Surgical treatment of peptic ulcer disease: current indications and techniques

The incidence of peptic ulcer disease has dramatically decreased in the last recent years, mainly due to the knowledge of Helicobacter pylori role in the pathogenesis and the eradication treatments. Also, effective acid-decreasing drugs have contributed to the healing of most ulcers. As a result, indications for elective surgery have also dramatically decreased. However, there are some indications for elective surgery such as refractory ulcers and cases of uncertain diagnosis. Also, developing of alternative therapeutic methods such as endoscopy or angioembolization has reduced the need for surgery. Endoscopic therapy is used in the treatment of bleeding ulcers with high rates of success and in cases of gastric outlet obstruction. Angioembolization is used in selected cases of bleeding ulcers. Surgery is today indicated when these procedures fail in hemorrhages of peptic origin. Other indication for surgery is perforated peptic ulcer, since non-operative treatment cannot be considered standard of care. Considerable debate exists concerning the need of adding acid-decreasing procedures to techniques of bleeding control alone in case of hemorrhage. Although the latter are associated with less side effects, the former are associated with lower rates of rebleeding. Simple closure of a perforation, however, appears enough if followed by Helicobacter pylori eradication and avoidance of NSAIDs. Importantly, any gastric ulcer must be biopsied to rule out malignancy, before deciding any conservative treatment

Versatility of therapeutic reduction mammoplasty in oncoplastic breast conserving surgery

Oncoplastic breast conserving surgery is the gold standard approach for the surgical treatment of early breast cancer. There is a well defined technique named “therapeutic mammoplasty” which is characterized for using a reduction mammaplasty technique to treat breast cancer conservatively. In our current practice, “therapeutic mammoplasty” or therapeutic reduction mammaplasty is our favorite oncoplastic breast conserving approach which it used in almost half of our patients. This technique is very versatile allows us the resection of tumors located in all breast quadrants of patients with moderate-to large-sized breasts. We describe a series of 57 patients who were treated using a therapeutic reduction mammaplasty. All surgical procedures were carried out by one comprehensive breast surgeon who planned and designed the surgery performing both oncologic and reconstructive procedures. Surgical margins were insufficient in eight patients (14%). Nine patients (15.8%) had a complication in early postoperative period and in one of them adjuvant radiotherapy was delayed four months due to a wound dehiscence

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen’s fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated

Is there Enough Justification for Questioning Body Mass Index (BMI) as Exclusion Criteria of Reduction Mammoplasty in the Surgical Treatment of Symptomatic Macromastia?

Background: Despite the fact that reduction mammaplasty is an effective and efficient treatment to symptomatic macromastia, frequently, women demanding this treatment are accepted or not depending on body mass index criteria. The aim of this work was to compare changes of quality of life on obese and no-obese women who undergoing breast reduction mammaplasty. Methods: A prospective study was performed on 56 consecutive women undergoing bilateral reduction mammaplasty for symptomatic macromastia, 21 of them had a BMI lower than 30 (No-obese group) and 35 with 30 or higher BMI (Obese group). Short Form SF-36 quality of life questionnaires were answered at interviews a week before the surgery and six months after. To evaluate the change of quality of life we used “effect size”. Results: Preoperative SF36 scores did not make differences between both groups. Six months after surgery only postoperative physical score of no-obese patients was significantly higher than obese one (52.11 vs 48.47, p>0.05). Both groups increased clearly their quality of life showing an increment of all SF36 domains with an effect size ranged from 0.53 to 2.07. More than seventy percent of obese women improved their scores exceeding means of preoperative scores. Conclusion: According to our results and the fact that the main goal of the breast reduction is ameliorate the quality of life there is no justification for exclusion obese patients with BMI >30 who suffer from symptomatic macromastia from reduction mammaplasty

Trombo libre en aurícula izquierda.

An 81 year old woman, diagnosed with rheumatic mitral valve disease and atrial fibrillation ten years previous, was admitted due to a right carotid transient ischemic attack and a acute coronary syndrome. No ST elevation was noted in the region supplied by the anterior descending artery coronary (troponin T increased and anterolateral negative waves T). In recent years years, she had maintained with (anticoagulants) an INR of 2.5-3.5; however, in the previous month the INR had dropped to 1.8. The transthoracic echocardiography showed an anterolateral hypokinesis and a globular hyperechoic mass of 2 x 4 cm which appeared to be a free floating thrombus in the dilated left atrium. This occasionally caused occlusion of the mitral valve, which itself had a severe rheumatic stenosis of approximately 1 cm2. Due to the high risk of occlusion of the mitral valve and systemic embolisms, the mitral valve replacement and thrombectomy was recommend to the patient. The patient refused this treatment and subsequently died 5 days later. This case emphasizes the importance of a suitable level of anticoagulation (INR between 2,5 and 3,5) in patients with mitral stenosis and chronic atrial fibrillation. These cases have a the high risk of thromboembolism, and urgent surgery is mandatory when a free floating left atrial thrombus is observed.Se presenta el caso de una mujer de 81 años de edad con antecedentes de valvulopatía mitral reumática y fibrilación auricular diagnosticada 10 años antes, que ingresó por un accidente isquémico transitorio carotídeo derecho y un episodio coronario agudo sin elevación del segmento ST en territorio de la arteria coronaria descendente anterior (troponina T elevada y ondas T negativas anterolaterales). En los últimos años había mantenido un adecuado nivel de anticoagulación (INR entre 2,5 y 3,5) con acenocumarol, a excepción del último mes en el que presentó un INR de 1,8. El ecocardiograma transtorácico evidenció una hipocinesia anteroapical y una masa de 2x4 cm, hiperecoica y de contornos redondeados sugestiva de trombo que flotaba libremente en una aurícula izquierda muy dilatada (A, B y C) y que, ocasionalmente, protruía en el ventrículo izquierdo (D) ocluyendo la válvula mitral que presentaba una estenosis reumática importante (área de 1,0 cm²). Debido al alto riesgo de muerte súbita por oclusión del orificio mitral y de embolismos sistémicos, como los que probablemente presentó esta paciente, está indicada la cirugía cardiaca urgente para realizar trombectomía y recambio valvular mitral. La paciente rechazó esta indicación y cinco días más tarde falleció de muerte súbita. Este caso clínico enfatiza la importancia de mantener un adecuado rango de anticoagulación (INR entre 2,5 y 3,5) en pacientes con estenosis mitral reumática y fibrilación auricular crónica debido al alto riesgo de tromboembolismo, así como la indicación de cirugía urgente ante el hallazgo de un trombo que flote libremente en la aurícula izquierda

