Asociación Médica de Puerto Rico - Asociacion Medica de Puerto

Transcription

B LETÍN
Asociación Médica de Puerto Rico
CONTENIDO
3
Mensaje del Presidente de la AMPR
Rolance G. Chavier Roper
Editorial Article/Articulo Editorial
4
42 Macklin Effect As Potential Responsible Com-
plication After Retrograde Intubation: A Case
Report
Normidaris Rodríguez MD, Víctor Cardona MD
Arbona System Reengineered In The Garcia- 47 Laparoscopic Splenectomy For Infarted Splenoptosis In A Child: A Case Report
Ariz Model: A National Health Reform Plan
Jorge Carmona MS, Humberto Lugo Vicente MD
From An Orthopedics Program Perspective
Manuel García Ariz MD, Enrique García-Peña MD,
Víctor Hernández-Polo MD, Franz Pino-Delgado MD, 50 Rare Benign Breast Tumor
Omar Pérez-Carrillo MD
Jaime Román-Díaz MD, Diógenes Alayón-Laguer MD,
Nelson Matos Fernández MD, Luis Báez MD, William
Caceres-Perkins MD, Daniel Conde-Sterling MD
Original Article/Articulos originales
10
Laparoscopic Liver Resection: Initial Expe- 54 Atypical Presentation Of Basilar Artery Thromrience In Puerto Rico
bosis Due To Hypercoagulable State And InciDavid H. Solís Lopez MD, Carlos M. Claudio MD, Diedental Patent Foramen Ovale: A Case Report
go R. Solís Lopez MD
15
Validacion De Una Escala De Actitudes Hacia
La Sexualidad En Una Muestra De Ancianos 58 Intestinal Endometriosis As A Cause Of Rectal
Puertorriqueños
Bleeding: A Case Report
Rosa Janet Rodríguez Benítez PhD, José Rodríguez
Gómez MD, Sean Sayers Montalvo, Ph. D
Review Article / Articulo de Reseña
24
Inside Look At Laparoscopic Colectomy
Ramón K. Sotomayor MD, Bolívar Arboleda MD, Andrés Guerrero, MD
Case Reports / Reporte de Casos
31
Anesthetic Management Of A Patient Undergoing Surgery For Bilateral Pheochromocytoma
Serafín C. López MD, Daniel E. Fernández MD, Osmar Creagh MD
33
Adult Evan’s Syndrome: Complete Hematologic Recovery With Steroids And Rituximab: A
Case Report
Karen J. Santiago-Ríos MD, Omayra Reyes MD,
Alexis Cruz MD, Nydia Rodríguez-Pabón MD, William
Cáceres MD
37
Marie Bernadine Hidalgo MD, Edwin Rodríguez MD ,
Valerie Wojna MD
Jeannette A. Vergelí Rojas MD, Lenny Pagán Rodríguez
MD, Carmen Santiago Muñoz MD, Sylvia Gutiérrez Rivera MD
64 CME Questions
Catalogado en Cumulative Index e Index Medicus
Listed in Cumulative Index and Index Medicus No. ISSN-00044849
Registrado en Latindex -Sistema Regional de Información en
Línea para Revistas Científicas de América Latina, el Caribe,
España y Portugal
BOLETÍN - Asociación Médica de Puerto Rico
Ave. Fernández Juncos Núm. 1305
P.O.Box 9387 - SANTURCE, Puerto Rico 00908-9387
Tel.: (787) 721-6969 - Fax: (787) 724-5208
e-mail:[email protected]
Web site: www.asociacionmedicapr.org
Web site para el paciente: www.saludampr.org
Central Nervous System Involvement By Follicular Lymphoma: A Case Report
Liza Paulo Malave MD, William Caceres MD
39
Guillain-Barre Syndrome After Influenza Vaccine Administration: Two Adult Cases
Valerie Bedard Marrero MD, Ramón L. Osorio Figueroa MD, Orlando Vázquez Torres MD
Diseño Gráfico e Ilustración digital de cubierta realizados por Juan Carlos Laborde
en el Departamento de Informática de la AMPR
E-mail: [email protected]
JUNTA DE DIRECTORES
Dr. Rolance G. Chavier Roper
Presidente
Dra. Wanda G. Velez Andujar
Presidente Distrito Sur
Presidente Consejo de Educación Médica
Dr. Raúl G. Castellanos Bran
Presidente Electo
Dr. Eduardo Rodríguez Vázquez
Presidente Saliente
Dr. José C. Román de Jesus
Presidente Consejo Ético Judicial
Dr. Pedro Zayas Santos
Secretario
Dra. Hilda Rivera Tubéns
Presidente Consejo Relaciones y Servicios Públicos
Dr. José R. Villamil Rodríguez
Tesorero
Dr. Salvador Torros Romeu
Presidente Consejo Servicios Médicos
Dra. Hilda Ocasio Maldonado
Vicepresidente
Dr. Jaime M. Diaz Hernandez
Presidente Consejo Salud Pública y Bienestar Social
Dr. Natalio Izquierdo Encarnación
Vicepresidente
Dr. Raúl A. Yordán Rivera
Vicepresidente
Dr. Arturo Arché Matta
Presidente Cámara Delegados
Dr.a. Ilsa Figueroa
Presidente Consejo Política Pública y Legislación
Dr. Eugenio R. Barbosa del Valle
Presidente Comité de Planes Prepagados y Seguros Médicos
Dr. Héctor L. Cáceres Delgado
Presidente Comité Afiliación y Credenciales
Dr. Juan Rodríguez del Valle
Vicepresidente Cámara de Delegados
Dr. Ney Modesti Tañon
Presidente Comité Ad-hoc de Compañerismo
Dr. Gonzalo González Liboy
Delegado AMA
Dr. José A. Rodríguez Ruiz
Presidente Comité de Historia, Cultura y Religión
Dr. Rafael Fernández Feliberti
Delegado Alterno AMA
Presidente del Comité Asesor del Presidente
Dr. Luis A. Román Irizarry
Presidente Comité Médico Impedido
Dr. Benigno López López
Presidente Distrito Este
Dra. Luisa Marrero Santiago
Presidente Comité de Seguros
Dr. Ángel E. Michel Terrero
Presidente Distrito Sur
Dr. José I. Gerena Díaz
Presidente Comité Ad-hoc Clínicas Multifásicas
Dra. Mildred R. Arché Matta
Presidente Distrito Central
Dr. Félix N. Cotto González
Presidente Comité Ad-hoc de Reclutamiento y
Servicios al Médico Joven
JUNTA EDITORA
Humberto Lugo Vicente, MD
Presidente
Luis Izquierdo Mora, MD
Juan Aranda Ramírez, MD
Melvin Bonilla Félix, MD
Francisco J. Muñiz Vázquez, MD
Carlos González Oppenheimer, MD
Walter Frontera, MD
Eduardo Santiago Delpin, MD
Mario. R. García Palmieri, MD
Francisco Joglar Pesquera, MD
Natalio Izquierdo Encarnación, MD
Yocasta Brugal, MD
José Ginel Rodríguez, MD
President Message/Mensaje del Presidente
La Relación
Medico-Paciente
Dr. Rolance G. Chavier Roper
Presidente de la Asociación Médica de Puerto Rico
E
E
l establecimiento de una buena rela
ción entre el médico y su paciente es fundamental
para que la calidad de los servicios ofrecidos sean
de excelencia. Desde que estudiamos en la Escuela de Medicina, se nos enseña que la toma de
un buen historial médico nos ofrece casi un 90%
de la información necesaria para llegar a un diagnóstico certero.
Es curioso que la Oficina de la Procuradora del Paciente(OPP) no apunte su mira a la interminable fila de camillas llenas de pacientes en
el Centro Médico, que a veces están 3 o 4 días
hacinados allí, por ejemplo. Lo fácil es responsabilizar al medico por la frustración genuina de los
pacientes. Hay que profundizar en el análisis de
las causas de aquello que nos incomoda.
El prolongado tiempo de espera en los consultorios médicos son el resultado de las políticas
públicas adoptadas en el actual modelo de “Reforma de Salud ” y por las pautas dictadas por otros
componentes del Sistema. Si se pierde tiempo en
verificar elegibilidad, conseguir permisos, referidos, preautorizaciones, etc. es por imposición del
actual modelo y no por capricho. La reglamentación impuesta por la OPP, que hace mandatorio
el sistema de citas no resuelve nada. Peor aún,
creará problemas y causará crisis en nuestras salas de emergencia en situaciones tales como bro
Con todos los problemas graves de nues- tes de dengue, influenza, etc.
tro actual Sistema de Salud (entre los que podemos mencionar el hacinamiento en el Centro Mé- ¡Por supuesto que es frustrante esperar
dico, la burocracia del actual modelo, la escasez prolongadamente para recibir servicios de cualde ciertas especialidades dentro de la medicina, quier índole! Reconocemos que esto ocurre con
la falta de programas de Residencia e Internados mayor frecuencia de lo debido y creemos que
acreditados para entrenar a los médicos del futu- nuestra profesión médica es capaz de autoevaro, el costo cada vez mayor de los medicamentos, luarse y mejorar. Después de todo, todos los méla falta de acceso a servicios de salud secundarios dicos y sus seres queridos también son pacientes.
y terciarios, especialmente en áreas rurales, lejos Lo que creemos lacera nuestra Relación Medicode las grandes ciudades, etc.) es para mi lamenta- Paciente es la imposición de un sistema de quereble que los esfuerzos de aquellas agencias crea- llas que pone a las partes en un potencial enfrendas para velar por los intereses de los pacientes, tamiento como adversarios. Esto en nada abona a
opten por atender el síntoma y no la enfermedad. la salud física ni mental del pueblo de Puerto Rico.
La confianza y dinámica entre el galeno y
el enfermo al que atiende debe estar cimentada
sobre los valores de sinceridad, confidencialidad,
privacidad y con el tiempo, el medico pasa a ser
un amigo, un consejero, un confidente. Otro factor crucial es la Libre Selección del médico por
parte del paciente. Esta relación sagrada no resiste intromisiones externas ni límites de tiempo,
ni mucho menos puede aceptar estar sometida a
multas, penalidades y pugnas entre las partes.
3
Editorial Article/Articulo Editorial
Arbona System
Reengineered In
The Garcia-Ariz
Model: A National
Health Reform Plan
From An
Orthopedics
Program
Perspective
Manuel García Ariz MD
Enrique García-Peña MD
Víctor Hernández-Polo MD
Franz Pino-Delgado MD
Omar Pérez-Carrillo MD
From the Department of Orthopedic, UPR School of Medicine, Puerto Rico Health Science Center, San Juan, Puerto
Rico.
Address reprints requests to: Manuel Garcia Ariz MD – Department of Orthopedic, (9th floor, UPR School of Medicine,
Puerto Rico Health Science Center, San Juan, PR. 00936.
E-mail: [email protected].
ABSTRACT
During the 1950’s the healthcare system of Puerto Rico was maintained exclusively by the local government. The Arbona
system, as it came to be known, although it
provided health care professionals on the island with multiple educational experiences,
presented substantial costs for the government. In the early 1990’s a program of privatization known as “La Reforma” was implemented with the ultimate goal of providing
a universal coverage system for the poor
and the needy. At present this program has
brought other issues regarding the quality of
medical services and loss of academic centers. This is a preliminary report that analyzes various aspects of both systems through
the search and analysis of background resources and literature, interviews, and physician/patient satisfaction surveys (on working
conditions and quality of services). The main
purpose of this report is to create a model
that proves to be efficient and coherent with
the island’s idiosyncrasies.
Index words: Arbona, health, reform, orthopedics, program
Background
From the beginning of the island’s commonwealth status in 1952, Puerto Rico’s medically
indigent population has relied exclusively on local
government for their healthcare needs. Originally the government maintained several hospitals,
emergency centers, and free clinics, including the
Rio Piedras Medical Center. The Arbona system,
(as it came to be known) named after its developer divided the island into sectors. Each sector
has its own tier system where patients in need of
medical assistance would be screened into different area hospitals depending on need and complexity of their problem.1 However, this system at
the time, presented substantial costs to the government while generating increasing criticism from
the public and media citing a sluggish bureaucracy and poor services from poorly motivated, and
lowly paid government workers and hospital staff.
On the positive side this system also provided a
rich environment for the island’s health care professionals to receive a full-bodied education and
numerous enriching experiences. In 1992, then
4
governor elect of Puerto Rico Pedro Rosselló proposed and implemented the privatization of the public health system, without first undertaking a trial
pilot program, under the name of “La Reforma”.
The privatization plan consisted of selling the previously government-owned hospitals and medical
centers to both local and American investors and
then implementing a universal coverage system
based on a set of primary care incentives plan for
the poor and needy island citizens. The main idea
behind this plan was that private companies could
better manage each institution, increasing overall
efficiency traditionally lost in government “red-tape” or bureaucracy.2 Today “La Reforma” has assumed the cost of caring for every sick, high risk
patient in our population, 8% of which is unreimbursed (not insured by it because they do not qualify). The group that is not covered includes illegal immigrants, the under-privileged, and people
with income above $15,000 but unable to pay for
private insurance. The old Arbona system still
presently takes care of this 8% of the population.3
In essence the government shifted from being a
health care provider in the old Arbona system, to
being a health care facilitator by paying capitation
to insurance companies that would channel HMO
capitation to the primary care provider.
part-time jobs at private institutions, where their
real daily effort was spent in pursuit of a higher
overall salary and income bracket, severely affecting the quality of health care being provided at
these institutions. Third, a lack of government
spending, budget cuts and rationing of materials
Subsequent to 1992, all government hos- made practicing medicine nearly impossible.
pital and medical centers were sold to private
companies and investors, including local medical “Que nos pasa Puerto Rico”: The Problem with
groups and companies composed mostly of general practitioners.2 In retrospect, some groups Health Care Reform
were more in tune with the business side of the
endeavor and would not honor it’s noble origins Present day medical centers are overcrow(as would be evident in future legal action against ded and because of this, the quality of care has
some of these physicians for corrupt acts within suffered dramatically at these tertiary centers that
the system). The only exceptions to the privati- were not made for such volume of patients. In thezation plan were the Rio Piedras Medical Center, se settings, on average, a patient at the Medical
Carolina Medical Center, and the Bayamon Regio- Center emergency room may spend over 24 hours
nal Medical Center, which the Commonwealth Go- waiting to receive proper definitive medical care
vernment presently continues to run. In essence, and treatment potentially increasing co-morbidithese institutions were left with the responsibility ties. The problems created by the overcrowding
of filling in the gap that the privatized institutions at these medical centers include the usage of the
did not want, despite receiving the funds to do limited number of beds which were intended for
so. These beacons, or remnants of the old Arbo- supra-tertiary level of care, and shortage of traina system, continue to serve the medical indigent ned personnel which include resident nurses and
population in Puerto Rico while running parallel to anesthesia operating room technicians. There is
the health reform system. These Medical Centers a high cost to treat all the patients that are referred
have become the safety net, or working horse, to to the medical centers instead of being treated at
which the government and population fall when it “lower tier” facilities. Since 1992 the payer sysconfronts the problems or inequities of the health tems shifted in favor of patients covered by the
care reform. They also provide the only and much Universal Health Reform (HMO). However, the
needed source of postgraduate education pro- Medical Centers are not reimbursed by the govergrams that fill the future needs of trained certified nment for the cost of treating uninsured patients
health care professionals on the island. (no Health Reform plan). The budget deficits for
the medical centers have increased yearly and, as
Having the opportunity to watch the system it stands today, are unable to pay many of their
work from its inner core (Centro Médico de Puer- suppliers. These suppliers in turn have stopped
to Rico) gives the authors of this article a unique providing vital services to some of these medical
opportunity to analyze the system and brainstorm centers, consequently decreasing overall quality
solutions to its problems. The “Arbona Reenginee- of care due to lack of available resources.
red”, or García-Ariz Model, provides long-term solutions to the problems facing healthcare today in “La Reforma” almost killed the medical edua low cost, effective, and safe manner.
cation system, effectively abolished practically all
of the academic centers that offered post gradua
It is a notable aspect of Puerto Rico, the te medical education. Hence removing the actual
isolation and distance from outside sources (read source of health care providers: nursing staff, te- mainland USA), which provides an ideal ground chnicians, and even physicians.4 The new chanfor research projects of this kind. We expect to ges in health care of the García-Ariz model should
provide the US Government vital insight into di- ensure this “cadre” or constant influx of new health
fferent health care reform programs and possible care professionals for the island’s future benefit.
solutions.
This model would provide an ever replenishing
pool or influx of health professionals, instead of
The Old Arbona System
what we currently are experiencing which is a
group of physicians that is slowly emigrating to
The Arbona System suffered from several better medical practice opportunities in the mainfundamental defects. First it lacked basic salaries land United States.
from which to compete for graduate school talent
and attending physicians. Secondly, because of The actual Health Care Reform works in
this lack of basic salary only part-time faculties a manner similar to incentives for primary care
were employed. This same faculty would work providers. Each patient is allotted a fixed amount
5
yearly for their health care visits. This covers all
visits to primary care providers (PCP), tests, and
specialty visits or consultations.2 The gatekeepers, sort-of-speak, are the primary care providers. They are in charge of their patients being
referred for special tests, labs, or specialty consults like surgery or orthopaedics. This in part was
put in to curtail excessive spending on behalf of
the patients, but has only worked against the best
interests of them.5 The more referrals the PCP
gives for labs, or specialty evaluations, the fewer
funds he earns at the end of the day (fewer capitations). So in fact, there is an incentive system in
place working against the patient when it comes
to seeking assistance outside of that which can
be provided by a PCP. In essence a “Universal
HMO” was created in place of the old Arbona system, were every patient had access to health care
without reservations.
Some of the main ideals of “La Reforma”
are still being met, but at a price. The system in
place puts a premium on time. The patient at all
points in time must return to PCP prior to obtaining or searching for additional medical services.
For example; if an orthopaedic surgeon orders xrays, the patient must return to his PCP to receive approval for these studies. It may take weeks
for a patient to receive an appointment, delaying
treatment protocol that may negatively affect patient care and outcomes. The primary care physician effectively becomes another employee of
the medical insurance company or, in this case,
the system. Therefore, even in theory, La Reforma
could increases overall disease morbidity across
the board. The issue of lack of access to health care
extends to the availability of specialist. What good
is the ability to access any doctor at any point, one
of their main selling points, when most specialists
do not accept the government provided medical
insurance? Historically, La Reforma has sustained
a poor track record when reimbursing physicians,
or even general medical supplies and studies, for
services rendered. Most of the reimbursement
occurs late and incomplete, pushing medical care
providers into a corner where they eventually
abandon the system out of necessity or frustration.6 This puts at premium healthcare providers
that have embraced the system, and accessibility
to said professionals as the main issue to be confronted, coming full circle to the crowded ER and
clinic waiting areas aforementioned in what was
left of the old Arbona System (i.e.: medical centers).
bring forth these ever so needed changes and
address Arbona’s and “La Reforma” fundamental
defects.
At the core of this change is a fulltime faculty, with a competitive base salary. To this base
salary a simple flexible billing system is added to
provide economic incentive for faculty to guarantee its own salaries within the University practice
scheme, thus expanding their patient pool, a model already in place at the Intramural Practice Plan
of the University of Puerto Rico. This expanding
body of fulltime faculty members would bring forth diversity of medical specialties, and serve as
the foundation for future residency programs. As
stated previously, quality in healthy care is a big
issue confronting the island’s health delivery. Unlike previous healthcare models, the new system
should guarantee quality of care to the medically
indigent population through accredited full-time attending physicians and residency programs that
would staff Arbona’s re-engineered multi-tier system. These would assure a low level of cost-effectiveness through an academic system of residency training programs (residents = workforce) and
accredited university-centered system that would
provide its own system of checks and balances
for educational services. This would address both
main problems faced today: access to quality
health care, and the constant flux of future medical
professionals. Residencies offer real solutions to
the problems of quality control and quality health
care previously seen in the old Arbona model.
CDTs
CDTs
CDTs
CDTs
Who would want to form part of the new system and Why?
Everyone. The new system would provide
a sense of great esteem for doctors, being part
of the solution to their island’s longtime medical
needs, making this option appeal on the basis of
moral integrity. It would also provide an extensive
supportive system through the play of numerous
The García-Ariz (GA) theorem
full time physicians and medical residents staffed
The García-Ariz Orthopaedic model would at the hospital, permitting a broader practice in
6
medicine and patient pool, along with practicing
evidence-based medicine and research opportunities. Full-time physicians in the new system
would ensure quality of care for patients, as well
as provide a stable paycheck to physicians, medical malpractice premium relief, in addition to other
incentive programs that would be set in place to
reinforce patient care as a priority. This is taking
place at the Medical Center, Orthopaedic Clinics
today and it is on what the authors of this article
base their ideals.
successfully decreasing the overcrowded state
and overall load seen at our public hospitals today
with the old Arbona system that is left operational.
In theory, the GA system should improve on
the malpractice crisis and rise in insurance premiums due to an improved product in the practice
of medicine and an overall higher approval rate
amongst the patient population due to the improved quality of care. These centers would enjoy
malpractice caps, self-insurable for their errors,
and being the forerunners of tort reform (no fault).
