect cancer early and those that can detect cancer early and also can detect adenomatous polyps, thus providing a greater potential for prevention through polypectomy. When possible, clinicians should make patients aware of the full range of screening options, but at a minimum they should be prepared to offer patients a choice between a screening test that is effective at both early cancer detection and cancer prevention through the detection and removal of polyps and a screening test that primarily is effective at early cancer detection. It is the strong opinion of these 3 organizations that colon cancer prevention should be the primary goal of screening........http://www.4shared.com/dir/6115382/9abe40e3/COLON_RECTO_Y_ANO.html
INCIDENTALOMA
Se considera incidentaloma suprarrenal la lesión adrenal no sospechada, clínicamente silente, descubierta casualmente por estudios de imagen realizados a priori, por problemas no relacionados con las glándulas suprarrenales. Nuestro objetivo es presentar series de incidentalomas, revisando el proceso diagnóstico y las técnicas de tratamiento.OTROS LINKS RELACIONADOS:
http://www.surgical-tutor.org.uk/default-home.htm?system/hnep/incidental.htm~right
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http://www.websurg.com/lectures/viewer.php?doi=lt01envanheerden002&redim=1
Q J Nucl Med Mol Imaging 2008 Jun ;52(1):84-8
Endocr J 2008 Mar ;
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1,161 patients with adrenal incidentalomas: indications for surgery.
Langenbecks Arch Surg 2008 Mar ;393(2):121-6
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Differential diagnosis of incidentally detected adrenal masses revealed onroutine abdominal CT.
Eur J Radiol 2008 Jan
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Malignant and unclear histological findings in incidentalomas. Eur Surg Res 1900 ;40(2):235-8
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Computed tomography, magnetic resonance imaging and (11)C-metomidate positronemission tomography for evaluation of adrenal incidentalomas. Eur J Radiol 2007 Dec ;0():-
Adrenal ganglioneuroma. A neoplasia to exclude in patients with adrenalincidentaloma. Acta Chir Belg 1900 ;107(6):670-4
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The incidental indeterminate adrenal mass on CT (> 10 H) in patients withoutcancer: is further imaging necessary? Follow-up of 321 consecutive indeterminate adrenal masses. AJR Am J Roentgenol 2007 Nov ;189(5):1119-23
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Marked chromogranin A elevation in a patient with bilateral adrenalincidentalomas, and its rapid normalization after discontinuation of proton pump inhibitor therapy. Clin Endocrinol (Oxf) 2007 Nov ;67(5):805-6
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The incidental indeterminate adrenal mass on CT (> 10 H) in patients withoutcancer: is further imaging necessary? Follow-up of 321 consecutive indeterminate adrenal masses. Int Braz J Urol 1900 ;33(6):860-1
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HERNIA INGUINAL EN NIÑOS
Hernia Inguinal en Niños.
DEFINICIÓN
La hernia es un defecto del canal inguinal, que permite la salida del contenido de la cavidad abdominal fuera del abdomen, a través de una bolsa o saco herniario.
| Hernia Inguinal Indirecta | 99 % | Saco herniario que protruye por el orificio inguinal profundo. |
| Hernia Inguinal Directa | 0.5 % | Protruye a través de la pared posterior del canal inguinal, por dentro de los vasos epigástricos, destruyendo o alcanzando la fascia transversal, puede penetrar por el canal inguinal y de aquí al escroto, por fuera de la vaginal y del cremáster. |
| Hernia Crural o Femoral | 0.5 % | Protruye por el orificio crural, por debajo del ligamento inguinal, y por dentro de la vena femoral. |
http://www.4shared.com/dir/6303007/7588575a/HERNIA_INGUINAL_EN_NIOS.html
TEP, TVP Y TTO. ANTITROMBOTICO
El TEP se define como la oclusión total o parcial de la circulación pulmonar por un coágulo sanguíneo proveniente de la circulación venosa sistémica, incluidas las cavidades cardiacas derechas. Se excluyen los embolismos de otro tipo, como aéreo, tumoral, de líquido amniótico, séptico, etc...ARCHIVOS Y FOTO EN: http://www.4shared.com/dir/6190418/a948bfc2/TEP-TVP_Y_TTO_ANTITROMBOTICO.html
Tromboembolismo pulmonar masivo
http://tratado.uninet.edu/c0208i.html
EMBOLIA PULMONAR: FISIOPATOLOGIA Y DIAGNOSTICO.
http://escuela.med.puc.cl/publ/boletin/Tromboembolismo/EmboliaPulmonar.html
HEMORRAGIA DIGESTIVA
Mallory-Weiss Tear Mallory-Weiss syndrome is characterized by upper gastrointestinal bleeding secondary to longitudinal mucosal lacerations at the gastroesophageal junction or gastric cardia. The original description by Mallory and Weiss in 1929 involved patients with persistent retching and vomiting following an alcoholic binge. However, Mallory-Weiss syndrome may occur after any event that provokes a sudden rise in intragastric pressure or gastric prolapse into the esophagus.