CARACTERIZACIÓN DE LOS SISTEMAS DE PRODUCCIÓN OVINA DEL MUNICIPIO PRIMERO DE ENERO， CIEGO DE ÁVILA / CHARACTERIZATION OF THE MUNICIPALITY'S SHEEP PRODUCTION SYSTEMS ON JANUARY FIRST， CIEGO DE AVILA

Este trabajo tuvo como objetivo caracterizar, direccionado a lo social, ecológico y tecnológico los sistemas de producción ovina existentes en el municipio Primero de enero de la provincia Ciego de Ávila, Fueron visitados 18 productores ovinos, se utilizó el método de la encuesta en su técnica de entrevista a partir de un cuestionario semiestructurado. El total de animales de los productores encuestados sumó 975 lo que significa que se logró encuestar a los poseedores del 68.8 % de la masa del municipio. Los resultados permiten identificar las condiciones subjetivas y objetivas que caracterizan la crianza ovina en el municipio y los factores que limitan el desarrollo de los sistemas de producción, entre los que se encuentra la alimentación de la masa basada fundamentalmente en el pastoreo extensivo sobre coberturas naturales, sin hacer un uso óptimo de otras fuentes alternativas de alimentación, ni de la integración ganadería-agricultura. Las instalaciones presentan deficiencias técnico-constructivas y notable grado de rusticidad que, no garantizan la protección y descanso de los animales. Existen deficiencias en el control de parásitos, con uso preferente de un mismo antiparasitario y escaso tratamiento y utilización de los residuales

Purulent pericarditis after liver abscess: a case report

We present the case of a 49-year-old woman, with previous clinical antecedents of recent hepatic metastasis, who was admitted to the ICU due to respiratory failure and hemodynamic instability. She was found to have purulent pericarditis complicated by pericardial tamponade and pleural effusion, as well as surgical site infection, which was the origin of the disease. Cultures of the surgical wound and the pericardial effusion were positive for Enterococcus faecalis and Escherichia coli. A pericardial tap was performed and the intra-abdominal abscess was surgically drained. Pleural effusion was also evacuated. She received antibiotic treatment and recovered successfully. The only after-effect was a well-tolerated effusive-constrictive pericarditis

Evaluation of Early Cholecystectomy versus Delayed Cholecystectomy in the Treatment of Acute Cholecystitis

Objective. To evaluate if early cholecystectomy (EC) is the most appropriate treatment for acute cholecystitis compared to delayed cholecystectomy (DC). Patients and Methods. A retrospective cohort study of 1043 patients was carried out, with a group of 531 EC cases and a group of 512 DC patients. The following parameters were recorded: (1) postoperative hospital morbidity, (2) hospital mortality, (3) days of hospital stay, (4) readmissions, (5) admission to the Intensive Care Unit (ICU), (6) type of surgery, (7) operating time, and (8) reoperations. In addition, we estimated the direct cost savings of implementing an EC program. Results. The overall morbidity of the EC group (29.9%) was significantly lower than the DC group (38.7%). EC demonstrated significantly better results than DC in days of hospital stay (8.9 versus 15.8 days), readmission percentage (6.8% versus 21.9%), and percentage of ICU admission (2.3% versus 7.8%), which can result in reducing the direct costs. The patients who benefited most from an EC were those with a Charlson index > 3. Conclusions. EC is safe in patients with acute cholecystitis and could lead to a reduction in the direct costs of treatmen

Treatment of children obesity and diabetes through gamification

Childhood obesity is nowadays a global epidemic. This illness sometimes comes with another associated problem, like Diabetes type II. In this paper we present a case of study about the results of the application of a gamified educational program. A 3-year longitudinal and prospective study was conducted a patient with obesity and diabetes. Different assessments regarding the health state of the patient have been developed (family background, physical/medical, emotional state and physical activity). Using Positive outcomes have been obtained in their medical registers and also, in their health habits. Thus, the application of gamification strategies in the educational program has positive impact in the health