The costly idea of defensive medicine would cease to be a problem, decreasing the overall cost of
health care. This by no means would represent a
call for socialized medicine. On the contrary, a place for the private enterprise would still comprise a
large sector of the population that would be looking for a high quality of care in these new regional
centers. Along the same line, it would do justice
to the University driven sector that now shares a
high burden for unreimbursed medical care of underprivileged population which they are called to
treat within their ER’s at University-like settings.
-Attainment of approximately two thirds fiscal autonomy of each center, thus decreasing dependency on commonwealth funds.
Stages for implementation of the GA System
Stage I: Academics (1-2 years)
-Establish fulltime faculty in each of the primary
medical disciplines: Internal medicine, Pediatrics,
Obstetrics and Gynecology, General Surgery, and
Family Medicine.
Stage II: Seeking Accreditation (2 years)
-The fulfillment of full accreditation to the medical
disciplines and the commencement of residency
training in internal medicine, general surgery, pediatrics and OB/Gyn. Residents equal a work force
with emphasis on learning their craft, and quality
of health care.
-Establish, or in some instances re-establish,
schools of nursing, OR technicians, anesthesiology technicians, radiology technicians, and physician assistants. All of which should be associated
with aforementioned medical schools, thus solving
the severe deficit of such staff that exists today.
-Mandatory service. In exchange for highly-affordable schooling (in the many different health care
professions) the students promise to provide service for two years at the start of their careers, a
pledge similar to those scholarship programs offered by the armed forces today.
Stage III: The Population
-This highly organized system will serve as a national registry to further conduct clinical research
and epidemiology for advancement of the public
health system.
-These regional hospitals would serve mainly the
indigent population but as efficiency and reputation
progresses it will attract the private sector patients.
This would provide hospitals with private funds and
decrease government contributions, making these
hospitals more self-sufficient budget-wise.
-Government legislation to support a budget to
obtain salaries for full-time board-certified faculty -These hospitals would provide vast opportunities
with the promise to serve and provide academic for emerging local talent in a variety of health care
teachings.
professions to practice their chosen discipline, in
an environment not available today, thus avoiding
-Take advantage of the economic crisis and buy emigration of medical professionals.
back regional hospitals, each hospital becoming a
regional medical center (i.e.: Mayaguez and Ponce ).
METHODOLOGY
-Ensure an affiliated accredited medical school to 1.
Interview with former Puerto Rico’s Health
provide guidance in academic affairs, and prepare Care Department director Dr. Johnny Rullán:
for accreditation status of future residency-internship programs.
a.
Arbona operational costs (pre 1992)
-Assignment of the medically indigent popula- b.
Health Care “Reforma” operational costs
tion (by region) to each academic medical center, (post 1992)
7
c.
Puerto Rico Medical Center operational
costs during Arbona
medicine and patient mix along with the opportunity of practicing evidence based medicine and research opportunities. Being a full-time physician in
d.
Puerto Rico Medical Center operational the new academic practice system would provide
costs during “Reforma”
a stable paycheck, medical malpractice premium
relief, along with other incentive programs that
2.
Analyze ASEM’s patient statistics:
would be set in place rewarding physicians for the
number of patients seen (evaluated). All of these
a.
Number of patients seen at ER pre 1992
ideas, in theory, should improve the malpractice
crisis and curtail a rise in insurance premiums due
b.
Number of patients seen at ER post 1992
to a safer environment in the practice of medicine and overall higher approval rate among the
c.
Operational costs pre and post 1992
patient population due to the improved quality of
care. These centers would enjoy, in our model,
3.
Patient Survey
the best of both worlds: private and public enterprise working alongside each other. The quality of
a.
Assess quality of medical services
care at these systems would eventually attract the
private sector (insured patients) and shift the hosb.
Difficulty in obtaining necessary referrals
pitals’ budget in favor of fiscal autonomy and less
government contribution. The new system would
c.
Availability of quality medical services
provide a sense of great esteem for doctors, making them part of the solution to their regional long
d.
Out of pocket expenses even with the health term medical needs.
care reform
The Arbona bottom line: a wheel that neee.
Assess patient satisfaction
ded no to be changed or discarded, but needed to
be oiled in accordance with the changing needs
f.
Assess delay of service due to “paper of society. Reform is not synonymous with total
work”
change. At times it may only mean changing a
spoke. In this case of Arbona’s wheel.
g.
Frequency of visits to the ER
Addendum
4.
Physician survey
What could this model contribute to the
a.
Patient volume
health care crisis in the USA?
b.
Time per patient
c.
Waiting time
d.
Complexity of patients
1.
This model is not made for doctors, lawyers
or insurance companies; it is made for the people
who are without coverage.
2.
This model will lower the cost by decreasing
defensive medicine at university government run
e.
Paper work before and after health care re- hospitals on those who participate that will beneform
fit to run under a malpractice cap. Would benefit
also to run a pilot program for tort reform. (The last
f.
Is disease prevention possible with current reporting data shows the cost of defensive medisystem
cine of approximately between 100 to 178 billion
dollars a year overall in the U.S.7)
CONCLUSION
3.
Pharmaceutical equipment companies who
All of the above mentioned problems of our participate in this program must cut prices to shacurrent healthcare system call for immediate ac- re the burden of these services rendered. They
tion to find new solutions by reengineering proven could enjoy tax benefit deductions as an incentive
systems, like the Arbona System. The stage of the for participating.
García-Ariz model provides a short term and long
term benchmarks grouped in a structured system. 4.
University government run hospitals are the
The new system should provide an extensive su- ones that right now are taking the burden of the unpport system through the interaction of numerous reimbursed care of the population. Also they are
full time physicians and medical residents staffed on the position to receive reimbursement to cover
at the hospitals, permitting a broader practice of cost and continue providing quality care. They
8
would benefit by increasing the educational side of in Puerto Rico: a sociocultural policy analysis. Dissertation
having this population to treat, creating new future (Doctor in Public Health). North Carolina, U.S.A. University
of North Caronina, Chapel Hill, Department of Health Polihealth professionals.
cy and Management of the School of Public Health, 2008.
5.
Registry control of this very sick population
(epidemiologically has high risk of chronic illnesses), data recording and evidence based medicine.
6.
There is no need to socialize medicine to
solve the problem. What we need to do is improve
the system of Medicaid by reengineering it. Universal health coverage is insane!
7.
All of the above items will create a healthy
climate for all involved. Specially, buffering the
liability medico legal crisis by avoiding defective
measures in these university settings. This will
establish early preventive education measures
based on evidence to care for this high risk population and cost control by involving the private
sector in the logistic with tax incentives; i.e. pharmaceuticals and technologic advances companies
which will get the incentives when they sell their
equipment. Thus guaranteeing quality health care
education with a continuous influx of patients that
at the present the private sector does not want and
can not handle financially.
8.
The creation of a plan to work for all those
involved such as: doctors, nurses, physician assistants, technicians, where they enjoy the respect
and job security incentive of working in this structured university setting. The private sector that is
interested to work under this structure will also be
welcomed.
9.
It does not burn any bridges; the system is
already in place. The university academic settings
are already partially taking care of the unreimbursed patient population right now.
10. It also gives time to continue to find new
ideas to make the system better. The other system really burns a big bridge of socialized medicine forever.
REFERENCES
1.
Arbona G., Ramirez De Arellano A., Regionalization
of health services: The Puerto Rican experience. Oxford:
New York: Oxford University Press; 1978.
2.
Pan American Health Organization, World Health
Organization. Health systems profile of Puerto Rico. Washington, DC. November 2007.
3.
US Census Bureau. Income stable, poverty up,
numbers of Americans with and without health insurance
rise, Census Bureau Reports. News release. August 24,
2004. [http://www.census.gov/Press-Release/www/releasses/archives/income_wealth/002484.html] Accessed September 25, 2009.
4.
Strand J., Enabling legislation for physician assistants
pp.42
5.
Andersen R.M., Revisiting the behavioral model
and access to medical care: does it matter? J Health Soc
Behav. March 1995;36(1):1-10.
6.
Comision Evaluadora del Sistema de Salud de
Puerto Rico. Informe al Gobernador. San Juan. 2005
7.
Weinstein S.L. “The cost of defensive medicine”.
AAOS Now. 2008.
RESUMEN
Durante los años cincuenta el sistema de salud de Puerto Rico era mantenido
exclusivamente por el gobierno local. El
Sistema de Arbona, como se llego a conocer por el nombre de su fundador, aunque
proveía a los profesionales de la salud con
múltiples experiencias educativas y académicas llego a presentar grandes costos
para el gobierno. Para la época de principio
de los años noventa un programa piloto de
privatización conocido como “La Reforma”
fue implementado con la meta de proveer
un sistema de cubierta de salud universal
para la población medico indigente. En el
presente este sistema ha dado a lugar una
serie de vicisitudes con respecto a la calidad de los servicios médicos y la merma
de instituciones académicas para la educación medica de la isla. En este reporte preliminar se analizara varios aspectos
de ambos sistemas a través de revisión
de la literatura, entrevistas a funcionarios
públicos y encuestas satisfacción personal a pacientes y doctores con respecto
a las condiciones de trabajo y calidad de
servicios médicos en el sistema actual. El
propósito final es crear un modelo de salud
que demuestre ser eficiente y a tono con la
identidad de la población de Puerto Rico.
9
Original Articles/Articulos originales
Laparoscopic
Liver Resection:
Initial Experience
In Puerto Rico
David H. Solís Lopez MD
Carlos M. Claudio MD
Diego R. Solís Lopez MD
From the Auxilio Mutuo Surgery Center of Liver and Pancreas, Auxilio Mutuo Hospital, San Juan, Puerto Rico.
Address reprints to: David H. Solis Lopez MD – PO Box
191227, San Juan, PR 00919-1227. E-mail: [email protected]
INTRODUCTION
ABSTRACT
Background: Laparoscopy has been
changing in general and particularly upper
gastrointestinal surgery for the last three decades. Hepatic surgery is one of the most
challenging fields in surgery and requires a
prolonged surgical education and knowledge.
This series describes our initial experience in
laparoscopic resection of liver lesions. Methods: This was a retrospective analysis of a
single institution. Sixteen patients undergoing
laparoscopic hepatectomy between January
2008 and August 2009 were included. The
data gathered included: lesion length, site
of lesion, surgical time, conversion to open,
operation rates, length of hospital stay, complications, mortality, and histology of lesions.
Results: Mean patient age: 63, which were
comprised by 5 males and 11 females. Thirteen patients had liver cysts; 2 patients had
metastatic liver cancer. One patient had End
Stage Liver disease and cirrhosis. The average size of the lesions was 10 cm. The mean
surgical time was 143.3 min. Conversion to
laparotomy was required in two patients. There were no perioperative or thirty day mortality, and no postoperative liver failure. Mean
postoperative stay was 3.5 days. Conclusion:
Laparoscopic liver resection appears safe and
viable procedure. Experienced hepatobiliary
surgeons with adequate laparoscopic skills
should perform this procedure. The technique
has a low morbidity and a short hospital stay,
and can be used for the treatment of patients
with different liver conditions.
Laparoscopy has fundamentally changed
general and particularly upper gastrointestinal
surgery since its beginning in the late 1980s.1 Laparoscopic surgery has become a popular surgical technique and has been used for the removal
of many organs since 1987.2-5 Hepatic surgery
is one of the most challenging fields in surgery
and requires a prolonged surgical education and
knowledge. Hepatectomy is one of the most difficult procedures in laparoscopic surgery.6 In 1992,
Gagner et al7 did the first successful partial hepatectomy by laparoscopy and Azagra et al.8 in
1996 performed the first anatomical laparoscopic
Index words: laparoscopy, liver, resection
left lateral segmentectomy. This series is our initial
experiences with sixteen cases of laparoscopic resection of liver lesions.
Surgical Procedure
MATERIAL AND METHODS
The procedures were performed after obtaining signed consent and under general anes
Sixteen laparoscopic liver resections were thesia. The anesthesiologists used pulse oximetry
performed at our center from January 2008 to Au- for peripheral oxygen saturation measurement. Argust 2009 which was composed of 5 male and 11 terial blood pressure was monitored continuously
female subjects by a single surgeon. Only 14 pa- by a radial artery catheter and periodic monitoring
tients were referred to our center with right upper of central venous pressure. The abdomen was
quadrant pain or epigastric pain, the other three draped after nasogastric intubation and urinary
were due to malignant liver lesions found in ab- bladder catheterization.
dominal CT-scans. The diagnosis of liver lesions
was based on clinical presentation and radiologi- Minor resections were performed with the
cal studies (Abdominal CT-scan). Patient data are patient in the supine position. The surgeon stood
shown in Table 1. Data recorded included surgical on either side of patient depending on the tumor
time, complications, and length of postoperative location. The pneumoperitoneum was insufflated
stay (see Table 2).
by open laparoscopy and controlled electronically
10
Table 1.
PATIENT CHARACTERISTICS
AGE SEX DIAGNOSIS
PATHOLOGY
LESION
1
69
M
Right Large Hepatic Cyst
Liver Cyst
2
62
F
Left Large Hepatic Cyst
Simple Cyst, Probably Lymphatic Origin
3
76
F
Small liver tumor, cirrhosis,
ESLD
Hepatocellular Carcinoma (HCC)
4
77
F
Symptomatic Anemia
Fibrous cyst wall with chronic inflammation
5
67
F
Large Liver Cyst
Benign Cyst Epithelia Lining
6
53
F
Right Liver Cyst
Biliary Cyst
7
77
M
Liver cyst
Simple biliary cyst
8
61
F
Right Liver Cyst
Simple biliary cyst
9
55
F
Right Liver Cyst
Biliary Cyst
10
65
F
Right Large Liver Complex
Cyst
Organizing Subcapsular Hemorrhage
11
78
F
Right Liver Cyst
Benign Simple Cyst
12
70
M
Malignant Neoplasm of Poorly differentiated
the Liver secondary carcinoma
(Esophageal cancer)
13
42
F
Left Liver Cyst
Benign Hepatic Cyst
14
40
F
Right Liver Cyst
Simple Cyst
15
60
F
Multiple Liver tumor
secondary Neoplasm
(Breast Cancer)
Metastatic Cancer
16
69
M
Large Liver Cyst
Solitary non-Parasitic Cyst
IV
III
9
9
VII
VIII
V-VII
V,VI
IVa,
VII,
VIII
IV-VIII
VII,VIII
4
8
17
4
VII,VIII
V, VI,
VIII
17
IVb
III-V
VI
4
15
5
N/A
V-VI
N/A
12
SITE
SIZE
(cm)
15
10
7
15
Table 2. PERIOPERATIVE CLINICAL PARAMETERS
TIME MIN
Post
operative
days
Complication
1
105
2
NONE
2
200
4
HAND ASSISTANCE
3
135
1
NONE
4
110
3
NONE
5
270
3
NONE
6
130
4
NONE
7
130
5
NONE
8
105
2
NONE
9
97
3
NONE
10
205
8
Open Hepatectomy after laparoscopic attempt, No cyst found on anterior surface in view no gross finding; cyst found posterior portion
11
144
6
NONE
12
119
2
NONE
13
118
3
NONE
14
99
3
NONE
15
60
2
NONE
16
265
5
Open partial Hepatectomy after laparoscopic attempt, Multiple adhesion in bowel and
colon attached to abdominal wall (Poor visualization of cyst)
11
at a constant abdominal pressure of 12 to15
mmHg. A 10-mm trocar placed 2 cm above the
umbilicus was used for abdominal exploration. The
trocar insertion sites depended on the location of
the lesion; four to seven trocars were necessary to
allow optimal manipulation.
the other only had a liver biopsy. One of the patients, which constituted 6.3% had end-stage liver
disease (ESLD) with cirrhosis and radiofrequency
ablation was performed. The average size of the
lesions was 10.1 ± 4.8cm (range 4 to 17) and they
were localized in both sides (see Table 1).
Non-anatomical liver resections were performed using the same procedure. The limits of
the resection were marked on the liver surface
with electrocautery approximately 2 cm from the
lesion margin. Liver transection was performed
using a laparoscopic ultrasonic dissector (AutoSonix, Tyco/USSC), which divides tissue ultrasonically with vibrating suction and coagulates vessels
less than 5 mm in diameter. Biliary and vascular
radicles were clipped with laparoscopic clips and
divided. In left lateral segmentectomy, the lateral
segment was mobilized by dividing the left triangular and falciform ligaments. Dissection of the
liver parenchyma was undertaken with the same
maneuver used during non-anatomical resections.
The liver resections as well left hepatic vein were
transected using a vascular endoscopic stapler
(Endo GIA II, 30-mm vascular cartridges).
The Hand assistance procedure is usually
on the non-dominant hand of the chief surgeon,
which facilitates better overall exposure, finger
dissection, tactile palpation, immediate homeostasis, and specimen retrieval via the hand port
incision. The position of Gelport (Applied Gelport
XE; Applied Medical Resources Corp, California,
US) is governed by the position of patient and the
type of liver resection. It is our practice to have a
6 – 7 cm long transverse incision (based on the
palm size of the operating surgeon) at the right
side of abdomen, or changing the umbilical port
with the hand-port. The incision should not be directly over the pathology or too close to the laparoscope; otherwise the view as well as the range
of movement would be very limited. The surgeon’s
hand can then be inserted through the self sealing
gel without loss of pneumoperitoneum. Air leak is
unusual and the cuff can also protect the wound
against tumor implantation. Items like gauze rolls
and artery clamps can be inserted through this
port.
The mean surgical time for the entire group
of patients as judged by length of time under general anesthesia was 143.3 ± 60.3 min (range 60
to 270). Conversion to laparotomy approach was
required in 2 out of 16 patients. One patient had
no cysts grossly visible due to multiple liver adhesions posteriorly, and the last one had multiple adhesions in bowel and colon attached to the
abdominal wall with poor visualization of the cyst
after history of peritonitis for perforated appendix.
There was no perioperative or thirty day mortality.
No patient had postoperative signs of liver failure.
Mean length of stay for laparoscopic liver resection was 3.1±1.3 (range 1 to 6). Mean length of
stay for open conversion were 6.5±2.1 (range 5
to 8). Laparoscopic hepatectomy significantly reduced the postoperative length of stay. Only one
patient required a blood transfusion due to symptomatic anemia.
DISCUSSION
The benefits and indications for laparoscopic liver surgery has opened a new horizon in the
surgical field leading the way to a wide variety of
more complex surgical procedures. The advantages of laparoscopic surgery versus open surgery
is early postoperative recovery, less pain medication, minimal blood loss, short hospital stay and
less fluid retention.9 Liver parenchyma should be
preserved to avoid hepatic failure after surgery or
in case of recurrent malignancy repeat the resections.10
RESULTS
Hepatobiliary surgeons are trying to reduce
bleeding in the hepatectomy surgery from traditional techniques.11,12 Experience in laparoscopic
surgery, improvements in instrumentation, video
equipment and surgical skills are increasing the laparoscopic management of various liver lesion.13-15
During the learning process, the first anatomic liver resection by laparoscopic technique that the
surgeon can do is the left lateral segmentomy.8, 17
Sixteen consecutive procedures were performed from January 2008 to August 2009. The
mean age average was 63.8 ± 11.7 years (range 40 to 78), 5 men and 11 women. In 81.3% (13
patients) had liver cysts with associated abdominal pain; one of these cases was diagnosed with
symptomatic anemia due to a large cyst, 12.5%
(2 patients) had metastatic cancer, one the liver
tumors was resected with adequate margins and
All the surgical procedures were realized
with the method of the carbon dioxide pneumoperitoneum and a mini-incision used with a complete laparoscopic boarding, except in two cases on
which open conversion was needed. In one case
the location of the mass was in the posterior part
of the liver with multiple adhesions and poor visualization. In the other case adherence of the small
bowel and colon due to history of peritonitis and.
12
perforation of appendix precluded using the technique. Another patient with advanced cirrhosis, a
non-transplant candidate with a 4 cm hepatocellular carcinoma was ablated and not resected (case
# 3)
Before surgery we evaluated the place,
size, type of the tumor. The best indicator for laparoscopic hepatectomy is the location of the lesion if is superficially or anatomically according to
Kaneko et al17. This new approach has been done
in cases of hepatocellular carcinoma17-19 and liver
metastasis17, whereas Hamy et al20, 21 reserved
laparoscopic resection for benign tumors. In our
series indication for laparoscopic approach were
peripheral solid tumors less than 5 cm length. All
liver cysts were resected regardless of size.
The introduction of the laparoscopic handassisted technique, which can achieve immediate homeostasis by direct compression and thus
minimize or even prevent air embolism without
major injury to the hepatic vein offers a notable
advantage9. Tumors in the posterior or superior
part of the right lobe are not recommended to
have laparoscopic hepatectomy due to problems
associated with exposure and control of bleeding
if injured adjacent structures of the main vessel
according to Kaneko et al17 and Cherqui et al22.
The acceptance of laparoscopic hepatectomy has
been limited due to difficulties with retraction and
resection of the tumor with free margins, due to
the lack of tactile sensation. Huang et al23 proved
that hepatic tumors in the posterior part of the right
lobe can be successfully resected with the technique of hand-assisted laparoscopic hepatectomy
reducing wound-related complication rates.