A Mallory-Weiss tear (MWT) likely occurs as a result of a large, rapidly occurring, and transient transmural pressure gradient across the region of the gastroesophageal junction. Acute distension of the nondistensible lower esophagus can also produce a linear tear in this region.
With a rapid rise in intragastric pressure due to precipitating factors, such as retching or vomiting, the transmural pressure gradient increases dramatically across the hiatal hernia, which abuts a low intrathoracic pressure zone. If the shearing forces are high enough, a longitudinal laceration eventually occurs. Within the hernia, the tear is more likely to involve the lesser curvature of the gastric cardia, which is relatively immobile compared to the remainder of the stomach.
Another potential mechanism for MWTs is the violent prolapse or intussusception of the upper stomach into the esophagus, as can be witnessed during forceful retching at endoscopy.
http://www.4shared.com/file/39549681/29fb7e90/Mallory_Weiss.html
ABDOMEN AGUDO
http://www.4shared.com/dir/4963883/d6b8f1c/ABDOMEN_AGUDO.html
Woman With an Acute Onset of Nausea and Vomiting
Background
A 46-year-old woman presents to the emergency department (ED) with a history of worsening, constant right upper quadrant pain that radiates to her back and side. She has had nausea and has vomited twice in the past several hours. She underwent a laparoscopic cholecystectomy 2 weeks ago, without complications, and returned to her normal diet. She has not had any bowel movements or flatulence since the pain began. She denies having any fever, chills, or rigors. Her medical history is significant only for high blood pressure, high cholesterol levels, and gallbladder disease. She takes lisinopril, aspirin, multivitamins, and ginseng. She denies smoking or drinking alcohol.
Woman With an Acute Onset of Nausea and Vomiting
Background
A 46-year-old woman presents to the emergency department (ED) with a history of worsening, constant right upper quadrant pain that radiates to her back and side. She has had nausea and has vomited twice in the past several hours. She underwent a laparoscopic cholecystectomy 2 weeks ago, without complications, and returned to her normal diet. She has not had any bowel movements or flatulence since the pain began. She denies having any fever, chills, or rigors. Her medical history is significant only for high blood pressure, high cholesterol levels, and gallbladder disease. She takes lisinopril, aspirin, multivitamins, and ginseng. She denies smoking or drinking alcohol.
On physical examination, the patient is awake, alert, and oriented. Her vital signs are within the normal range, with a heart rate of 84 bpm and a blood pressure of 124/76 mm Hg. She appears to be in mild distress. The cardiorespiratory examination yields normal findings, with clear lungs and a regular heart rhythm. Her abdomen is soft, but her bowel sounds are decreased, and she has marked tenderness in the right upper quadrant. The rest of her abdomen is minimally tender, with no evidence of guarding or rebound and no palpable masses. The other physical findings are normal.
The laboratory investigation reveals an elevated WBC count of 14.0 × 109/L (14.0 × 103/µL), with a left shift of 87% neutrophils. Her liver function tests, lipase level, and basic chemistry panel are unremarkable.
Contrast-enhanced computed tomography (CT) scans of the abdomen and pelvis are ordered. Figure 1A shows an anteroposterior (AP) scout image, and Figure 1B shows a selected axial section.
ACTIVIDADES DE CIRUGIA ENDOSCOPICA
ACTIVIDADES EN LA DIVISION ENDOSCOPIA Y CIRUGIA PERCUTANEA
| | LUNES | MARTES | MIERCOLES | JUEVES | VIERNES |
| 08-09 | | ATENEO CIR. | | ATENEO HOSP | |
| 09-10 | PASE | PASE | PASE | PASE | PASE |
| 10.00 - 12.00 | CONSULTORIO CIRUGIA -Roldan 31 -Bernardi 32 | CONSULTORIO CIRUGIA -Albizzati 31 -Buonomo 30 | CONSULTORIO CIRUGIA -Taboada 31 -Bernardi 32 | CONSULTORIO CIRUGIA -Flores 31 -Buonomo 30 | CONSULTORIO CIRUGIA -Quinteros 31 -Gomez 32 |
| 10.00 - 20.00 | | ENDOSCOPIA | | ENDOSCOPIA | |
| 14.00 - 20.00 | CONSULTORIO GASTROENT. -Villamea 32 -Cuadrado 31 | ECOGRAFIA | CONSULTORIO GASTROENT. -Villamea 32 -Cuadrado 31 | ECOGRAFIA | CONSULTORIO GASTROENT. -Villamea 32 -Cuadrado 31 |
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