Use of the inserted hand, which is arguably
the ultimate surgical instrument, allows provision of
an improved surgical field for division of the triangular and coronary ligaments using gentle counterattraction of the liver and temporary homeostasis for minor bleeding from the transected surface
with finger compression. The use of this technique
is less invasive compared with the conventional
open hepatectomy procedure on which the wound
should be extended to the flank. However the clinical benefits of hand-assisted approach are lower
than the total laparoscopic approach due to 6 to 8
cm incision required for access to this device.23
The Hand-Port system has some disadvantages. First, in a long operation, fatigue in the
inserting hand may occur, in this situation the surgeon and the assistant must change position to
continue the procedure. Secondly, an air leak can
occur. This occurs if the inflatable ring retractor
base is not fully expanded, or if there is a disconnection between the base and pneumatic retractor
sleeve during handling of the liver.23
With the hand-assisted technique the surgeon has an optimal tactile sensation, which allows
following the chosen transection margin without
difficulty. There are many theories and preventive measures that have been proposed,24 but the
strategies in the prevention of wound metastasis
are the retrieval bag for specimen and wound protection. The Hand-Port system provides protection
for the wound with the sleeve, and has access for
specimen retrieval comparable to open procedures.
Laparoscopic hepatectomy can be done
exactly the same way that in open hepatectomy.
Minimal bleeding can be achieved laparoscopically using adequate visualization and with the use
of the hand port for bleeding control when needed. Laparoscopic hepatectomy offers significant
benefits activities to the patients compared with
open hepatectomy: less post-operative pain, less
abdominal trauma, smaller incisions, shorter hospital stays and earlier ambulation.2
CONCLUSION
Laparoscopic hepatectomy is a safe and
viable procedure. It should be performed by experienced hepatobiliary surgeon with adequate laparoscopic skills. The technique has a low morbidity
and a short hospital stay, and it can be used for
the treatment of patient with difference liver conditions.
REFERENCES
1.
Charles H C Pilgrim, Henry To, Val Usatoff, and Peter M Evans, Laparoscopic hepatectomy is a safe procedure
for cancer patients. HPB (Oxford). 2009 May; 11(3): 247–
251.
2.
Bernard Descottes, Fouzi Lachachi, Maxime Sodji,
Denis Valleix, Sylvaine Durand-Fontanier, Bertrand Pech,
de Laclause, and Dominique Grousseau, Early Experience
With Laparoscopic Approach for Solid Liver Tumors: Initial
16 Cases. Ann Surg. 2000 November; 232(5): 641–645.
3.
Dubois F, Berthelot G, Leavard H. Laparoscopic
cholescystectomy: historical perspective and personal experience. Surg Laparosc Endosc 1991; 1: 52-60.
4.
Clayman RV, Kavoussi LR, Soper NJ, et al. laparoscopic nephrectomy. N Engl J Med 1991; 324: 1370-1371.
5.
Lefor AT, Melvin WS, Bailey RW, Flowers JL, Laparoscopic splenectomy in management of immune thrombocytopenia purpura. Surgery 1993; 114: 613-618.
6.
Eric Vibert, Ali Kouider, and Brice Gayet, Laparoscopic anatomic liver resection. HPB (Oxford). 2004; 6(4):
222–229.
7.
Gagner M, Rheasilt M, Dubuc J. Laparoscopic partial hepatectomy for liver tumour. Surg Endosc 1992;6:97-8.
8.
Azagra JS, Goergen M, Gilbart E, Jacobs D., Laparoscopic anatomical (hepatic) left lateral segmentectomytechnical aspects. Surg Endosc.1996; 10: 758-61.
13
9.
Tang CN, Tsui KK, Ha JPY, Yang GPY, Li MKW, A
single-centre experience of 40 laparoscopic liver resections.
Hong Kong Med J Vol 12 No 6 December 2006: 419-425.
10.
Nishio H, Hamady ZZ, Malik HZ, et al. Outcome following repeat liver resection for colorectal liver metastases.
Eur J Surg Oncol 2007; 33:729 –34.
11.
Bismuth H, Castaing D, Garde OJ. Major hepatic
resection under total vascular exclusion. Ann Surg 1989;
210:13–19.
12.
Strong RW, Lynch SV, Wall DR, Ong TH. The safety
of elective liver resection in a special unit. Aust NZ J Surg
1994; 64:530 –534.
13.
Fabiani P, Katkhouda N, Iovine L, Mouiel J. Laparoscopic fenestration of biliary cysts. Surg Laparosc Endosc
1991; 1:162–165.
14.
Katkhouda N, Fabiani P, Benizri E, Mouiel J. Laser
resection of a liver hydatid cyst under video-laparoscopy. Br
J Surg 1992; 79:560 –561.
15.
Gugenheim J, Mazza D, Katkhouda N, et al. Laparoscopic resection of solid liver tumours. Br J Surg 1996;
83:334 –335.
16.
Samama G, Chiche L, Brefort JL, Le Roux Y. Laparoscopic anatomical hepatic resection. Report of four
left lobectomies for solid tumors. Surg Endosc 1998; 12:76
–78.
17.
Kaneko H, Takagi S, Shiba T. Laparoscopic partial
hepatectomy and left lateral segmentectomy: technique and
results of a clinical series. Surgery 1996; 120:468–475.
18.
Hashizume M, Takaneka K, Yanaga K, et al. Laparoscopic hepatic resection for hepatocellular carcinoma.
Surg Endosc 1995; 9:1289–1291.
19.
Yamanaka N, Tanaka T, Tanaka W, et al. Laparoscopic partial hepatectomy. Hepato-Gastroenterology 1998;
45:2333–2338.
20.
Laporte J, Hamy A, Paineau J, Visset J. Laparoscopic surgery for benign hepatic tumors: a series of 5 cases [in
French]. J Chir 1996; 133:432– 436.
21.
Hamy A, Paineau J, Savigny JL, Visset J. Laparoscopic hepatic surgery: report of a clinical series of 11 patients. Int Surg 1998; 83:33–35.
22.
Cherqui D, Husson E, Hammoud R, et al. Laparoscopic liver resection: a feasibility study in 30 patients. Ann
Surg. 2000; 232:753–762.
23.
Huang Ming-te, Lee Wei-jei, Wang Weu, Wei Po-li,
Chen Robert J., Hand-Assisted Laparoscopic Hepatectomy
for Solid Tumor in the Posterior Portion of the Right Lobe.
Ann Surg. 2003 Nov.; 238(5): 674–679.
24.
Ziprin P, Ridgway PF, Peck DH, et al. The theories
and realities of port-site metastases: a critical appraisal. J
Am Coll Surg. 2002; 195:395–408.
RESUMEN
Trasfondo: La laparoscopia ha ido cambiando en general y en particular la cirugía gastrointestinal de tracto superior para las últimas
tres décadas. La cirugía hepática es uno de los
campos más difíciles de la cirugía y requiere un
amplio conocimiento quirúrgico. Esta serie describe nuestra experiencia inicial en la resección
laparoscópica de las lesiones hepáticas. Métodos: Análisis retrospectivo de una sola institución. Se incluyeron dieciséis pacientes sometidos a hepatectomía laparoscópica entre enero
de 2008 y agosto de 2009. Los datos recolectados incluyeron: longitud de la lesión, localización de la lesión, tiempo quirúrgico, conversión
a las tasas de operación, la duración de la estancia hospitalaria, complicaciones, mortalidad,
y la histología de las lesiones. Resultados: La
edad media de los pacientes: 63 años, que estaban compuestas por 5 varones y 11 mujeres.
Trece pacientes presentaron quistes en el hígado, 2 pacientes tenían cáncer de hígado metastásico. Un paciente tuvo Etapa Final de la Enfermedad hepática (ESLD) y cirrosis. El tamaño
promedio de las lesiones fue de 10 cm. El tiempo quirúrgico promedio fue de 143.3 min. Dos
de los dieciséis pacientes tuvieron conversión a
laparotomía. No hubo mortalidad perioperatoria
o 30 días postquirúrgico, y no hubo insuficiencia
hepática postoperatoria. La estancia promedio
postquirúrgica fue de 3.5 días. Conclusión: La
resección laparoscópica del hígado parece un
procedimiento seguro y viable. Debe ser realizada por un cirujano hepatobiliar experimentado con suficientes habilidades laparoscópicas.
La técnica tiene una morbilidad baja, estadía
hospitalaria corta, y puede ser utilizado para el
tratamiento de pacientes con diferentes enfermedades hepáticas.
www.asociacionmedicapr.org
Herramientas
Clínicas
Noticias
Médicas
eHr
eRx
Educación
Médica
Boletin
RESUMEN
La literatura señala que en la población
de envejecidos ocurren una serie de cambios
biológicos relacionados a la sexualidad los
cuales no son el final de ésta 1,2. Los ancianos
(personas de 65 años en adelante) que son
saludables y activos tienen oportunidades de
expresión y actividad sexual en todas las formas, incluyendo masturbación, manifestándose hasta pasados los 74 años de edad 8. Este
estudio pretende investigar si la Escala de Actitudes hacia la Sexualidad en Envejecidos es
un instrumento valido y confiable para medir
actitudes hacia la sexualidad en un grupo de
ancianos en Puerto Rico. Se pretende además, aportar al progreso y desarrollo de instrumentos que midan y puedan cernir aspectos de sexualidad y conductas de riesgo que
enfoquen en la población anciana para futuros
estudios y el desarrollo de programas preventivos y de orientación que cumplan con las
necesidades específicas de los envejecidos.
Los sujetos de esta investigación consistieron
de una muestra de 265 adultos de 65 años en
delante de una base de datos secundaria. El
diseño de este estudio fue uno de tipo ex post
facto. Los datos obtenidos fueron analizados
a través de estadísticas descriptivas y análisis
factoriales para establecer una relación entre
las variables de estudio (i.e., actitudes hacia
la sexualidad, sexualidad) usando el programa SPSS-X versión 14; además se determino
estadísticamente que el instrumento es uno
valido y confiable (alfa de Cronbach= 0.95), lo
cual será de gran valor para futuras investigaciones.
Validacion
De Una Escala
De Actitudes
Hacia La
Sexualidad
En Una Muestra
De Ancianos
Puertorriqueños
Rosa Janet Rodríguez Benítez PhD*
José Rodríguez Gómez MD**
Sean Sayers Montalvo, Ph. D
Procede de la * Escuela de Profesiones de la Salud (EPS)
UPR Recinto de Ciencias Medicas, ** Facultad de Ciencias
Sociales, UPR Recinto de Rio Piedras y € Universidad Carlos Albizu, Recinto de San Juan, PR.
Solicitar copias a: Rosa Janet Rodríguez-Benítez, MPH,
PhD - P.O. Box 365067, San Juan PR 00936-5067. Correo
electrónico: [email protected]
Palabras Claves: sexualidad, ancianos puertorriqueños, actitudes, escalas
Reseña de Literatura
El afecto físico y emocional es necesario
en todas las etapas de la vida. El proceso de desarrollo de la madurez sexual comienza desde la
concepción y termina en la muerte. Esta se influencia por la maduración biológica y envejecimiento
en progreso a través de las etapas socialmente
definidas como son la niñez, adolescencia, adultez y adultez tardía; y las relaciones interpersonales, incluyendo familia, compañeros íntimos y
amigos. Estas fuerzas le dan forma a los géneros
y sus identidades sexuales, así como actitudes y
conductas. Esta misma diversidad contribuye a la
vitalidad de la sociedad. En el individuo van ocurriendo una serie de cambios biológicos, fisiológicos y psicológicos los cuales incluyen cambios en
el funcionamiento sexual en la adultez tardía que
son comunes al envejecer y que afectan la capacidad sexual. Sin embargo, también es común y
se puede perpetuar, el interés y el deseo sexual,
los cuales pueden continuar hasta la muerte1,2.
Se ha asumido, en forma errónea, que la vejez
automáticamente origina una serie de cambios
dramáticos que producen la incapacidad sexual.
Otro aspecto que no se discute ampliamente es
la perdida de afecto emocional y físico, que acompaña el hecho de enviudar, la enfermedad física
y la institucionalización; y como esto afecta la
sexualidad en el anciano puertorriqueño2,3. Los
estereotipos negativos acerca de la vejez y nociones preconcebidas afectan la interacción hacia el
15
aspecto humano del envejecimiento y la necesidad
de intimidad4. Esta claro que el envejecimiento no
siempre constituye la “edad dorada” puesto que
se pueden presentar varias dificultades en este
periodo asociados a aislamiento, pobreza, incapacidad física, sobre consumo de medicamentos
y problemas mentales; sumados a los cambios
biológicos como la menopausia y la andropausia.
La literatura señala que estos cambios biológicos
tanto en el hombre como en la mujer no son el
final de la actividad sexual5,6,7. Los viejos que son
saludables y activos tiene oportunidades de expresión sexual y actividad en todas las formas,
incluyendo masturbación; de hecho, las mismas
conductas sexuales continúan hasta pasados los
74 años de edad8. Estudios pioneros en sexualidad geriátrica han demostrado que el 50% de los
hombres sobre la edad de 70 años tienen coito,
pero ello depende de la función eréctil y, debido
a que la disfunción eréctil aumenta con la edad,
muchos de ellos optan por otras prácticas sexuales como la masturbación mutua y la gratificación
oro-genital que representan alternativas razonables para las parejas envejecidas9. Desafortunadamente muchos estudios de sexualidad geriátrica se enfocan en poblaciones mas educadas y
económicamente aventajadas. Estudios en poblaciones de bajo nivel económico y educación limitada plantean que la sexualidad en envejecidos
varia por su trasfondo económico y educativo10,11.
Investigadores como Cohen y colegas12, encontraron que los hombres jóvenes pobres y de clase trabajadora estaban orientados al coito y que
encontraban como inaceptables otras prácticas
sexuales. Los hombres ancianos de trasfondo socioeconómico similar comparten estas creencias
y ven, por ejemplo, una disfunción eréctil, como
la terminación del coito, la insatisfacción y el final de toda su vida sexual. Con el advenimiento
de medicamentos como el Sildenafil se toma en
cuenta que los envejecidos están concientes de
su sexualidad y que desean perpetuarla 13. El interés en la vida sexual se preserva en la vida tardía
de la mayoría de personas en múltiples culturas8.
La preconcepción sobre la sexualidad que muchos ancianos tienen por habérseles socializado
en forma represiva, es especialmente evidente en
las creencias que estos demuestran, al momento
de calificar lo correcto de lo incorrecto en cuanto a
la actividad sexual.
Muchas de las sociedades modernas, entre ellas la anglosajona, tiende a tener una actitud
negativa hacia la expresión sexual en los envejecidos, aun cuando esto esta cambiando al presente 14. Estas actitudes afectan la forma en como los
ancianos son tratados en la sociedad y en los programas establecidos para ellos. Sin embargo, una
gran cantidad de viejos continúan activos sexualmente apoyados por tener actitudes positivas
16
sexuales entre ellos mismos. Estudios señalan
que un aumento en la frecuencia sexual, aumenta la satisfacción y disminuye los sentimientos de
depresión, ansiedad, coraje, y vergüenza hacia la
actividad sexual en los envejecidos 9. Los sentimientos de abandono y soledad son sentimientos
no placenteros que influyen en la salud mental del
individuo. La población anciana refiere que se encuentran solos y este porcentaje aumenta con la
edad. La soledad tiende a asociarse con el estado
de salud de las personas, pero cuando un compañero cae en una enfermedad grave se trastoca
la relación de pareja y la persona que le acompaña sufre muchas veces mayor soledad que la
persona enferma 15. En estudios en centros de
cuido se encontró que el 40% de los envejecidos
reporto sentimientos de soledad y abandono8. La
intimidad sobrepasa en esta etapa las expresiones de amor involucrando sentimientos de seguridad emocional, respeto, ayuda, comunicación y
compañía, a su vez, se correlacionan fuertemente
con la satisfacción y el bienestar 15. Se ha estudiado ampliamente las actitudes sexuales y sus
diferencias en género, pero muy poco sobre estas
en la población envejecida. Los estudios de Portovna y Newman en el 1984 14 y mas reciente el
estudio de Walker y Ephross en 1999 15 muestran
cuan activos pueden estar los ancianos en términos sexuales. Los autores señalan que los viejos
son tolerantes hacia las actividades sexuales; por
ejemplo, el 80% de los participantes estaban de
acuerdo con los reactivos de que masturbarse es
aceptable para los viejos 15. Otros estudios refuerzan el señalamiento de que muchos envejecidos
son más liberales en sus actitudes hacia la sexualidad 3,11. Sin embargo, existen factores como lo
son la salud física, los tabúes sociales, el estatus
conyugal, el conocimiento hacia la sexualidad, la
autoestima y las actitudes hacia la sexualidad que
pueden afectar el comportamiento sexual que tienen los ancianos. La sexualidad no se desvanece con la edad pero depende de estos factores5.
Varios factores de naturaleza psicológica también
influencian la actividad sexual en el envejecido.
Algunos autores han relacionado el decaimiento
de la actividad sexual en el envejecido con la rutina, fatiga, la insatisfacción familiar, la economía,
más que con los cambios fisiológicos naturales de
la edad 6. Como se ha mencionado anteriormente,
algunos cambios fisiológicos como fallar en tener
una erección se puede percibir en el hombre como
primer signo de impotencia y muchas veces produce ansiedad 16. Esto se hace más problemático
cuando se une el uso de medicamentos y los procesos naturales de envejecimiento. En la mujer,
los procesos de menopausia, de igual manera, le
pueden producir dichos sentimientos. Otros factores que se ha relacionado a la vejez y la sexualidad lo son la satisfacción sexual y conyugal. Existen estudios donde se menciona una disminución
en la relación entre satisfacción sexual y conyugal pasados los 60 años 5. Este fenómeno es mas
obvio en mujeres demostrando que la dimensión
sexual toma un lugar menos importante en lo conyugal con la edad; este factor podría estar ligado a
los aspectos culturales que le restan importancia
a la sexualidad en la vida conyugal con la edad y
no necesariamente a condiciones fisiológicas 6.
Al presente, hay una cantidad limitada de estudios que tratan el tema sobre satisfacción sexual
y satisfacción marital relacionados con la sexualidad en el anciano(a) puertorriqueño(a). Se han
hecho pocos estudios en relación a las actitudes
de los envejecidos hacia la sexualidad, en parte
debido a la resistencia de los viejos en hablar de
sexualidad, o a los mismos estigmas y prejuicios
por parte de los investigadores gerontológicos y
geriátricos.
En general se acepta que las personas
envejecidas que continúan teniendo relaciones
sexuales tienen una muy importante fuente de refuerzo que mantiene su bienestar físico y mental 17.
Sin embargo, muchos detienen su vida sexual por
las actitudes negativas que presenta la sociedad
y que son reforzadas por ellos mismos. Estudios
señalan que aquellos envejecidos que continúan
teniendo actividad sexual tienen más actitudes
positivas hacia la sexualidad 10.
Otros estudios indican que esta población
de envejecidos, de una manera u otra, esta activa sexualmente y se han diseñado programas de
intervención para proveerles de información incluyendo de transmisión de enfermedades sexuales
(ETS) 18, 7. Sin embargo, estos no son suficientes
ni llegan a la mayoría de los ancianos. Diversas
instituciones, tanto gubernamentales como privadas, han dirigido esfuerzos y acciones para llevar
información a esta población de diversos aspectos sobre ETS entre ellas de educación acerca del
HIV/SIDA. Desafortunadamente muchos de estos
esfuerzos no llegan manteniendo a la población
de ancianos como una de alto riesgo para sufrir
de ETS. Históricamente los envejecidos en Norteamérica fueron ignorados en los programas de
prevención para HIV/ SIDA 19. Estudios demuestran que los mayores factores de riesgo en la población de envejecidos incluye actividad sexual
sin protección, uso de alcohol, uso de drogas,
transfusiones de sangre recibidas antes de 1985
y mal diagnóstico de enfermedades tales como
Alzheimer, Parkinson, enfermedades respiratorias
y ETS 16 . Los estereotipos prevalecientes de que
los envejecidos no están sexualmente activos han
contribuido a que la población de ancianos sea
una invisible a los educadores de salud en relación a enfermedades de transmisión sexual como
el VIH/SIDA. Un estudio con ancianos en una comunidad de los Estados Unidos reporto que hasta
un 65% de los residentes entre las edades de 60
a 71 años tenían actividad sexual y un 20% de 78
años o más tenían algún tipo de actividad sexual
19
. El sexo sin protección entre hombre con un
compañero infectado representa el 60% de infecciones de SIDA en los envejecidos y es la principal conducta de riesgo asociada con VIH/SIDA en
los ancianos norteamericanos 20. En Puerto Rico
al presente necesitamos indagar más sobre este
tipo de conducta en población anciana, aun cuando ya hay esfuerzos pioneros.
La transmisión heterosexual del HIV en los
envejecidos ha aumentado dramáticamente desde mediados de los años 80 y ahora hay un gran
porcentaje de casos de SIDA en cualquier grupo
de edad 19. El uso del condón se ha asociado históricamente en la prevención de embarazo, por lo
cual ha sido ignorado por la población envejecida.
La lubricación vaginal de la mujer y la delgadez
de las paredes vaginales resultado de la pérdida
de estrógeno se unen al declinar del sistema inmunológico; colocando a la mujer anciana en mayor riesgo de infectarse de HIV durante la relación
sexual que una mujer más joven 7. Entre el 90%
y 100% no utilizan condones y el 90% de las mujeres que han reportado conductas de riesgo no
se perciben a si mismas en riesgo 21. Los signos y
síntomas tempranos del HIV como lo son la perdida de peso, fatiga, decrecimiento de las capacidades físicas y mentales, muchas veces se mal
diagnostican confundiéndose con otras enfermedades, sobre todo en población anciana. Alzheimer, Parkinson y enfermedades respiratorias son
algunos de los pocos ejemplos de enfermedades
que tienen síntomas similares a la infección con
HIV y que son comunes en los envejecidos. El
HIV también se asocia a las ETS, especialmente
a aquellas que causan ulceraciones tales como
sífilis y herpes. Las ulceraciones hacen más fácil
la entrada del virus y por desgracia muchas personas no saben que están infectadas por que no hay
síntomas 22. La educación y prevención acerca del
SIDA se ha hecho exclusiva a las personas jóvenes y personas de edad media. Desde 1980 se
ha indicado que los envejecidos tienen poco conocimiento del virus del HIV y piensan que tienen
poca probabilidad de adquirirlo a diferencia de los
más jóvenes. Lo cual hace necesario comenzar a
crear conciencia en esta dirección.
Justificación para el estudio
El propósito de este estudio es examinar la
confiabilidad y validez de una escala de actitudes
hacia la sexualidad en la población envejecida.
El estudio repercutirá en gran medida en mayor
conocimiento de la realidad y necesidades de la
población de ancianos que residen en égidas y
residentes de la población en general.
17
Es crucial utilizar instrumentos validos que
logren medir las variables involucradas para trabajar con las necesidades y programas de intervención en relación a sexualidad y conductas de
riesgo en la población envejecida.
(2004) la cual mide actitudes de los ancianos hacia la sexualidad. Esta consta de 65 reactivos en
formato tipo Likert de 4 puntos de 0 a 3; la escala fue originalmente diseñada por la Dra. Sarah
Malavé en Puerto Rico. En adición se utilizó una
hoja sociodemográfica para recoger datos persoHipótesis o pregunta de investigación
nales de los participantes. En la misma se solicito
información tal como edad, escolaridad, género,
¿Es la Escala de Actitudes Hacia la Sexua- estado civil, fuente de ingresos y condiciones de
lidad en el Envejecido, un instrumento valido y salud.
confiable para medir actitudes en relación a la
sexualidad en la población anciana?, ¿Podrá uti- Procedimientos para garantizar los derechos
lizarse como un instrumento de cernimiento valido de los participantes
y confiable para identificar posible actividad sexual
en la población anciana en estudios futuros?
A continuación se presenta la metodología
de las distintas áreas de análisis que se realizaron
Participantes
para recoger la información del banco de datos
utilizado como parte del análisis de validez y con
Los sujetos de esta investigación consistie- fiabilidad del instrumento a probarse en este esron de una muestra de 265 envejecidos entre las tudio. Mediante consentimiento por escrito previo
edades de 65 años a 85 años, 130 participantes se le garantizo al participante la confidencialidad
del listado de Egidas Registradas en el área cen- mediante la asignación de un código numérico
tral de la isla de Puerto Rico y 135 participantes para mantener su nombre en el anonimato. En el
de la población anciana residentes en el área me- mismo se les indico a los participantes que podían
tropolitana.
retirarse sin penalidad alguna de la investigación
en cualquier momento y que su participación era
Procedimientos para el muestreo
de manera voluntaria y no se penalizaría de manera alguna a aquella persona que no deseara
Los mismos fueron seleccionados por dis- participar. Se les informo a los participantes que
ponibilidad y se encontraban entre las edades de no tenían que contestar todas las preguntas del
65 años en adelante, con residencia tanto en estudio y que podían abandonar el mismo o susla zona metropolitana como fuera de ésta. Los pender la entrevista en cualquier momento. Se les
criterios de inclusión de esta investigación son notifico de forma clara y sencilla que se guardara
aquellas personas entre las edades de 65 años su confidencialidad en todo momento y que peren adelante con residencia legal en Puerto Rico, sonas ajenas no tendrán acceso a la información
que se encuentren en condiciones optimas de sa- provista por los participantes del estudio. Se les
lud física y/o mental, residentes en égidas y que indicó a los participantes de posibles riesgos, si
consientan de manera voluntaria a participar del alguno surgiera y como se manejaría la situación
estudio una vez se les informe de que consiste el incluyendo el que los investigadores podrían hamismo.
cer un referido al participante para servicios psicológicos en la Clínica dentro de las facilidades de
Los criterios de exclusión de esta inves- la Universidad, en caso de que ocurriesen efectos
tigación son aquellos personas menores de 64 adversos como consecuencias de dicho estudio.
años y aquellos participantes entre las edades de El estudio no conllevaba ningún riesgo conocido
64 años en adelante que estén bajo tratamiento y a menudo las personas se encontraban conforpsicológico o psiquiátrico, con algún impedimento tables en el proceso de entrevista y disfrutaban
de salud física y/o emocional que pudiese impe- de la misma. Se les indicó a los participantes que
dir su participación en el estudio (ancianos bajo de sentir algún malestar o molestia al ser admila custodia legal de un tutor o representante le- nistrados los instrumentos lo notificaran para susgal por incapacidad física o mental ), confinados, pender y tomar las medidas necesarias acerca
deambulantes, usuarios de drogas o en cualquier de la situación. Se le informó a los participantes
situación de vulnerabilidad física o mental que los de forma explicita y sencilla mediante orientación
descalifique para participar de este estudio.
previa a la administración de los instrumentos el
propósito de la investigación y como se manejaInstrumentos
ría la información obtenida, así como no recibirían
ningún beneficio directo o indirecto por participar
Para esta investigación se utilizo un banco en el estudio.
de datos previos que recogía información de 265
participantes de un estudio que utilizo la Escala Procedimientos generales
de Actitud Hacia la Sexualidad en el Envejecido
18
La investigación se llevo a cabo en algunas égidas de Puerto Rico preseleccionadas por
disponibilidad y fácil accesibilidad, y con participantes no-residentes en las égidas (fuera y dentro
del área metropolitana). Se obtuvo el endoso de
la Procuraduría de la Persona de Edad Avanzada
para realizar este estudio. Se llamo a los Directores y/o Coordinadores de Servicios de las Egidas,
los cuales fueron contactados por teléfono a través del listado de egidas registradas en PR, para
solicitar su endoso y permiso para colocar anuncios en los tablones de edictos de las diferentes
égidas colocándose estos anuncios en diferentes
lugares donde la población anciana podía tener
acceso. En estos anuncios se explico de forma
general el propósito del estudio, riesgos y beneficios del estudio, confidencialidad y se les solicito
a la personas que desearan participar de manera
voluntaria del estudio, contactaran a los investigadores a través de los directores y coordinadores,
quienes a su vez, organizaron las citas de visitas a los centros. A aquellas personas que nos
contactaron y que deseaban participar del estudio se procedió a solicitarle autorización mediante consentimiento escrito para tomar parte en la
investigación una vez se les explico formalmente
y de manera detallada los pormenores de la misma (propósito del estudio, riesgos, beneficios y
confidencialidad). La muestra de participantes se
selecciono por disponibilidad de la población anciana que reside en égidas en la isla de Puerto
Rico y la no-residente en égidas. Se utilizó este
método de selección con conocimiento previo de
la amenaza a la validez externa que representa
este tipo de muestra.
Los participantes que consintieron en tomar parte del estudio se les indicó que su propósito es el obtener instrumentos validos y confiables
que nos den información sobre algunas variables
relacionadas con la sexualidad en la población
anciana y variables tales como actividad sexual y
actitudes hacia el sexo. Se les informó que el estudio repercutiría en gran medida en mayor conocimiento de la realidad y necesidades en relación
a la sexualidad en la población envejecida.
Los instrumentos que se utilizaron fueron
la Escala de Actitudes hacia la Sexualidad en el
envejecido y la hoja de información sociodemográfica. Se les indicó a los participantes que le
serían administrados unos instrumentos cortos y
de fácil administración. La participación de los envejecidos consistió en llenar un cuestionario donde se requiere completar una planilla con datos
socio-demográficos y el instrumento Escala de
Actitudes hacia la Sexualidad en el envejecido.
Se les proveyó los mismos a los participantes de
manera individual y se les indicó las instrucciones
de la hoja de información sociodemográfica y del
instrumento, de forma tanto oral como escrita. Se
le pidió al participante que colocara una marca de
cotejo en el encasillado que más se asemejara a
lo que piensa. La duración de la administración de
los instrumentos a los participantes tardo de quince (15) a treinta (30) minutos aproximadamente
para completarse. La recolección de los datos se
llevó a cabo en el entorno usual de los participantes.
Las planillas de recolección de datos se registraron en una matriz de datos computarizada
utilizando SPSS-X versión 14.0; los que finalmente se convirtieron en la base de datos a utilizarse en este trabajo. En ningún momento se utilizó
aquella información que identificara a los participantes del estudio.
Diseño de investigación
El diseño de este estudio fue uno tipo ex
post facto, lo cual implica que las variables bajo
estudio no son alteradas por el investigador. Esta
investigación pretende la validación de instrumentos que midan la relación existente entre las actitudes sobre sexualidad; la actividad sexual (sexualidad) y el envejecido (edad). En esta investigación
sexualidad se definió operacionalmente como
conjunto de sensaciones, definiciones, actitudes y
acciones que representan, y son en sí mismas, las
responsables de como nos movemos en el mundo
del sexo, el amor y las relaciones interpersonales.
El envejecido (edad) se definió operacionalmente
como aquellas personas de 65 años o más.
Análisis Estadísticos Psicométricos
Los datos obtenidos fueron analizados a
través de estadísticas descriptivas como promedios, desviaciones estándar y porcentajes de los
reactivos entre otros. Los reactivos fueron analizados utilizando métodos de consistencia interna (alfa de Cronbach) y validez de constructo. Se
realizaron análisis de factores con el programa
de SPSS-X versión 14.0. Se obtuvo el coeficiente
de alfa de Cronbach y se realizó reducciones de
datos por análisis de factores entre las variables
para establecer la válidez y confiabilidad del instrumento.
Hallazgos y Resultados Psicométricos
Los participantes del estudio (N= 265),
obtuvieron en la versión final de la Escala de Actitudes hacia la Sexualidad del Envejecido, puntuaciones en relación con la confiabilidad del instrumento (Consistencia Interna), con un índice alfa
de Cronbach de 0.95. Lo anterior significa que la
escala demuestra una confiabilidad adecuada según Cronbach (1984).
19
Análisis de reactivos
Se realizaron índices de discriminación para
cada uno de los reactivos de la escala. Para que un
reactivo tenga un índice de discriminación adecuada, según Cronbach (1984), debe estar entre un
índice de .30 a .70; los reactivos que están sobre o
por debajo de estas puntuaciones se eliminan con
la finalidad de tener una versión corta, manejable
y sencilla del instrumento a tono con la población
de ancianos que va dirigida. Los resultados de los
análisis psicométricos realizados indican que existen 21 reactivos de la escala original que no discriminan adecuadamente, y al eliminarlos la consistencia interna de la escala aumenta de .93 a .95
(véase Tabla 2).
Hallazgos y Resultados de la Muestra Estudiada acorde con la Escala
Posterior a esto se realizó un análisis de factores exploratorio a los reactivos de la escala final
(44 reactivos) encontrando que 10 componentes
en conjunto lograron obtener un valor Eigen mayor
de 1 explicando el 68.21 % de la varianza en la escala. El análisis generó estos 10 componentes que
se presentan en la Tabla 1, con sus valores Eigen y
el porcentaje de variación explicada para cada uno
y en conjunto.
La muestra del grupo Egidas estaba comprendida por un 60 % de mujeres y 40 % de
hombres, un 68.8 % entre las edades de 65 a
74 años, un 26.6 % entre las edades de 75 a 84
años, y 4.7% mayores de 85 años. En su mayoría
casados (30.8%) seguidos de personas viudos/
as (27.7%), solteros (23.1%); con un estado de
salud el cual describían como regular en general
(49.2%), y un nivel de educación de escuela superior (48%). Sus ingresos en su mayoría fluctuaban de $0 a $9,999 al año (91.4 %). En términos
de la muestra estudiada acorde con la Escala de
Actitudes hacia la Sexualidad en el Anciano, se
encontró que el 73.4 % reportan tener una actitud
positiva hacia la expresión de la sexualidad en la
vejez versus un 26.6 % que demuestra actitudes
negativas hacia la expresión de la sexualidad.
Para religión se encontró que por género las femeninas católicas (72.7%) y protestantes (70%);
y los hombres católicos (85.7%) y protestantes
(87.5%) tenían actitudes positivas hacia la sexualidad.
En adición, se realizó un análisis de factores con rotación Varimax para conocer en cuantos
factores se pueden agrupar los 44 reactivos que
discriminan adecuadamente de la escala; se obtuvieron cinco factores donde se agrupan la mayor
cantidad de reactivos. A su vez, estos cinco factores pueden explicar el 53.47% de la varianza de la
puntuación obtenida por los reactivos de la escala.
La Tabla 3 presenta la composición de los cinco
factores donde se agrupan los 44 reactivos de la
escala final; conteniendo solo reactivos cuyo índice
es mayor o igual de .30.
La muestra del grupo No Egidas estaba
comprendida por un 48.3 % de mujeres y 51.7
% de hombres, un 70 % entre las edades de 65
a 74 años, un 25 % entre las edades de 75 a 84
años, y 5% mayores de 85 años. En su mayoría
casados (67.9%) seguidos de personas viudos/as
(23.2%), solteros (6%); con un estado de salud el
cual describían como bueno en general (53.3%),
en su mayoría católicos (71.7%) y un nivel de educación universitario (44.7%). Sus ingresos en su
mayoría fluctuaban de $20,000 a $29,999 al año
(23.7%).
Tabla 1
Componentes principales extraídos en el análisis de factores de la Escala de Actitudes
hacia la Sexualidad en Envejecidos (n =265)
Componente
Valor Eigen
1
14.337
2
3.455
3
2.175
4
1.879
5
1.683
6
1.632
7
1.377
8
1.215
9
1.156
10
1.105
20
% de variación
explicada 32.584
7.852
4.943
4.271
3.826
3.708
3.129
2.762
2.628
2.510
% acumulativo de
variación
32.584
40.436
45.378
49.650
53.475
57.184
60.313
63.075
65.703
68.213
En términos de religión por genero se encontró que a diferencia
de las égidas, en el grupo
no-égidas, el 76.9% de las
mujeres católicas tenían
actitudes positivas hacia
la sexualidad versus las
protestantes y ateas que
en 100% demostraron
actitudes negativas hacia
la sexualidad. Para el género masculino, de igual
manera, 76.9% de los
hombres católicos y ateos
tenían actitudes positivas
hacia la sexualidad versus
la totalidad de los protestantes (100%) que tenían
actitudes negativas sobre
la sexualidad.
Discusión y Conclusiones
La literatura señala que en
la población de envejecidos ocurren una serie de cambios biológicos relacionados a la sexualidad los cuales no son el final
de ésta 1. Los ancianos que son
saludables y activos tiene oportunidades de expresión sexual
y actividad en todas las formas,
incluyendo masturbación, y estas
pueden continuar hasta pasados
los 74 años de edad 8. En esta investigación se realizó un análisis
de factores para evaluar la confiabilidad y validez de la Escala
de Actitudes hacia la Sexualidad
en Envejecidos, para medir actitudes hacia la sexualidad en
un grupo de ancianos en Puerto
Rico.
Se obtuvo un índice alfa de
Cronbach de 0.95, lo que significa que la escala demuestra una
confiabilidad adecuada dado que
un índice adecuado de consistencia interna no debe ser menor de
0.70 23. El índice obtenido en la
escala es considerado como uno
adecuado. Para determinar la validez de constructo se realizó un
análisis de factores exploratorio
encontrando que diez componentes lograron obtener un valor
Eigen mayor de 1 explicando el
68.21 % de la varianza. Lo anterior es sumamente adecuado en
términos psicométricos 23
Tabla 2
Índices de discriminación (rbis) para los reactivos eliminados
Reactivo
rbis
7. La mujer envejecida tiene mayor experiencia sexual.
9. Las mujeres envejecidas no deben de tener más de
una pareja sexual.
11. Las mujeres envejecidas controlan mejor sus impulsos sexuales que los hombres.
18. Las mujeres envejecidas tienen derecho a masturbarse. 21. Mujer envejecida que se respete no aceptaría
nunca tener relaciones sexuales con otras mujeres.
22. Las mujeres envejecientes prefieren estimulación
del clítoris.
30. La mujer envejecida que practican el sexo frecuentemente es más saludable.
31. La mujer envejecida puede tener relaciones sexuales independiente-mente su estado civil.
35. El hombre envejecido tiene derecho a disfrutar el
sexo sin importar estado civil.
40. La mujer envejecida no debe reprimir su sexualidad.
44. La mujer envejecida tiene que servirle al hombre en
el sexo.
47. La mujer envejecida tiene que ser sumisa en el sexo.
53. Al hombre envejecido le molesta la idea de consultar problemas sexuales con otras personas.
54. La masturbación es necesaria para que los envejecidos descarguen las emociones.
57. Los hombres envejecidos pueden tener sexo con
cualquier mujer
59. Los envejecidos homosexuales son una minoría
en la sociedad.
60. Los actos sadomasoquistas entre envejecidos no
son peligrosas ni física ni mentalmente.
61. La bisexualidad es algo normal entre la población
de envejecidos.
63. Los envejecidos bisexuales tienen un problema de
personalidad.
64. Los envejecidos homosexuales son personas normales.
65. Las personas envejecidas pueden optar por cualquier práctica sexual sin que se las prohíban.
-.22
.14
.27
.02
.27
.22
.20
-.21
-.17
-.02
.71
.76
.25
-.21
.22
.26
.22
-.07
.29
.06
-.03
Tabla 3
Reactivos agrupados en factores
FACTOR 1
FACTOR 2
FACTOR 3
FACTOR 4
FACTOR 5
Reactivo Índice
Reactivo Índice
Reactivo
Reactivo Indice
Reactivo Indice
21
23
3
8
15
25
17
40
37
39
41
42
35
34
26
24
28
5
Estereotipos Sexuales
Mitos sociales/
religiosos
Prácticas Deseo sexual sexuales Índice
19
.813
31
.788
10
.719
20
.781
1
.745
14
.710
27
.763
29
.691
11
.707
22
.739
6
.655
44
.671
18
.639
2
.526
9
.635
36
.638
12
.525
13
.467
7
.502
30
.440
43
.319
16
.421
32
.381
38
.415
33
.306
4
.400
.775
.708
.694
.691
.682
.593
.539
.473
.412
.354
.301
.356
Rol de la mujer en el sexo
.750
.706
.685
.617
.554
.318
21
La importancia de tener instrumentos válidos y confiables para medir las actitudes hacia
la sexualidad en los envejecidos se incrementa
enmarcándose en las necesidades de dicha población y en el ambiente social de índole individual y comunitario, donde se carece de recursos,
medidas y orientación hacía el tema en la población envejecida. El estudio presenta limitaciones
en términos del muestreo por disponibilidad que
limita la genereralización de los hallazgos. Se
recomienda replicar el mismo con una muestra
más amplia y el desarrollo de estudios posteriores
que nos den mayor luz sobre la validez de este y
otros instrumentos para medir actitudes sobre la
sexualidad en la población anciana. Encontramos
que en terminos de nuestra muestra, las actitudes
para hombres y mujeres clasificadas en actitudes
positivas y actitudes negativas, reportan, en general actitudes positivas hacia la expresión de la
sexualidad.
En términos de la muestra estudiada acorde con la Escala de Actitudes hacia la Sexualidad
en el Anciano, se encontró que el 53 % reportan
tener una actitud positiva hacia la expresión de
la sexualidad en la vejez versus un 47 % que demuestra actitudes negativas hacia la expresión de
la sexualidad. No se encontraron diferencias significativas por género [F (1,40)= .047, p=.829] y
edad [F (1,40)= 1.830, p=.184], en actitudes hacia
la sexualidad por lugar de residencia pero si en
el factor que envuelve “deseo sexual” por categorías de edad por lugar de residencia (égidas)
[F (2,114)= 4.44, p=.014]. No hay diferencias significativas por género para lugar de residencia [F
(1,117)=.381, p=. 538)] entre égidas y no égidas.
Encontramos que en términos de nuestra
muestra, los ancianos/as reportan, en general actitudes positivas hacia la expresión de la sexualidad. Cabe señalar que algunos ancianos, son
socializados y creen a tono con nuestra realidad
cultural, las falsas expectativas enseñadas donde
muchos detienen su vida sexual por las actitudes
de censura que presenta la sociedad (mitos sociales, culturales, estereotipos y religión) y que,
interesantemente, son reforzadas por ellos mismos. Parece ser que a pesar de ello, el deseo de
continuar su actividad sexual, les hace tener mayor apertura hacia la sexualidad. Sugerimos que
hayan programas/talleres de educación sexual
donde se dirija a los ancianos a reconocer que la
conducta sexual es una expresión normal del envejecer y que se requiere romper con los estigmas
sociales negativos existentes, pero a la vez les
provea de educación en áreas de autoprotección
para minimizar conductas de riesgo en las que
puedan estar implicados por desconocimiento o
por minimizar riesgo debido a creencias erróneas.
Estudios señalan que aquellos envejecidos que
22
continúan teniendo actividad sexual tienen más
actitudes positivas hacia la sexualidad 10 Esta
investigación aporta al progreso y desarrollo de
instrumentos que midan y puedan cernir aspectos de sexualidad que enfoquen en la población
anciana para futuros estudios. De igual forma, el
estudio provee dirección para lograr el desarrollo
de programas preventivos y de orientación sexual
que cumplan con las necesidades específicas de
los envejecidos en Puerto Rico sobre todo para el
disfrute de su sexualidad en forma saludable.
REFERENCIAS
1. DeLamater, J., & Friedrich, W. N. (2002). Human sexual development. The Journal of Sex Research, 39(1), 10-14.
2. Liboy, J. , Rodríguez, J.R. & Lizardi, E. (2007) Las Disfunciones
Sexuales en las Personas de Edad Avanzada: Elementos a considerarse para una adecuada intervención psicológica. Hospitales
61 (20), 23-31.
3. Nazario, J. A, & Rodríguez, J. R. (1996). Reconceptualización
cognitiva en la percepción de la actividad sexual de los ancianos:
Neoformación estructural de actitudes hacia la sexualidad en la
vejez. Boletín Asociación Médica, 88 (10-12), 94-96.
4. Hadro-Venzke, M. (1992). Sex and aging: the heart has no
wrinkles. The Journal of
the American Medical Association,
268(7), 70-72.
5. Trudel, G., Turgeon, L., & Piche, L. (2000). Marital and sexual
aspects of old age. Sexual and Relationship Therapy, 15(4), 381415.
6. Covey, H. C. (1989). Perceptions and attitudes toward sexuality
of the elderly during the middle ages. The Gerontologist, 29(1), 93105.
7. Crose, R, Drake, L.K. (1993). Older women’s sexuality. Clinical
Gerontologist,12(4), 51-57.
8. Milles, S. H., & Parker, K. (1999). Sexuality in the nursing home:
Iatrogenic loneliness. Generations, 23(1), 36-43.
9. Tefilli, M. V., Dubocq, F., Rajpurkar, A., Tiguert, R., Barton, C.,
Li, H., & Dhabuwala, C. B. (1998). Assessment of psychosexual
adjustment after insertion of inflatable penile prosthesis. Urology,
52(6), 1106-1112.
10. Dunn, K. M., Croft, P. R., & Hackett, G. I. (1999). Association
of sexual problems with social, psychological and physical problem
in men and women: A cross-sectional population survey. Journal of
Epidemiology and Community Health, 53(3), 144-148.
11. Metz, M. E., & Miner, M. H. (1998). Psychosexual and psychosocial aspects of male aging and sexual health. The Canadian
Journal of Human Sexuality, 7(3), 245-259.
12. Cohen, R., & Steinman, W. (1990). Sexual function and practice in elderly men of lower socioeconomic status. The Journal of
Family Practice, 31(2), 162-166.
13. Steers, W. D. (1999). Viagra-after one year. Urology, 54(1), 1217.
14. Portovna, M., & Newman, M. A. (1984). Elderly women´s attitudes toward sexual activity among their peers. Health Care for
Women International, 5(1), 289-298.
15. Walker, B. L., & Ephross, P. H. (1999). Knowledge and attitude
toward sexuality of a group of elderly. Journal of Gerontological
Social Work, 31(1-2), 85-107.
16. Read, J. (1999). ABC of sexual health: sexual problems associated with infertility, pregnancy, and ageing. British Medical Journal, 318(7183), 587-599.
17. Wiley, D., & Bortz, W. M., II. (1996). Sexuality and aging: usual
and successful. The Journal of Gerontology, 51A(3), 142-150.
18. Schiavi, R.C. , Schreiner, P., Mandeli, J., Scahnzer, H. & Cohen
E. (1990). Healthy aging and male sexual fuction. American Journal of Psychiatry,147(6), 766-771.
19. Williams, E., & Donelly, J. (2002). Older Americans and AIDS:
Some guidelines for prevention. Social Work, 47(2), 105-111.
20. Binson, D., Pollack, L., & Catania, J. A. (1997). AIDS related
risk behaviors and safer sex practices of women in midlife and older in the United States: 1990 to 1992. Health Care for Women
International, 18(4), 343-354.
21. Kessel, B. (2001). Sexuality in the older person. Age and Aging,
30(2), 121-124.
22. Van de Ven, P. Rodden, P. Crawford, J. & Kippax, S. (1997)
Comparative Demographic and Sexual Profile of Older Homosexually Active Men. Journal of Sex research 34 (4), 349-360.
23. De Vellis, R. F. (1991) Scale Development : theory and Application. Newberry Park: NY, Sage.
ABSTRACT
SWORD WAY
The literature indicates that elderly population is at high risk that affects their sexual activity;
however, this is not the end of sexuality expression in this population. Elderly (people 65 years and older) who are healthy and active has more opportunities of sexual expression and activity in all forms,
(including masturbation, and oral sex), and these activities can continue until 74 years or older. This
study tries to explore if the Scale of Attitudes towards Sexuality Behavior in the Elderly develop in
Puerto Rico, is a valid and reliable instrument to measure attitudes towards the sexuality in an elderly
sample. In addition, the research tries to contribute to the progress and development of instruments
that measure, and screen, sexuality aspects and risk behaviors that focus in the elderly population.
This may help to promote future studies and the development of preventive programs that help to
fulfill specific necessities in elderly. The research subjects consist of a secondary database sample
of 265 adults of 65 years or older. The design of this study was an ex post facto type. The collected
data were analyzed using descriptive statistics and factorial analyses to establish an association between the study variables (i.e., attitudes towards the sexuality and sexuality) using SPSS-X program
version 14; also was concluded that the instrument is a valid and reliable (Alpha Cronbach= 0.95),
which is considered adequate. It’s expected that the scale will be valuable for future research in this
area.
Puerto Rico Medical
Association Do Jan
1305 Fernández Juncos Ave.
Santurce, PR 00907
Phone: (787) 238-6722
www.uskda.webs.com
Review Article / Articulo de Reseña
Inside Look
At Laparoscopic
Colectomy
Ramón K. Sotomayor MD
Bolívar Arboleda MD
Andrés Guerrero, MD
From the Department of Surgery, Hospital Interamericano
de Medicina Avanzada (HIMA)- Caguas, Puerto Rico.
Address reprint requests to Dr. Ramón K. Sotomayor - #300
Ave. La Sierra Box 61, San Juan, PR 00926, Email: [email protected].
Presented at the 60th Annual Meeting of the Puerto Rico
Chapter of the American College of Surgeons, February
25th, 2010.
INTRODUCTION
Laparoscopic surgery has evolved into a
viable alternative to open colon surgery. The advantages of smaller incisions than traditional open
surgery, less post operative pain, less narcotic requirements and faster return to normal activities
are attractive to patients, family members, employers and third party insurers. Patients have less
postoperative ileus and start diet sooner. Smaller incisions mean reduced catabolic response,
wound infection rate, postoperative hernia development, and less intraabdominal adhesions. Nevertheless, laparoscopic surgery has to be as safe
and effective as open surgery in management of
surgical conditions.
ABSTRACT
Laparoscopic colectomy has developed
into a viable alternative to colon surgery. This
paper presents an overview of the development
and current status of laparoscopic surgery of the
colon with a brief review of the evidence of efficacy of laparoscopic surgery in cancer management. The experience with laparoscopic surgery
of the colon at a tertiary hospital in Puerto Rico
is discussed with review of 142 consecutive cases treated for diverticulosis, cancer or polyps
performed from 2005- 2010. Data on operative
time, technical issues, need for transfusions,
specimen size, number of lymph nodes is presented. Data on time to start diet and length of
hospital stay are discussed. Surgical complications in the series are discussed in detail and recommendations made on avoidance of technical problems during laparoscopic colon surgery.
Recommendations are made on the development and advancement of laparoscopic colonic
surgery in Puerto Rico.
Index words: laparoscopy, colectomy
Laparoscopic colectomy takes longer. More
expensive equipment is utilized such as optics,
monitors lenses, energy devices and specialized
staplers for endoscopic use, as well as ureteral
stents in some cases along with wound protectors and hand assist devices. There is also- as is
expected when new technology is being utilizedskepticism in the community and amongst referring physicians as to whether it is an adequate
operation both in benign and malignant conditions. As we progress in adapting new surgical techniques, we as surgeons must question whether
Laparoscopic colectomy is a difficult ope- these procedures are adequate, whether they are
ration to learn and teach. The colon is a complex being properly performed and whether or not they
organ, a large bulky structure, and the technical are actually helping patients.
aspects of obtaining adequate exposure for the
performance of a safe operation takes time to mas- The American Society of Gastrointestinal
ter because they are different from open surgery. and Endoscopic Surgeons (SAGES) in 2004 isThere is need to manage large vessels without the sued a statement in this regard (1). According to
benefit of sutures or Ligasure, and the specimen SAGES, in cancer management, the operation
needs to be extracted via a small incision which in should have equivalent survival when performed
turn has to be protected from contamination. Mo- by experienced surgeons; adherence to standard
reover is the issue of restoring continuity of the cancer resection technique- vessel control at the
gastrointestinal tract. The surgeon has to be fami- origins, careful tissue handling, and en bloc resecliar with the different forms of anastomosis which tion should be utilized. SAGES also recommend a
will vary according to the patient and to the type of prerequisite of 20 colon resections with anastomooperation being performed. This is an issue that sis for benign or non curable cancer prior to using
adds difficulty and risk to the procedures.
laparoscopy for curable cancer (1).
24
In 2006, SAGES and the American Society of Colon and Rectal Surgeons (ASCRS) developed practice guidelines addressing the overall
performance of laparoscopic colectomy. In this
guidelines both societies stressed the importance of appropriate proximal and distal margins with
appropriate lymphadenectomy, en bloc resection
for T4 lesions and open conversion if not feasible. Tumor perforation must be avoided, and a “no
touch” technique is recommended. In terms of the
risk of wound implants, the guidelines state that it
is mainly a technical phenomenon that depends
on tissue handling and therefore the extraction incisions should be protected at all times during mobilization of the specimen with various retractors
and protectors to decrease the risk of implantation
of the tumor. In fact, tumor implantation and abdominal wall recurrence as of today should be no
more common than in open surgery (2).
The previous recommendations were issued before widespread use of laparoscopy for
diverticulosis and for cancer and they were issued
based on experience from selected centers. The
question then follows whether adequate outcomes
are applicable to a large segment of the surgical
community. Sufficient numbers of laparoscopic
resections have now been performed in the United States to compare large numbers of patients
throughout different hospitals. In terms of overall
safety and outcome with resections for both benign and malignant diagnosis, an administrative
data base study published in Annals of Surgery
in 2008 looked at 32,000 colectomies. One-third
were done laparoscopic and 66% were open. The
laparoscopic colectomy group had a shorter stay
in the intensive care unit, shorter total length of
hospital stay, fewer complications and less operative mortality. There was less use of skilled nursing
facilities post op, but a higher rate of reoperations
(3).
In cancer management, data from the initial Clinical Outcomes Study Trial (COST) has now
had an eight year follow up (4). The initial trial of
872 patients at 48 institutions concluded that the
recurrent cancer rates were similar stage for stage in open and laparoscopic resections. Curiously
the COST trial did not report the number of lymph
nodes in each group. In the recently published
follow-up report the 5-year- disease-free-survival
has been almost equal in both groups, (open 68.4
%, laparoscopic 69.2 %), overall 5-year-survival
(open 74.4%, laparoscopic 76.4%) are similar as
well as recurrence rates ; (open surgery 21.8 %,
laparoscopic 19.4 %). The trial concludes that laparoscopic colectomy is not inferior to open surgery on long-term oncologic endpoints on a randomized trial (5).
Another 2008 study compared a large number of laparoscopic and open colectomy for cancer over the course of four years. Laparoscopic
colectomy use increased from 3.8 % to 5.2 %.
This study found that patients were more likely
to have laparoscopic colon surgery if they lived in
high income areas, had Stage I disease, with similar perioperative mortality, recurrence rates and
5-year-survival. However, this study found that laparoscopic colectomy patients tended to have 12
or more lymph nodes examined less frequently
while higher volume hospitals tended to have specimens with higher number of lymph nodes (6).
This shows that laparoscopic surgery is very operator dependent and that experience and volume
are critical for the quality of the operation.
METHODS
Technical Aspects: Hand assisted vs. full laparoscopic resections
There are two basic ways of performing minimally invasive colectomy. In-hand assisted colectomy, in which a “hand port” is utilized; one of
the surgeon’s hands is inserted inside the abdomen and used as an instrument for retraction and
exposure. The other technique is complete or full
laparoscopic resection, in which standard ports
are utilized, the dissection is completed fully with
laparoscopic instruments and an incision is made
to extract the specimen. This incision can be used
to complete an extracorporeal anastomosis or in
left colon resections is used to prepare the colon
for an intracorporeal anastomosis with a circular
stapler. Although different in many ways, several
studies have shown that there is no difference in
outcome, pain scores, length of stay or time to
start diet with either technique. Specimen size,
margins, and lymph node counts are the same (7,
8).
There are some technical issues with use
of the hand ports. The incision is slightly larger,
usually about 7-8 cm compared to about 3- 5cm
in full laparoscopy (See Figure 1). It is very important to properly place the hand port in a way that
does not interfere with the operation; actually if improperly done the hand can get in the way of the
operative field and hand fatigue can be an important issue in completing the operation. Most of the
time in which a conversion is needed is because
of one step of the operation that cannot be safely
performed, so a hand assist technique can help
pass that difficult step and complete the operation.
Thus, hand assisted techniques can be used to
manage a particularly difficult intraoperative situation, and in that way, reduce the need to convert
completely to an open procedure (7).
25
Figure 1– The picture on the left shows the incisions for the hand assisted technique for left colon resection. A 7 cm pe-
riumbilical incision was used. The right side shows a 3-5 cm suprapubic incision for placement of the retractor and extraction
of the specimen. The numbers correspond to the port size.
One advantage of hand assisted surgery is
that one can palpate the organs and have tactile
feel during surgery. In complete laparoscopy this
sensation is not available so one has to rely on
other techniques to compensate for this. We have
found that when two surgeons work together full
or total laparoscopy works well and from the ergonomic standpoint, in our experience, is better than
hand assist because awkward positioning of the
hand is diminished. Figure 2 shows an example
of a resection for an upper rectal cancer using full
laparoscopy. As the tumor cannot be palpated, a
sigmoidoscope is inserted via the rectum by the
assistant surgeon in order to visualize the tumor
and make sure that the division of the rectum with
the endoscopic stapler is done distal to the tumor.
MATERIALS
The hospital and office medical charts of all
patients undergoing laparoscopic colon resection
at HIMA San Pablo- Caguas, a tertiary hospital
in Caguas Puerto Rico from 2005 to the present
were analyzed. During this time three surgeons
were performing laparoscopic resection. The initial
65 cases from 2005-2008 were previously reported (8). The second set of patients consists of 77
cases from 2008 to January 2010.
26
RESULTS
The initial 65 cases were all done using
hand-assisted technique. Mean operative time
was 195 minutes. Overall, 13.8 % required conversion to open surgery. During the initial year 21%
were converted to open; after the 1st year performing laparoscopic colectomy, the rate dropped to
10.8%. Left colon resections were more difficult
with a higher conversion rate, namely due to difficulty in dealing with inflammation in diverticulosis,
splenic flexure mobilization and adhesions. Diet
was started an average of three days after surgery
and length of hospital stay was 4.5 days. There
were several complications due to bleeding with 3
reoperations in the early post operative period; but
no patient required a stoma as a result of a complication and there were no operative deaths. The
average lengths of the specimens were 17cm and
the average lymph node counts was 14.8 nodes
(9).
For the first part of 2008 most cases were
still started with a hand assisted device and late
in the year most cases were performed using full
or total laparoscopic resection technique. There
were 77 cases in this group; 49% (38/77) male,
and 51% (39/77) female with an average age of
60 (range 34-90 years). Diverticulosis or recurring Table 2 shows the immediate outcome. Avediverticulitis occurred in 55% (42/77) of the cases, rage operative time actually increased from 195 to
and 45% (35/77) for polyps or cancer.
235 minutes although most of the cases were in
the three hour range.
The increase in operating time was due
mostly to the change
in technique. We did
have some very lengthy cases, patients
with multiple previous
surgeries with extensive adhesions that perhaps should have been
selected for open surgery due to their difficulty. Three patients
required transfusions,
time to start diet on
average was 3.5 days
and overall length of
stay was 6.4 days and
4.8 days respectively
Figure 2 - The rectum is being dissected, a sigmoidoscope is used to identify the site in patients who did not
of the lesion, which is proximal to the arrow prior to division with the endoscopic linear
have a complication.
stapler.
Table 1 shows the distribution of cases performed and shows an increase in successful use
of full laparoscopic resections with 58% (45/77)
of cases completed with full laparoscopy. Some
of the cases were started and completed with the
hand assist device; some were started with full laparoscopy and completed with hand assistance.
Table 1. Increase in use of full or total laparoscopic
resection 2008-2010.
Operation type: # cases(n)
(%)
Left colectomy
57/7730
full laparoscopy /5727/57
HAL left colon 75 %
52
48
Right and trans-
20/7715
verse colon
/205/20
resections
full laparoscopy
HAL right colon
25 %
75
25
Overall
45/77
full laparoscopy
HAL resections 58%
43
n = 77
Table 2. Immediate outcome of laparoscopic colectomy 2008-2010
Operative time
235 minutes (mean)
120-480 minutes
Conversions Reoperations
transfusions
Time to start
diet Length of stay
all patients
wound com-
plication
5/77
2/77(leak, obstruction)*
3/77
6.4 %
2.5 %
3.9 %
3.5 days (mean)
2-8 days
6.4 days
4.8 days
3-25 days
3-13 days
n = 77
Two patients required re-intervention within
the first week, one due to an anastomotic leak and
one due to an acute obstruction of the anastomosis. Both patients had a prolonged length of stay.
Nevertheless, most patients had very smooth post
operative course tolerating diet early in their hospital stay and with very few cases of post operative ileus. We have been very conservative in
discharging the patients from the hospital, waiting
until patient bowel function is almost normal prior
to discharge.
27
Table 3 lists the reasons for conversion to
open surgery. Overall, five patients were converted to open after an attempt was made at hand
assisted completion. The first patient had an uneventful surgery but had positive leak test during
air insufflation of the anastomosis. In all cases of
left colon resections, a sigmoidoscope is inserted
after performance of the anastomosis, and air is
insufflated in the rectum to check for leaks. His
extraction incision was extended, and under direct
visualization, the defect in the anastomosis identified, sutured, 1 ml of fibrin glue was placed over
the area, and the patient did extremely well post
op. The other four patients listed were difficult due
to chronic abscess, extensive adhesions, obesity
and difficulty with the anastomosis which required
an open approach.
This was a ureter that had actually been
stented before surgery. The patient recovered
well. One patient had an acute obstruction of an
anastomosis. This was a side to side stapled intracorporeal anastomosis after a splenic flexure
resection. The patient required re-operation, diverting colostomy and Hartman’s procedure.
Three patients developed clinical leaks after low pelvic anastomosis with the circular stapler and their clinical course and management
is summarized in Table 5. One patient was successfully treated with intravenous antibiotics and
resolved. She had undergone a full laparoscopic
left colon resection for diverticulosis; intraoperative she had an incomplete donut of the anastomosis with a circular stapler. We were able to
identify the area of the defect, she was sutured
In terms of oncologic outcome the num- laparoscopically and retested until the anastober of lymph nodes ranged from four to 34 with mosis was air tight, she developed fever post op
an average of 15 lymph nodes per specimen. The and was treated with antibiotics and a drain that
great majority of cases had more than 12 lymph had been placed during surgery. This patient was
nodes so we feel they were staged adequately. readmitted several weeks later and again treated
The length of the specimens ranged from 13.5cm with antibiotics as she presented no evidence of
to 45 cm with an average of 20 cm as measu- an abscess. The second patient had a mid rectal
red by thepathology lab after formalin fixation. cancer and a low pelvic anastomosis. The donuts
No patient had a positive margin of resection. were intact and the air leak test negative. She developed fever on post op day 3, and a CAT scan
Major surgical complications are listed on showed a pelvic abscess. She was successfully
Table 4. Some of the initial cases had ureteral treated with percutaneous drainage. Due to persistent output via the drain, direct visualization
stents placed to help identify the ureters.
with
colonoscopy
was done. A defect in
Table 3. Reasons for conversion to open surgery 2008-2010
the anastomosis was
identified, and it was
Patient Diagnosis
Reason for conversion Outcome
sealed with endoclips. The patient re1
diverticulosis
Positive air leak test in no adverse outcome
mained for 20 days in
anastomosis
the hospital but did not
require fecal diversion.
2
diverticulosis
chronic abscess
no adverse outcome
3
left colon cancer extensive adhesions, obesity, prolonged
surgery
4 sigmoid cancer
huge inguinal hernia
Fascial dehiscence
5 left colon cancer
no adverse outcome
Extensive adhesions, obesity, difficulty w
anastomosis
One patient developed occlusion of the ureters secondary to bleed secondary to the stents themselves; it was resolved with double-j catheter insertion. One patient had an intraoperative laceration
of the ureter. This was identified intraoperative and
repaired by the urologist using the lap disc incision.
28
Deep venous throm
bosis, congestive
heart failure
The last patient
had undergone resection for an upper rectal
cancer. Signs of ongoing sepsis required
re exploration, drainage and diverting ileostomy, which has been
recently closed and
the patient is doing
well.
DISCUSSION
Laparoscopic colectomy started in 1991
with a pilot program of 20 patients. At that time, Dr.
Moses Jacobs wrote- that laparoscopic colectomy
- “should be considered a procedure in evolution,
and feel that in time it may become as popular as
laparoscopic cholecystectomy” (10). It is not clear
whether this will ever be achieved in the United
States or in Puerto Rico due to the difficult technical aspects of laparoscopic surgery.
Of the total number of 142 patients, four patients in our series had problems with the anastomosis and required prolonged therapy or further
surgery. The one patient with the obstruction of the
colon, on retrospect appears to have a technical
problem with a
stapled intraTable 4. Major surgical complications: All patients 2005-2008.
corporeal side
to side anastoType # (% ) n=142
Outcome
mosis with a
45mm endosureter transection 1 (0.7 %)
intraoperative repair via lap disc
copic stapler.
ureteral stent occlussion 1(0.7)
Double-j-catheter
anastomosis obstruction 1 (0.7)
Reoperation, diverting colostomy & We believe that
such problems
Hartman’s pouch
may be avoianastomotic leaks** 3 (2.1)
1 drain,1 antibiotics , 1 ileostomy
ded in the futransfusions
5 (2.5)
no surgery
ture. The three
readmission small
leak patients
bowel obstruction
1(0.7)
gastric suction ,resolved
all had low pelvic anastomo** details of leaks detailed in table 5.
sis with a circular stapler.
Table 5. Problems with anastomosis with circular stapler, action and outcome - All patients 2005-2010.
Patient age, sex
Diagnosis Air leak test
Intraoperative action
70 y/o, F
mid rectal Negative
--
cancer (10 cm)
51 y/o, M
upper rectal Negative
--
cancer (15 cm)
60 y/o, F
diverticulosis
Positive
40 y/o, M
diverticulosis Positive
Outcome
Leak, pelvic abscess drain,
clip, LOS 20 d
reoperation ileostomy,
LOS 25 days
Lap suture, leak test neg post op fever, readmission
Conversion, suture, fibrin No adverse outcome,
glue
LOS 6 days
LOS = length of stay
We have demonstrated the feasibility of laparoscopic colon surgery starting out with hand
assisted laparoscopic surgery, with good results,
short length of stay and a low rate of complications. Early complications in the initial set of 65
patients seemed to be the result of lack of familiarity with the laparoscopic energy instruments
with major problems in the early period being due
to bleeding. Our technique has evolved to full laparoscopic colon resection in most cases and haveseen that in most cases the operation is very
safe and patients do extremely well. Although
this is not a randomized trial, we can compare our laparoscopic cases to previous and present open cases and categorically say
that
pain is less, and patients recover much sooner.
Two of them were rectal cancer cases and had
negative leak tests intraoperative. It has been
shown that leaks are more common in the lower
rectum, with multiple linear stapler firings during the division of the rectum, and with larger
diameter circular staplers. A study with 270 patients in which 17 had anastomotic leaks identified the number of firings as the most important
factor, and recommend diverting ileostomy in cases that require multiple staple firings (11). One
of the strategies to decrease leak, has to be to
attempt to divide the rectum with a single staple
firing and avoid larger diameter circular staplers.
In term of other complications, it seems that
most of the main problems related to open surgery
29
such as atelectasis, cardiopulmonary problems,
and wound complications are markedly diminished. We feel that the operative problems in this
and other series are mainly related to technical
issues of the operation and can be diminished with
experience, improved equipment, good visualization, good assistance and extreme attention to detail .
As laparoscopic surgery develops in Puerto
Rico, strategies need to be developed to decrease
operating time, and maintain high standards of oncologic quality and most importantly improve patient safety. At the present time we are using a surgical team approach with two surgeons for most
of the case and that seems to work well in making
a difficult operation run more smoothly. Training
for laparoscopic procedures needs to continue to
evolve, and industry has to continue to support
training of physicians with interest in advanced laparoscopic surgery. Hospitals must do their part
and invest in better equipment, improve and maintain technology. They should develop modern dedicated operating rooms in order for laparoscopic
colectomy to develop in a safe and responsible
manner; and they must continue not to rely on the
surgeons to train operating room teams but rather
to invest in training of the operating room staff.
Finally, it is not clear in Puerto Rico how
much colon surgery is being done or what fraction
is done laparoscopic. We are confident that our
series represents a true and honest introspection
into our work but in order to gauge whether or not
this technology is good for our patients across the
island more research is needed. One consideration for the future may be to create an industry
sponsored registry of laparoscopic colon surgery.
This way, information can be shared, and we can
use this information to improve modern surgical
practice and in that way improve patient care.
REFERENCES
1.
Position Statement of the Society of Colon and
Rectal Surgeons (ASCRS) and Society of Gastrointesintal
Endoscopic Surgeons(SAGES) on Laparoscopic Colectomy
for Curable Cancer, 2004.
2.
Guidelines for Laparoscopic Resection of Curable
Colon and Rectal Cancer. Practice guideline published on
07/2006 by the Society of American Gastrointestinal Surgeons.
3.
Delanney, Connor, Mch, PhD. et al. Clinical Outcomes and Resource Utilization Associated to Laparoscopic
and Open Colectomy Using a Large National Database. Annals of Surgery 2008; 24(5): 819-824.
4.
Nelson, Heidi , The Clinical Outcomes Study Group.
A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer. The New England Journal of Medicine 2004; 350:250-9.
30
5.
Fleshman, James, MD. et al. Laparoscopic Surgery for Cancer is Not Inferior to Open Surgery Based on
5 Year Data from COST Study Group Trial. Annals of
Surgery 2007; 246(4): 655-664.
6.
Billimoria, Karl Y, et al. Use and Outcomes of Laparoscopic Assisted Colectomy for Cancer in the United
States. Archives of Surgery 2008: 143(9): 832-840.
7.
Targarona, EM et al. Prospective randomized
trial comparing conventional laparoscopic colectomy with
hand assisted colectomy. Applicability, immediate clinical
outcome, inflammatory response and cost. Surgical Endoscopy 2002; 16: 234-239.
8.
Ozturk, Erzin, MD, et al. Hand Assisted Laparoscopic Colectomy : Benefits of Laparoscopic Colectomy at
No Extra Cost. 2009; 209(2): 242-247.
9.
Sotomayor, Ramon, MD and Bolivar Arboleda.
Experience with Hand Assisted Laparoscopic Surgery of
the Colon. Boletín Asociación Médica de Puerto Rico.
2008; 100 (1):13-19.
10.
Jacobs, Moses, et al. Minimally Invasive Colon
Resection (Laparoscopic Colectomy) Journal of Laparoscopic and Percutaneous Techniques. 1991; Sept. 1(3):
144-150.
11.
Soo Kim, Jin MD et al. Risk Factors for Anastomotic Leakage after Laparoscopic Intracorporeal Colorectal Anastomosis with a Double Stapling Technique. Journal of the American College of Surgeons, 2009; 209(6):
694-701.
RESUMEN
La cirugía laparoscópica del colon
ha evolucionado a una alternativa viable
a la cirugía abierta. Este artículo presenta un repaso del desarrollo y el estado
actual de la cirugía laparoscópica de colon y un repaso de la evidencia y eficacia
en el manejo laparoscópico de carcinoma del colon. Se discute la experiencia
con esta cirugía en un Hospital terciario
en Puerto Rico, detallando un repaso
de 142 casos tratados para enfermedad diverticular y cáncer del colon desde el 2005 al 2010. Se presenta datos
de tiempo operatorio, asuntos técnicos,
necesidad de transfusiones, tamaño del
espécimen, y número de ganglios linfáticos. Se discuten asuntos relacionados
al tiempo de comenzar la ingesta oral y
la estadía hospitalaria. En esta serie se
discuten complicaciones quirúrgicas en
detalle y se hacen recomendaciones de
cómo se podrían potencialmente prevenir. Se proveen ideas de cómo promover
el avance de la cirugía laparoscópica del
colon en Puerto Rico.
Case Reports / Reporte de Casos
ABSTRACT
Pheochromocytomas are rare
neuroendocrine tumors. Patients with
pheochromocytoma may develop
potentially lethal cardiovascular and
other complications, especially in the
setting of diagnostic or interventional
procedures (e.g. upon induction of
anesthesia or during surgery). Perioperative management of patients with
pheochromocytoma requires detailed
knowledge on the pathophysiology
and potential complications. This is
a case of a 38 year-old, male, with
history of bilateral pheochromocytoma, and hypertension secondary to
pheochromocytoma, that was scheduled for open bilateral cortical-sparing adrenalectomy under general
anesthesia combined with thoracic
epidural anesthesia. Although resection of bilateral pheochromocytomas
continues being a challenging situation for the anesthetic management,
morbidity and mortality can be significantly decreased with preoperative
α-antagonists treatment, as well as
volume restoration, vasoactive drugs,
and closely monitoring intra- and
postoperatively.
Anesthetic Management
Of A Patient Undergoing
Surgery For Bilateral
Pheochromocytoma:
Index words: anesthetic, management, surgery, bilateral, pheochromocytoma
INTRODUCTION
The most important disease process associated with the medulla of the adrenal gland is
pheochromocytoma (1), which is a rare neoplasm
that develops from the chromaffin tissues (2, 3).
Only in 10% of adults the tumors are bilateral
(1). Surgical removal of the tumor is the definitive treatment of this condition. The perioperative
management remains a complicated anaesthesia
challenge (4), as 25% to 50% of hospital deaths
in patients with pheochromocytoma occur during
induction of anesthesia or during surgery (2, 3).
CASE REPORT
This is a case of a 38 year-old, male, with
history of bilateral pheochromocytoma as part of
the Multiple Endocrine Neoplasm II-A syndrome,
A Case Report
Serafín C. López MD
Daniel E. Fernández MD
Osmar Creagh MD
From the Department of Anesthesia, UPR School of Medicine, Puerto Rico Health Science Center
Address reprints requests to: Serafín C. Lopez MD – Department of Anesthesia, UPR School of Medicine, Puerto
Rico Health Science Center, Rio Piedras, PR 00936. Email:
[email protected]
and hypertension secondary to pheochromocytoma, that was scheduled for an open bilateral
cortical-sparin adrenalectomy. Patient had also
undergone total thyroidectomy due to medullary
carcinoma of the thyroid gland. The day before surgery, the patient was completing 14 days
of treatment with phenoxybenzamine and blood
pressure was under control. All preoperative work
up was within normal range. A central line was placed for central venous pressure monitoring.
Prior placement of American Society of
Anesthesiology’s standard monitors plus an arterial line, anesthesia slow controlled induction was
performed with xylocaine, propofol, fentanyl, and
cisatracurium. Sevofluorane was added for maintenance of anesthesia. Then an epidural catheter
was placed at T8-T9 level, for postoperative analgesia management.
During tumor manipulation, the patient
experienced transient arterial hypertension, controlled with volatile anesthetics. After removal of
the adrenal medulla, patient started with arterial
hypotension, managed initially with phenylephrine and continued with norepinephrine since the
former did not produce the vasopressor response
desirable. Electrocardiographic tracing remained
unchanged. After both tumors were resected, a
dextrose containing solution was started to avoid
hypoglycemia.
At the end of the surgery patient was started on an infusion of bupivacaine 0.125 % through
31
the epidural catheter for postoperative analgesia.
Emergence from anesthesia took placed without
complications. Patient was extubated uneventfully,
and taken to the post anesthesia care unit, where
he remained fully awake, free of pain, with normal
vital signs. Then, the patient was transferred to the
intensive care unit and was hemodynamically stable for the remainder of his hospital stay. The patient was discharged from the hospital on the third
postoperative day.
DISCUSSION
The reduction in perioperative mortality rates with the excision of pheochromocytoma has
followed the introduction of α-antagonists once the
diagnosis of pheochromocytoma is established (1,
5). Phenoxybenzamine, between 80 and 200 mg/
day has traditionally been used (1, 2). Most clinicians recommend beginning α-blockade therapy
at least 10 to 14 days before the surgery; and continue them until the morning of surgery (1), which
was the case of our patient.
Although there is no clear advantage to one
anesthetic technique over another, drugs that are
known to liberate histamine are avoided (1, 2, 6).
For induction of anesthesia, we choose a potent
sedative-hypnotic, in combination with an opioid
to achieve an adequate depth of anesthesia before laryngoscopy to minimize the sympathetic response to this maneuver. Manipulation of the tumor
may also produce acute hypertensive crises (1, 2,
6) that were successfully treated in our patient by
deepening the anesthetic level.
The reduction in blood pressure that may
occur after tumor resection can be dangerous (1,
3, 6). Restitution of intravascular fluid deficits is
the initial therapy in this situation; then phenylephrine or norepinephrine is administered (1, 3, 6).
These patients are also prone to significant hypoglycemia from the suppression of b- cell
function after removal of the tumor (6), reason why
we considered switching to a glucose-containing
intravenous fluid while monitoring glucose levels
closely.
CONCLUSION
Resection of bilateral pheochromocytoma
continues being a challenging situation for the
anesthetic management but morbidity and mortality can be significantly decreased with preoperative α-antagonists treatment, as well as volume restoration, vasoactive drugs, and closely monitoring
intra and postoperatively.
32
REFERENCES
1.
Barash, Cullen, Stoelting; Clinical Anesthesia; 5th
ed; Philadelphia, PA; Lippincott Williams & Wilkins; 2005;
1142-1144
2.
Miller; Miller’s Anesthesia; 6th ed; Philadelphia, PA;
Churchill Livingstone; 2005; 1042-1044
3.
Pacak K; Preoperative management of the
pheochromocytoma patient; J Clin Endocrinol Metab; 2007;
92(11); 4069-4079
4.
Ahmed A; Perioperative management of pheochromocytoma: anaesthetic implications; J Pak Med Assoc;
2007; 57(3); 140-146
5.
Knüttgen D; Anaesthesia for patients with
phaeochromocytoma -specifics, potential complications
and drug strategies; Anasthesiol Intensivmed Notfallmed
Schemerzther; 2008; 43(1); 20-27
6.
Yao; Yao & Artusio’s: Anesthesiology. Problemoriented patient management; 6th ed; Philadelphia, PA; Lippincott Williams & Wilkins; 2008; 767-781
RESUMEN
Los feocromocitomas son tumores neuroendocrinos raros. Los pacientes con feocromocitomas pueden desarrollar complicaciones cardiovasculares letales y otras
complicaciones, especialmente en el marco de procedimientos diagnósticos o intervencionales (ej. durante la inducción de la
anestesia o durante la cirugía). El manejo
perioperatorio de los pacientes con feocromocitomas requiere de un conocimiento
detallado de la fisiopatología y potenciales complicaciones. Este es el caso de un
hombre de 38 años de edad, con historial
de feocromocitoma bilateral e hipertensión
secundaria al mismo, programado para una
adrenalectomía bilateral bajo anestesia
general combinada con anestesia epidural
torácica. Aunque la resección de feocromocitomas bilaterales continúa siendo un reto
para el manejo anestésico, la morbilidad
y mortalidad puede ser disminuida significativamente con tratamiento preoperatorio
con α antagonistas, así como restauración
de volumen, drogas vasoactivas, y estrecho monitoreo intra- y postoperatorio.
ABSTRACT
Evans syndrome is an autoimmune disorder characterized by the simultaneous or sequential development
of autoimmune hemolytic anemia and
immune thrombocytopenia. It may be
primary (idiopathic, or associated with
other diseases. First line therapy is immunosupression. A second line therapy
includes danazol and splenectomy. Rituximab was approved by the Federal
Drug Administration since 1998 for the
treatment of lymphomas. We report a
46-year-old-male Hispanic with Evans
syndrome. He presented with severe
life threatening autoimmune hemolytic
anemia and subsequently developed
autoimmune thrombocytopenia. After
treatment with steroids and rituximab
he remains in remission. This case report supports the use of rituximab in an
adult patient with Evans syndrome.
Adult Evans Syndrome:
Complete Hematologic
Recovery With Steroids
And Rituximab:
Index words: autoimmune, hemolytic,
anemia, Evan syndrome, steroid, rituximab
A Case Report
Karen J. Santiago-Ríos MD
Omayra Reyes MD
Alexis Cruz MD
Nydia Rodríguez-Pabón MD
William Cáceres MD
From the Hematology-Oncology Section, Department of Medicine, VA Caribbean Healthcare System.
Address reprints requests to: Karen Santiago Rios, MD –
Hematology-Oncology section, VA Caribbean Healthcare
System, 10 Calle Casia, San Juan, Puerto Rico 00921 [email protected]
INTRODUCTION
Autoimmune hemolytic anemia (AIHA) is a
process of red-cell destruction secondary to the
production of auto-antibodies. Warm autoimmune
hemolytic anemia is most commonly associated
with the development of IgG that react with protein
antigens on red blood cells (RBCs) at body temperature (1). In many cases, the cause of production of autoantibodies remains idiopathic. A variety
of etiologies for the development of warm AIHA
have been described; malignancies such as CLL,
connective tissue disorders, viral infections, prior
blood transfusions or immunodeficiency disorders
(2). First line therapy is immunosupression, however 10% of patients are non responders and up
to 50% require maintenance therapy. Second line
therapies include splenectomy. Immunosuppressive drugs (azathioprine or cyclophosphamide) may
also reduce the production of auto-antibodies. Indications for the use of these agents include poor
response to steroids, inability to tolerate or the
need of maintenance prednisone. Intravenous gamma globulin (IVIG) is only occasionally effective
in the treatment of refractory autoimmune hemolytic anemia (3). In responders, the effect is usually transient. Although multiple case studies have
demonstrated the effectiveness of anti-CD20 monoclonal antibody rituximab in both children and
adults with refractory AIHA and ES, the majority
of data relates to children (4, 5, 6, 7). Transfusion
of PRBCs is needed if anemia becomes severe
enough to interfere with adequate oxygenation.
Transfusion of fully compatible blood is unlikely,
since autoantibodies usually react with antigens
present commonly in the general donor population. We report a 46 year old male Hispanic with
ES. He presented with severe life threatening
autoimmune hemolytic anemia and subsequently
developed autoimmune thrombocytopenia. He remains in complete hematologic recovery after the
use of steroids and rituximab.
Case History
In May 2008, a 46 year-old male was referred to the emergency room with complains of general malaise and myalgia of four days of evolution
with associated unquantified fever, chills and anorexia. These symptoms were followed by jaundice,
decreased urinary output and dark colored urine.
The patient referred a possible contact with rat urine
when he removed with a shovel a dead rat from his
dog’s cage. He denied recent travel, sick contacts
or change in medication. His past medical history
was remarkable for diabetes mellitus, obesity, hypertension and depression. Physical examination
was remarkable for an obese, alert and oriented
33
male with jaundice. Rectal examination showed
no evidence of gastrointestinal bleeding. Laboratory results were remarkable for a large drop in
hemoglobin (Hgb) levels (from 16.8 g/dL in October 2008 to 7.4 g/dL at time of evaluation on emergency room). CBC was also remarkable for leukocytosis (25.2 cells x103) with immature forms
(bands), nucleated RBC, (Table 1); increased
spherocytes and polychromatophilia on peripheral
smear (Figures 1 and 2). Platelet count was normal
(159 cells x103). Serum chemistry was remarkable for acute renal failure (creatinine 4.60 mg/dl,
BUN 64.7 mg/dl, EGFR 14), hypophosphatemia
(1.5 mg/dL), and hyperbilirubinemia (total bilirubin
13.71 mg/dL) with predominance of indirect bilirubin (8.3 mg/dL). Haptoglobin levels were in 2.7
mg/dL and LDH in 2,854 U/L. (table 1). Blood type
was O positive and blood antibody screen positive
for IgG and C3. Two months earlier the patient had
a normal renal function. An assessment of autoimmune hemolytic anemia was done and the patient
was started on high dose steroids. Despite this
treatment, Hgb levels continue decreasing (4.8 g/
dL). Patient was then started on IVIG. His condition continued to deteriorate due to worsening oliguric renal failure, anemia and hyperbilirubinemia
(Hgb dropped to 3.1g/dl, creatinine increased to
8.71 mg/dL and total bilirubin increased to 19.53
mg/dL). The patient also developed thrombocytopenia (56 cells x103). Platelet antibodies were requested and were reported positive. The patient
required hemodialysis support and blood transfusion. He was continued on IV steroids and gamma
globulin. Three days after starting steroids, there was further decrease of Hgb levels (3.1 g/dL)
and serum creatinine increased to 9.65 mg/dl. For
this reason the patient was started on rituximab
on may 7, 2008 (375 mg/m2 weekly). Leptospira
antibodies were ordered and results were negative (<1:50 by indirect hemagglutinatin assay). HIV
test and ANA panel were also negative. Abdominopelvic CT scan was done, showing evidence of
diverticulitis. Bone marrow aspiration and biopsy
with flow cytometry analysis showed no evidence
of myeloproliferative or lymphoproliferative disorder. He received four doses of rituximab, five days
of IV gamma globulin and one month of prednisone. After completing the fourth dose of rituximab
and eight weeks of hemodialysis there was normalization of renal function , bilirubin, hemoglobin,
haptoglobin and LDH levels. The cause of ES remains idiopathic. Sixteen months after diagnosis,
the patient remains of treatment and in remission.
(Table 2, Figure 3).
DISCUSSION
AIHA is a disorder in which autoantibodies
directed against red blood cells are produced.
34
Approximately 50% of the cases of AIHA are idiopathic. Associated causes of production of autoantibodies to red blood cells are autoimmune diseases, hematologic malignancies, viral infections
(especially in children) and medications. Signs and
symptoms of AIHA may include jaundice, pallor,
tachycardia, low-grade fever, hepatosplenomegaly or lethargy. The clinical syndrome associated
with hemolysis ranges from a rather indolent and
chronic course, to an acute and life threatening
anemia with renal failure requiring hemodyalisis
support, as in this case. If hemolysis is not corrected, pulmonary edema, with myocardial infarction
and arrhythmia may be the final outcome.
Tables 1 and 2: initial laboratories.
WBC
RBC HGB
HCT
MCV MCH
MCHC
RDW
PLT
MPV
BANDS
SEGS
LYMPHS
MONOS
EOSINO
BASO
NRBC
25.2 X10-3
2.5 X10-6
7.4g/dL
21.0%
84fl
29.6uug
35.2gm/dL
15.1 %
159 X10-3
11.5fL
19 %
46 %
18%
10%
4%
0%
5%/WBC
GLUCOSE
BUN
CREA
NA+
K+
CL-
CO2
CPK
EGFR
T BILI
ID BILI
ING PHO
CA++
MG
ALB
HAPTOG
104 mg/dL
64.7 mg/dL
4.60 mg/dL
131 mEq/L
4.8 mEq/L
97 mEq/L
20 mEq/L
466U/L
14 ml/min
13.71mg/dl
8.3 mg/dl
1.5mg/dl
8.6 mg/dl
2.1mg/dl
3.4 G/dl
2.7mg/dl
ES is a rather rare disease in which thrombocytopenia and/or immune neutropenia, develops simultaneously or sequentially with AIHA. It
is characterized by a chronic and relapsing course, and treatment has been variable and sometimes unsuccessful, making its management a
challenge. Current standard treatment consists of
transfusions, corticosteroids, splenectomy, IVIG,
anabolic steroids, vincristine, alkylating agents, or
cyclosporine. However, these treatment options
are often unsuccessful and the may be associated
with serious side effects. (1).
In 1998, the FDA approved the use of rituximab for the treatment of B-cell Non-Hodgkin’s
lymphoma that has not responded to standard
therapies. It is the first monoclonal antibody to be
approved in the United States for the treatment of
cancer. Rituximab has emerged as a promising
treatment for idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia, including
ES. The administration of rituximab causes depletion of B-cells expressing the surface antigen
CD20. The mechanism of action is not completely
understood. However it involves cellular killing
Figure 1.
Peripheral smear with increased spherocytes, polychromatophilia
Figure 3. Graph of hemoglobin and platelet counts over time
Figure 2. Nucleated red blood cells,
increased spherocytes
secondary to the antibody-dependant cellular toxicity and complement activation. In the case described, administration of rituximab
was not associated with adverse events. Rituximab is usually well
tolerated in the setting of AIHA. Reported serious side effects are
rare, but include Pneumocystis carinii pneumonia, varicella pneumonia, Escherichia coli pyelonephritis, neutropenia and progressive multifocal leukoencephalopathy (1,9). Our patient received 4
weekly doses of rituximab (375 mg/m2) without side effects and
continues in remission more than 16 months after diagnosis of hemolytic anemia (Hgb 16 g/dl, platelet 255 cells x103, creatinine
1.47 mg/dL, LDH 197 U/L, total bilirubin .82 mg/dL and haptoglobin
265.8 mg/dl). This case supports the use of rituximab in the setting
of autoimmune hemolytic anemia and ES.
REFERENCES
Table 3. Hemoglobin and platelet
count results before and after treatment
with rituximab (5/08 day 1 of treatment)
1.
Marc Michel, Valerie Chanet, Agnes Dechartres, Anne-Sophie Morin,
Jean-Charales Piette, Lorenzo cirasino, Giovanni Emilia, Francesco Zaja, Marco
Ruggeri, Emmanuel Andres, Philippe Biergi, Bertrand Godeau and Francesco
Rodeghiero. The Spectrum of Evan’s syndrome in adults:new insight into the
disease based on the analysis of 68 cases. Blood 10:1182, 2009
2.
Scwartz RS et al. Autoimmune hemolytic anemias, In Hoffman /r et al,
eds. Hematology: Basic Principles and Practice, 3rd ed. Philadelphia: Churchill
Livingstone:60, 2000
3.
Bradley C. Gehrs and Richard C. Friedberg. Autoimmune Hemolytic
Anemia. American Journal of Hematology 69:258-271, 2002
4.
Flores, G, Cunningham-rundles, c, Newland, AC, et al. Efficacy of intravenous immunoglobulin in the treatment of autoimmune hemolytic anemia:
Results in 73 patients. American Journal of Hematology 44:237, 1993
5.
S. Ramanathan, J Koutts, and M. S. Hertzberg. Two cases of refractory
autoimmune hemolytic anemia treated with rituximab. American Journal of Hematology 78:123-126, 2005
6.
Bussone G, Ribeiro E, Dechartres, A, et al. Efficacy and safety of rituximab in adult’s warm antibody autoimmune hemolytic anemia: retrospective
analysis of 27 cases. American Journal of Hematology 84:153, 2009
7.
Marco Zecca, Bruno Nobili, Ugo Ramenghi, Silverio Perrotta, Giovanni
Amendola, Pasquale Rosito, Momcilo Jankovic, Paolo Pierani, Piero De Stefano, Mario Regazzi Bonora, and Franco Locatelli. Rituximab for the treatment of
refractory autoimmune hemolytic anemia in children. Blood 101:3857, 2003
8.
Monica Morselli, Mario Luppi, Leonardo Potenza, Luca Facchini, Stefania Tonelli, Daniele Dini, Giovanna Leonardi, Amedea Donelli, Franco Narni and
Giuseppe Torelli. Mixed warm and cold autoimmune hemolytic anema: complete recovery after 2 courses of rituximab treatment. Blood 99: 2478-3479,2002
35
Educación
Médica
Continua
9.
Kenneth R. Carson, Andrew M. Evens, Elizabeth a.
Richey, Thomas M. Habbermann, Daniele Focosi, John F. S
Seymour, Jacob Laubach, Susie D. Bawn, Leo I. Gordon,
Jane N. Winter, Richard R. furman, Julie M. Vose, Andrew
D. Zelenetz, ronac Mamtani, Dennis W. Raisch, Gary W.
Dorshimer, Steven T Rosen, Kenji Muro, Numa R. GottardiLittell, Robert L. Talley, Oliver Sartor, David Green, Eugene
O. Major, and Charles L. Bennett. Progressive multifocal
leukoencephalopathy after rituximab therapy in HIV-negative
patients: a report of 57 cases from the Research on Adverese Drug Events and Reports project. Blood, 113:4834-4840,
2009.
RESUMEN
El síndrome de Evans es un desorden
autoinmune caracterizado por el desarrollo
simultáneo de anemia hemolítica y trombocitopenia autoinmune. Puede ser primario
(idiopático) o asociado a otras condiciones La
primera línea de terapia es inmunosupresión.
La segunda línea de terapia incluye danazol
y esplenectomía. Rituximab se aprobó por la
Administración Federal de Drogas en el 1988
para el manejo de linfomas. Reportamos un
paciente varón hispano de 46 años con síndrome de Evans. Debuto con anemia hemolítica autoinmune severa y subsiguientemente
desarrollo trombocitopenia autoinmune. Luego de manejo con esteroides y rituximab se
encuentra en remisión. Este reporte de caso
ilustra el uso exitoso de rituximab en el manejo de un paciente adulto con síndrome de
Evans.
Es tiempo
de decisiones
Mantengase informado visitando
periódicamente nuestro website
www.asociacionmedicapr.org.
Registros Electrónicos de
Salud y mucho más
ABSTRACT
In this report, we describe a
patient with Follicular Lymphoma
with central nervous system involvement, rarely reported in indolent lymphomas. Central nervous
system involvement in indolent
non-Hodgkin’s lymphoma is a rare
and unexpected complication and
should be considered in the differential diagnosis of patients presenting with de-novo neurological
signs.
Central Nervous System
Involvement By Follicular
Lymphoma:
Index Words: central nervous system, indolent non-Hodgkin’s lymphoma
A Case Report
Liza Paulo Malave MD *
William Caceres MD*
From the * Hematology-Oncology Section, VA Caribbean
Healthcare System, San Juan, Puerto Rico.
Address reprint request to: Liza Paulo Malave MD, Jardines del Parque Apto # 5004 Parque Escorial Carolina,PR
00987 E-mail: [email protected]
INTRODUCTION
Central nervous system (CNS) involvement is
a well recognized complication of aggressive nonHodgkin’s lymphoma (NHL) rarely reported in indolent lymphomas. 1The central nervous system
(CNS) becomes involved after non-Hodgkin’s lymphoma (NHL) in about 8 % of patients, but rarely
after follicular lymphoma.3 It has been estimated
that this complication occurs in 3% of low-grade
lymphomas.1 Serum lactate dehydrogenase (LDH)
concentrations over twice the normal, bone marrow involvement and stage IV disease are known
risk factors for CNS involvement. 3 Early studies
have showed that patients with Burkitt’s and lymphoblastic lymphoma,4 certain subtypes such as
testicular lymphoma or lymphoma involving the
paranasal sinuses encompass a high risk of CNS
involvement,1 and over the years, effective CNS
prophylaxis strategies for these diseases have
been developed.4 There is currently no recommendations regarding prophylactic treatment or
staging examinations to rule out CNS involvement
in indolent lymphoproliferative disorders. We report a patient with indolent stage IV follicular lymphoma, grade 1, who developed CNS involvement
while receiving treatment for systemic lymphoma.
Case History
A 49 year-old man with a past medical history
of hypertension was diagnosed by biopsy of retroperitoneal mass lymph nodes with Stage IV Follicular lymphoma, grade 1, in November 2008 (see
Figure 1). Inmunoperoxidases stains performed to
confirm the above diagnosis included CD79 and
CD43 which were focally positive in germinal center
and interfollicular region, BCL-2: strongly positive
Figure 1. CT-scan of the abdomen showing large soft tissue density within the retroperitoneum, just anterior to the
aorta, suggestive of large nodular lesions.
in germinal center and BCL-6: focally positive in
germinal center. Initial chemotherapy was provided with the R-CHOP regimen. R-CHOP includes
Rituximab, Cyclophosphamide, Hydoxydaunorubicin (doxorubicin), Oncovin (vincristine) and
Prednisolone. The patient came to our institution
in January 2009 with neurological symptoms suggestive of a CNS disease. History and physical
examination disclosed nuchal rigidity, unquantified
fever, nausea, disorientation and headaches. CT
scan of the brain without contrast was negative
for intracranial bleeding or hemorrhage. A lumbar
puncture was done for diagnosis and CSF sample studies results were consistent with malignant
lymphoid cells (see Figure 2). Flow cytometric
analysis of the CSF fluid using CD45 vs. log side
scatter gating revealed a population of neoplastic lymphocytes with B-cell phenotype; positive for
CD19 and CD20. The neoplastic cells expressed
37
CD10 and were negative for CD5, CD34, CD3,
and CD2. The patient was treated with Intrathecal
chemotherapy with high dose Methotrexate plus
cytarabine twice weekly. Patient only received two
intrathecal chemotherapy due to development of
a cardiorespiratory arrest during his hospital stay,
requiring prolonged ACLS and endotracheal intubation. Patient was declared dead on January
2009.
DISCUSSION
CNS involvement in indolent NHL does
exist, although it is a rare complication, and the literature is scarce. We presented a patient with Indolent stage IV follicular lymphoma, grade 1, who
developed CNS involvement.
CNS involvement after follicular lymphoma
is extremely rare, in fact there are only a few case
reports in the literature. 2 According to available
literature CNS involvement after FLCL carries a
poor prognosis as confirmed by our case. 2 Our
patient had a poor response to treatment with a
survival of approximately three months.
Considering that CNS involvement in indolent lymphoma is a rare complication, it will continue to be an unexpected occurrence. Due to it’s
rarity and studies showing low risk of CNS recurrence,5 there still no place for prophylactic CNS
chemotherapy for patients with these disorders. In
conclusion, central nervous system involvement
by Follicular Lymphoma should be considered in
the differential diagnosis of new neurological signs
and symptoms in patients with FLCL.
Figure 2. Lymphoma cells in cerebrospinal fluid.
REFERENCES
RESUMEN
1.
G.Spectre, A. Gural, G.Amir, A. Lossos. Central nervous system involvement in indolent lymphomas. Annals of
Oncology 2005; 16: 450-455
2.
Tomita N. Kodama F. Sakai R. Predictors factors for
central nervous system involvement in non-hodgkin’s lymphoma: significance of very high serum LDH concentrations.
Leuk Lymphoma 2000;38:335-343
3.
Luca Laurenti, Simona Sica, Maria Teresa Voso.
Central nervous system involvement after follicular large cell
lymphoma. Haematologica 2001; 86:99
4.
Steven H. Bernstein, Joseph M. Unger. Natural
History of CNS Relapse in Patients with Aggressive NonHodgkin’s Lymphoma: A 20-year Follow Up Analysis of
SWOG 8516-The Southwest Oncology Group 2009; 37:114119
5.
A. Hollender, S. Kvaloy, O.Nome. Central Nervous
System Involvement following diagnosis of non-Hodgkin’s
Lymphoma: a risk model. Annals of Oncology 13:1099-1107,
2002
En este reporte, describimos a un
paciente con Linfoma Folicular con envolvimiento del Sistema Nervioso Central, raramente reportado en linfomas indolentes.
Envolvimiento del Sistema Nerviosos Central en linfomas indolentes no-Hodgkin’s es
raro y una inesperada complicación la cual
debe ser sospechada y considerada en el
diagnostico diferencial de pacientes con
signos neurológicos de novo.
38
ABSTRACT
We describe two adult cases of neurologic complications occurring after the administration of the influenza vaccine. The first
case described is a 68 year-old man who experienced paresthesias of the upper and lower
extremities two weeks after vaccination, and
the second case was a 64 year-old female
who exhibited paraplegia eighteen days after
vaccination. Diagnosis of acute idiopathic demyelinating polyradiculopathy (Guillain-Barré
syndrome) was made for both patients, and
intravenous gammaglobulin therapy was given
with marked improvement of the first case, but
poor response on the second case. Although
the efficacy of influenza vaccination has been
widely accepted, such neurologic complications might occur in the elderly and adult population. Even if Guillain-Barré syndrome was a
true side effect of vaccination, the risk is substantially lower than is the risk for complications
following influenza. The rare occurrence of
neurological complications after influenza vaccine should not discourage against the vaccination.
Key words: acute inflammatory demyelinating
polyradiculoneuropathy, influenza vaccine,
Guillain-Barré Syndrome, side effects.
Guillain-Barre
Syndrome After
Influenza
Vaccine
Administration:
Two Adult Cases
Valerie Bedard Marrero MD
Ramón L. Osorio Figueroa MD
Orlando Vázquez Torres MD
From the Department of Medicine, Ponce School of Medicine, Ponce, Puerto Rico.
Address reprints requests to: Valerie Bedard Marrero MD
- Urb. Constancia calle San Francisco #2879 Ponce PR
00717. E-mail: [email protected]
Presented at the “45th Scientific Conference Dr. Americo
Serra”, Ponce School of Medicine, Ponce, Puerto Rico, April
25, 2008, and “Ponce School of Medicine 4th Scientific Conference”, Ponce, Puerto Rico, June 7, 2008.
INTRODUCTION
the patient had decreased sensation confined to
the lower extremities, and initial laboratory work
up was within normal limits, including a brain CT
Scan. The patient was admitted for further evaluation due to the rapid progression of symptoms and
findings, which later included respiratory difficulties and the inability to void. At this time physical
examination included a decreased sensation in
the distribution of cranial nerve V, from V1 to V3
on the left side, with a decreased corneal and gag
reflexes. There was a flaccid paralysis in all four
extremities as well. A presumptive diagnosis of
GBS was established. Prophylactic intubation was
performed and the patient was started on intraveCASE REPORTS
nous immunoglobulins for five days. A positive re
Patient 1 was a 68-year-old man presen- port for IgG Anti-GM 1 Ab supported the diagnosis
ting to our institution with tingling sensation of of GBS. Patient improved significantly, regaining
hands and feet of two days of evolution. He had some strength and sensation, and he was no lona past medical history significant for hypertension ger mechanical-ventilator dependant.
and, upon questioning, he refers receiving the inPatient 2 was a 64-year-old woman presenfluenza vaccination by his primary care physician two weeks prior to the onset of symptoms. The ting to our institution with the chief complaint of epirest of the review of systems was unremarkable gastric pain of one day of evolution. She had a known
or otherwise non-contributory. On physical exam past medical history of coronary artery disease,
Guillain-Barré Syndrome (GBS) is a heterogeneous grouping of immune-mediated processes generally characterized by motor, sensory,
and autonomic dysfunction, predominantly caused by T cells directed against peptides from the
myelin proteins P0, P2, and PMP22 of the oligodendrocytes (11). Although GBS is generally acknowledged as a post-infection illness, seldom
has vaccination been found to cause GBS (1, 2, 4,
5). Here, we report two cases of geriatric patients
who suffered from neurologic complications after
the administration of the influenza vaccine.
39
diabetes mellitus, asthma, severe diabetic neuropathy and chronic low back pain. Further questioning revealed that patient had received influenza
vaccination by her primary care physician eighteen
days prior to the onset of symptoms. The rest of
the review of systems was unremarkable and on
physical examination the patient had tenderness to
palpation on the epigastric, left and right upper quadrants of the abdomen for which she was admitted.
Initial laboratory work up, including amylase and
lipase levels, came back within normal limits. An
upper endoscopy revealed gastritis and esophagitis. Up to this point patient was neurologically intact. Three days later she developed generalized
weakness and shortness of breath. Physical examination at that time showed deep tendon reflexes
+1 in upper extremities and absent in lower extremities. The strength was symmetrically decreased,
2/5 in all four extremities. Electromyogram (EMG)
was performed, showing extremities denervation
due to 80% axonal loss. Lumbar puncture yielded
a cerebro-spinal fluid (CSF) with 268.2 mg/dL of
proteins, 172 mg/dL of glucose, and 1 WBC. The
diagnosis of GBS syndrome was established and
intravenous immunoglobulin therapy started. The
patient’s condition continued to deteriorate and
progressed to quadriplegia and respiratory failure
requiring mechanical ventilation. C. jejuni Ab and
stool for Shigella, Salmonella and E. coli were all
negative, as well as titers of EBV, Influenza A & B,
Enterovirus, Parainfluenza I, II & III and Echovirus.
The patient remained dependant on mechanical
ventilator with minimal motor improvement upon
discharge home.
DISCUSSION
In our first case, the patient presented with
a better outcome after the administration of intravenous immunoglobulins (IVIG) with slow but sustained improvement of sensory and motor deficit,
leading us to the presumptive diagnosis of Acute
Inflammatory Demyelinating Polyradiculoneuropathy (AIDP) subtype of GBS based on the IgG
Anti-GM 1 Ab results, physical examination and
history. Nevertheless, CSF analysis and EMG studies, which would have aid in the certain diagnosis
of GBS in this case, were not performed. In the
second case, recovery of the sensory and motor
functions was never achieved despite the immunotherapy and physical therapy. The diagnosis of
Acute Motor Axonal Neuropathy (AMAN) subtype
of GBS was then very suggestive based on the
results obtained and the poor clinical progression,
lumbar MRI, cerebrospinal fluid analysis, immunologic and EMG studies.
years (90%) and those with chronic medical conditions (10). The influenza vaccine is administered
annually during the fall season in areas having a
temperate climate and particularly to those above
65 years, with high risks to develop lower respiratory tract infections, with underlying chronic medical
conditions, such as chronic obstructive pulmonary
disease, severe asthma, and congenital heart problems, among others. Some studies suggests that
the vaccination among elderly persons in the community, the Trivalent Influenza Vaccine (TIV) is 3070% effective in the prevention of hospitalizations.
Among elderly persons in nursing homes, the TIV
is 50% - 60% effective in preventing hospitalization and pneumonia, 80% effective in preventing
death, and 30% - 40% preventing influenza illness
(12). In 1994, Nichol et al, stated that the influenza
vaccination reduced hospitalization due to CHF by
37% and was 54% effective in reducing mortality
from all causes (3). Of the cases discussed here,
age and severe asthma respectively, were the indications for administration of the vaccine.
There has been some concern that certain
immunizations might trigger GBS in susceptible
individuals. Schonberger et al, mentioned an increased incidence of the syndrome after the association with the A/New Jersey “swine influenza vaccine”, that was notable for a relative risk of GBS
ranging from 4.0 to 7.6 (1). Lasky et al, in a retrospective case study of the combined 1992–93 and
1993–94 vaccine campaigns in the USA, identified
a marginally significant, very small increase in the
risk of GBS of one case per million vaccines above background incidence (2).
To determine the risk of acquiring a neurological complication after the administration of
the influenza vaccine is a very difficult task, which
arise the inquiry of the possibility of an immunological predisposition among patients receiving the
vaccine. The mechanism of autoimmune reactions
following immunization has not yet been elucidated. One of the possibilities is molecular mimicry;
when a structural similarity exists between some
viral antigen and a self-antigen. This similarity may
be the trigger to the autoimmune reaction (6). Our
cases had underlying chronic diseases, only the
second case, had more advanced comorbidities,
such as diabetic neuropathy and chronic back
pain, that might be related to an underlying immunological status that predispose the patients to
such reaction.
Another issue to be considered on the relationship between the influenza vaccine and GBS
is the endotoxin concentration in the content of
Influenza and pneumonia comprise the 6th the vaccine. Mark R. Geier examined contents of
leading cause of death in the United States and influenza vaccines of different manufactures from
the 5th leading cause among adults age above 65 1991-1999 of those cases reported to the Vaccine
40
Adverse Events Reporting System (VAERS). There was an increase risk of acute GBS (RR 4.3) and
severe GBS (RR 8.5) in comparison to an adult Td
vaccine control group. Influenza vaccines contained from a 125 to 1250-fold increase in endotoxin
concentrations in comparison to an adult Td vaccine control. Endotoxin concentrations varied up to
10-fold among different lots and manufacturers of
influenza vaccine (5).
Even if GBS was a true side effect of vaccination, the risk is substantially lower than is the
risk for complications following influenza. Therefore, the rare occurrence of the complications
and the possibility of neurological complications
after influenza infection should not discourage us
against vaccination. Special considerations should
be undertaken on those patients who are at more
risks of presenting these rare side effects (eg.
Previous GBS, Multiple Sclerosis, egg allergies,
etc.), following the guidelines of CDC and FDA.
Even though adult cases with GBS after influenza vaccination are rare, if a person shows some
neurological signs after the vaccination the home
doctor should still refer the patient to a neurologist
as soon as possible.
Though we reaffirm ourselves that the small
risk of GBS following vaccination should not discourage us from recommending it to our patients
at risk, the question arises as to what is the incidence of influenza in Puerto Rico, and how at risk
we really are. Influenza is a condition common to
temperate climates, which is not the case of our
region. If influenza is not, in fact, as prevalent in
Puerto Rico, the small risk of GBS associated to
influenza vaccine maybe is not that small after all
for us.
REFERENCES
(1)
Schonberger LB, Bregman DJ, Sullivan-Bolyai JZ,
et al. Guillain - Barré syndrome following vaccination in the
National Influenza Immunization Program, United States,
1976-1977. Am J Epidemiol 110: 105-123,1979.
(2)
T. Lasky, G.J. Terracciano, L. Magder, et al. The Guillain-Barre syndrome and the 1992–1993 and 1993–1994 influenza vaccines, N. Engl. J. Med. 339 (1998) 1797–1802.
(3) Nichol KL, Margolis KL, Wuorenma J, Von Sternberg TL. The efficacy and cost effectiveness of vaccination
against influenza among elderly persons living in the community. N EnglJ Med. 1994;331:778-784.
(4) Penina Haber, MPH Frank DeStefano, MD, MPH
Fredrick J. Angulo, DVM, PhD et al. Guillain-Barré Syndrome Following Influenza Vaccination. JAMA, November 24,
2004—Vol 292, No. 20
(5) Mark R. Geier,a, David A. Geier,b and Arthur C. Zahalskyc Influenza vaccination and Guillain Barre syndrome
Clinical Immunology 107 (2003) 116–121
(6) Y. Shoenfeldf1 and A Aron-Maor Vaccination and
Autoimmunity—‘vaccinosis’: A Dangerous Liaison? Journal
of Autoimmunity Volume 14, Issue 1, February 2000, Pages
1-10
(7) John D. Grabenstein, RPh, PhD, FASHP .GuillainBarré Syndrome and Vaccination: Usually Unrelated. Immunologic Pharmacopeia Volume 36, Number 2, pp 199–207
2000
(8) Naoko Nakamura, Kazuya Nokura, Takaaki Zettsu,
et al. Neurologic Complications Associated with Influenza
Vaccination: Two Adult Cases. Internal Medicine Vol. 42, No.
2 (February 2003)
(9) Richard Kent Zimmerman MD, MPH, Recent changes in influenza vaccination recommendations, 2007. The
Journal of Family Practice. February 2007, Vol 56, No 2
(10)
Richard A C Hughes, David R Cornblath. GuillainBarré syndrome. Lancet 2005; 366: 1653–66
(11) http://www.cdc.gov/FLU/PROFESSIONALS/VACCINATION/effectivenessqa.htm. Centers for Disease Control and Prevention, Flu Vaccine Effectiveness: Questions
and Answers for Health Professionals
RESUMEN
Describimos los casos de dos pacientes adultos que presentaron complicaciones neurológicas luego de la administración de la vacuna contra la influenza de temporada. El primer
caso describe a un paciente masculino de 68 años de edad el cual presentó parestesias de las
extremidades superiores e inferiores dos semanas después de la administración de la vacuna,
y el segundo caso descrito es de una fémina de 64 años de edad quien presentó paraplegia 18
días después de la administración de la vacuna. El diagnóstico de Poliradiculopatía Demielinizante Idiopática Aguda fue establecido para ambos pacientes, y tratamiento con gamaglobulinas
intravenosa fue iniciada con una mejoría marcada en el primer caso, pero una respuesta pobre
fue observada en el segundo caso. Aunque la eficacia de la vacuna contra la influenza de temporada ha sido ampliamente aceptada, estas complicaciones neurológicas pueden ocurrir en los
ancianos y en la población adulta. Aún cuando el Síndrome de Guillain-Barré fuera un efecto secundario real de la vacuna contra la influenza, el riesgo de padecerlo es substancialmente menor
que los riesgos de complicaciones al contraer la influenza. Por lo tanto, aún cuando rara vez se
podrían presentar complicaciones neurológicas luego de la administración de la vacuna, esto no
debe desalentarnos sobre la vacunación.
41
Macklin Effect As
Potential
Responsible
Complication After
Retrograde
Intubation:
A Case Report
Normidaris Rodríguez MD
Víctor Cardona MD
From the Department of Anesthesia, U.P.R. School of Medicine.
Address reprints requests to: Normidaris Rodriguez MD –
Department of Anesthesia, 9th floor, UPR School of Medicine, PR Health Science Center, Rio Piedras, PR 00936. Email [email protected].
ABSTRACT
Retrograde intubation is currently
part of the Difficult Airway Algorithm of the
American Society of Anesthesiologists, and
as such, every anesthesiologist should be
competent in this procedure. Nevertheless,
when performing it, one must be aware that
it is not exempt of complications. We review
the case of a patient who, after being intubated using this technique, developed signs
and symptoms compatible with the Macklin
effect. Macklin effect involves a three-step
pathophysiologic process: blunt traumatic
alveolar rupture, air dissection along bronchovascular sheaths, and spreading of this
blunt pulmonary interstitial emphysema into
the mediastinum.
Index words: Macklin, effect, complications,
retrograde, intubation
INTRODUCTION
Case History
In the practice of anesthesiology, one of the
biggest challenges one can face is the management of the difficult airway. History and physical
examination can lead to the prediction of having
a hard time with an airway, but in many cases,
surprise can arise. The American Society of Anesthesiologists (ASA) has established the algorithm
for the difficult airway. The Difficult Airway Algorithm of the American Society of Anesthesiologists
(ASA) (see Figure 1) was developed to guide clinicians in the management of the patient who is
either predicted to have a difficult airway or whose
airway cannot be adequately managed after induction of anesthesia1. A difficult airway is defined
as the clinical situation in which a conventionally
trained anesthesiologist experiences difficulty with
face mask ventilation of the upper airway, difficulty
with tracheal intubation, or both2. Included in the
Difficult Airway Algorithm is the option of retrograde intubation, which as in any procedure, complications are not uncommon. Retrograde intubation
is an excellent technique for securing a difficult
airway alone or in conjunction with other alternative airway techniques3. We report the case of a
patient who was intubated using this technique
and developed during his hospitalization a complication of which we believe was the result of the
Macklin effect.
A 24-year-old male patient, 65 kg, was
taken to the operating room to undergo maxillofacial surgery. The patient was involved in an aggression fight the night before surgery, resulting
with extensive facial trauma. He had past medical history of bronchial asthma, as well as chronic
smoker. Upon arrival to the pre-anesthesia area
the physical examination of the patient revealed
multiple hematomas on cervical area. The patient
also was unable to extend the neck and would
open his mouth less than one cm due to an associated mandibular fracture. Initially, awake fiberoptic intubation was considered, but upon further
evaluation, he was still bleeding from multiple oral
sites and abundant bloody fluids were present in
his oral cavity. We then decided to proceed with
retrograde intubation. After preoxygenation with
100% oxygen, induction was made with Fentanyl 200 mcg, propofol 120 mg, and succinylcholine
100 mg. Retrograde intubation was successful on
first attempt, obtaining wire out of the right nostril
while a cuffed ETT 6.5 Fr passed through his trachea, with positive capnogram wave, and bilateral
breath sounds on auscultation, without acute complications. Surgery was performed – bilateral mandibular open reduction and internal fixation – on
a total time of 80 minutes. Patient was extubated
afterwards at the operating room and taken to the
42
Post-Anesthesia Care Unit (PACU) hemodynamically stable, and in no distress. Patient was discharged from the PACU to his room two hours after arriving without complains, completely stable
with 100% peripheral saturation at room air. The
next morning at physical examination patient was
noticed to have subcutaneous emphysema. By
the evening patient started to complain of pleuritic
chest pain, mild shortness of breath, and subcutaneous emphysema was more extensive. Chest
x-ray performed showed pneumomediastinum with
subcutaneous emphysema. A Venturi mask with
50% oxygen was placed, and patient remained with
peripheral saturations above 95% throughout the
night. The next morning, as symptoms persisted,
and patient still complained of chest pain, a chest
CT-scan was done which showed subcutaneous
emphysema, pneumomediastinum, pneumoperitoneum, and bilateral small penumothorax. Symptoms started to resolve on the second postoperative
day, weaning the supplemental oxygen. On postoperative day #3, patient was free of pain, reporting
no shortness of breath, and subcutaneous emphysema was partially resolved. He was discharged on
post-operative day #4, and on follow-up one week
later, he stated being asymptomatic.
the needle used might be large enough to produce
a leakage of air that could spread via the mediastinum in the retrocardium, producing spontaneous
pneumomediastinum, and dissecting retroperitoneally into the abdomen, causing the finding of
pneumoperitoneum. This is the same mechanism
how pneumoperitoneum can be identified in patients with ruptured pulmonic blebs. Spontaneous
pneumomediastinum is often referred to as respiratory pneumomediastinum because it is caused by
leakage of air from the respiratory tract. This leakage is the result of alveolar wall rupture secondary
to high intra-alveolar pressure caused by artificial
ventilation7, and in the case of our patient, he did
have the period of mechanical ventilation while he
was undergoing surgery.
The CT-scan done during his hospitalization
also helped the primary physician to exclude other
causes of pneumomediastinum (see Figures 2 and
3). Studies have shown that the Macklin effect can
frequently be demonstrated in patients with spontaneous pneumomediastinum of non-traumatic respiratory causes by CT-scans7.
DISCUSSION
The Macklin effect is described after blunt
traumatic pneumomediastinum but also in pneumomediastinum arising in various conditions, such
as neonatal respiratory distress syndrome, asthma
crises, positive-pressure mechanical ventilation,
and Valsalva maneuvers. A case of spontaneous
pneumopericardium and pneumomediastinum
after alcohol-induced emesis is reported4. Besides, in the literature there are two cases of subcutaneous emphysema described associated with
pneumomediastinum after general anesthesia in
which there was a high suspicion that the phenomena resulted from alveolar rupture with Macklin
effect5. As in our case, close observation is the best
management strategy. The Macklin effect is associated to a three-step pathophysiologic process: 1)
blunt traumatic alveolar ruptures, 2) air dissection
along bronchovascular sheaths, and 3) spreading
of this blunt pulmonary interstitial emphysema into
the mediastinum, peritoneum and neck/chest subcutaneous tissue6. Alveolar rupture is followed by
centripetal dissection of the released alveolar air
through the pulmonary interstitium along the peribronchovascular sheaths into the mediastinum.
This pathophysiologic process was first described
by Macklin in 19397.
In our case, the air dissecting through the
soft tissue of the neck might be secondary to penetration of the trachea with the needle at the time of
the retrograde intubation. Although the procedure
was successful after the first attempt, the gauge of
CONTINUE IN PAGE 46
REFERENCES
1. Rosenblatt WH, Whipple J: The Difficult Airway Algorithm
of the American Society of Anesthesiologists. Anesth Analg
2003; 96:1233.
2. Practice Guidelines for Management of the Difficult Airway,
an Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology 2003; 98:1269-77.
3. Hagberg CA: Current Concepts in the Management of the
Difficult Airway, Vol 29. The American Society of Anesthesiologists, Inc.
4. Ring A, Liebert T, Stern J: Pneumopericardium after hyperemesis: Possible result f the Macklin effect. Chirurg 2009,
Mar 4.
5. Chang YY, Yien HW, Hseu SS, Chan KH, Tsai SK: Subcutaneous emphysema associated with pneumomediastinum
after general anesthesia. Official Journal of the Taiwan Society of Anesthesiologists 2005; 43:99-103.
6. Wintermar M, Schnyder P: The Macklin Effect. Chest
2001; 120:543-547.
7. Sakai M. Murayama S, Gibo M, Akamine T, Nagata O:
Frequent Cause of the Macklin Effect in Spontaneous Pneumomediastinum, Demonstration by Multidetector-Row Computed Tomography. Journal of Computer Assisted Tomography 2006; 30 – Issue 1:92-94.
RESUMEN
In conclusion, when performing retrograde
intubation, every physician must be aware of the
potential complications that can arise. Risks and
benefits must be measured, as for every patient having a secure airway is of utmost importance. Retrograde intubation is simple, straightforward, and
should be skill-maneuver by every anesthesia care
provider. It is especially useful in patients with cervical C-spine injuries, abnormal anatomy, or who
have suffered airway trauma3. This case demonstrate that Macklin effect can be a potential responsible complication after retrograde intubation.
La intubación retrógrada es parte del
algoritmo de vía aérea difícil de la sociedad
estadounidense de anestesiólogos, y como
tal, todo anestesiólogo debería poder ser
competente en este procedimiento. No obstante, al realizarlo, uno debe estar al tanto de
que no está exenta de complicaciones. Presentamos el caso de un paciente que, después de que se intubara utilizando esta técnica, desarrolló signos y síntomas compatibles
con el efecto de Macklin. El efecto de Macklin
ocurre después de un proceso patofisiológico de tres pasos: ruptura traumática de los
alveolos, disección de aire a lo largo de las
vainas broncovasculares, y la difusión del enfisema intersticial hacia el mediastino.
El proyecto de tecnología
informática de salud de la AMPR abarca
no sólo eHr sino múltiples servicios
adicionales
ABSTRACT
Wandering spleen is a rare birth defect
characterized by absence or weakness of one
or more of the ligaments that hold the spleen in
its normal position. In this report we present the
case of a 6-year-old girl admitted with diffuse
abdominal pain, fever and emesis. Ultrasound
and CT scan revealed the spleen was not found
in its normal anatomical position. An enlarged
spleen was identified displaced anteriorly and
inferiorly at the L3 to L5-S1 level. Doppler ultrasonography of the splenic vessels revealed
no blood flow consistent with infarction. Patient
was taken to the operation room for a laparoscopic splenectomy. Treatment of choice for
splenoptosis is surgery, either splenopexy or
splenectomy. Decision to perform splenopexy
or splenectomy depends on the viability of the
spleen after detorsion. If the spleen appears
infarcted, a splenectomy should be performed.
Splenopexy is a reasonable option when the
spleen appears viable after detorsion.
Laparoscopic
Splenectomy For
Infarcted
Splenoptosis
In A Child:
A Case Report
Jorge Carmona MS*
Humberto Lugo Vicente MD**a
From the * UPR School of Medicine, and the ** Section of
Pediatric Surgery, Department of Surgery, UPR School of
Medicine, Puerto Rico Health Science Center, Rio Piedras,
Puerto Rico.
Address reprints request to: Humberto Lugo-Vicente MD,
PO Box 10426, San Juan, PR 00922. Email: [email protected]
Index words: splenoptosis, laparoscopic splenectomy
INTRODUCTION
Case Report
The spleen is a solid organ located in the left
upper quadrant of the abdomen. It is the largest collection of lymphoid tissue in the body. The spleen
removes and filters out unnecessary or foreign material; breaks down and eliminates worn out blood
cells; and produces white blood cells, which aid the
body in fighting infections. Rotation of the stomach and growth of the dorsal mesogastrium translocate the spleen from the midline to the left side
of the abdominal cavity (1). Rotation of the dorsal
mesogastrium establishes a mesenteric connection, the splenorenal ligament, between the spleen
and the left kidney (1). The gastrosplenic ligament
is the portion of the dorsal mesentery between the
spleen and the stomach. Two avascular ligaments,
the lienophrenic and lienocolic further fix the spleen
to the diaphragm and colon respectively. There is
a wide variety of congenital and acquired anomalies of the spleen, such as: asplenia, splenomegaly,
accessory spleen, polysplenia, and splenoptosis
or “wandering spleen” (1). Some of these variants
have no clinical significance. On the other hand, an
anomaly such as splenoptosis may present as an
acute abdomen due to torsion and splenic infarction.
A 6-year-old girl was admitted to the University Pediatric Hospital with two days history of
diffuse abdominal pain, fever and emesis. Physical examination revealed the patient had diffuse abdominal tenderness and a palpable midline
mass below the umbilical level. Hematological
and biochemical investigations showed leukocytosis (WBC 16.3) and anemia (Hgb 8.4 gm/dl).
CT-Scan of the abdomen and pelvis was
performed showing an enlarged spleen measuring approximately 15 cm x 7.4 cm x 7.3 cm displaced anteriorly and inferiorly at the L3 to L5-S1
level. Coiling appearance of the splenic hilum was
suggested. CT scanning also revealed ascites
and a calcific density in the gallbladder bed. All
other abdominal organs were unremarkable. Abdominal ultrasonography with Doppler was then
performed to examine blood flow to the ectopic
spleen. Visualized sections of the spleen showed
homogeneous echotexture and color flow interrogation was not successful, consistent with splenic
infarction. Patient was prepared on an urgent basis for surgery.
47
Preoperative antibiotics and hydration were
given. Under general anesthesia the child was
placed in a right semilateral position with kidney
flexion using four trocars technique. During the
laparoscopic procedure, the infarcted spleen was
attached only to a twisted pedicle. Using an endovascular gastrointestinal stapler the pedicle was
clamped and divided. Next the spleen was placed
inside an endoscopy bag and removed from the
abdominal cavity morcellated.
The patient remained stable during hospital
stay with no acute distress, abdominal pain, and/
or distention. Child received triple immune prophylaxis against post-splenectomy sepsis. She
was discharged home three days later.
B infections is recommended in elective cases
(6).
The decision to perform splenopexy or
splenectomy depends on the viability of the spleen
after detorsion (7). If the spleen appears infarcted,
a splenectomy should be performed. Laparoscopic splenectomy can be performed by two approaches: anterior and semilateral (4). In the anterior
approach the patient is in the supine position and
retraction of the spleen must be performed against
the force of gravity, which leads to more capsular
tears, increased blood loss, transfusion rates, and
conversion rates (4). The main advantage of this
approach is that other surgeries can be performed
at the same time without changing position. The
semilateral approach is also known as the “hanging spleen technique”. It is the preferred approDISCUSSION
ach by most surgeons (4). The patient is placed
Wandering spleens are mainly found in in the right semilateral decubitus position forcing
children and women aged 20 to 40 years old (2). the spleen to hang from the diaphragm so that the
Congenital wandering spleen is a very rare birth dorsal side of the spleen can be easily exposed
defect characterized by the absence or weakness and the perisplenic ligaments dissected under diof one or more of the ligaments (e.g., the gastros- rect vision (4). This approach gives a clear view
plenic and splenorenal ligaments) that hold the of the pancreas; hence injuries to the tail of the
spleen in its normal position in the left upper qua- pancreas are reduced significantly.
drant of the abdomen (3). Acquired “wandering”
Splenopexy is a reasonable option when
spleen may occur in adulthood due to injuries or underlying conditions that may weaken the liga- the spleen appears viable after detorsion and the
ments that maintain the spleen in its normal po- splenic vein is not thrombosed (7). Splenopexy can
sition in the left upper quadrant (e.g., connective be achieved by creating an extraperitoneal pocket
tissue disease, pregnancy, trauma, and surgery). or wrapping the spleen in absorbable mesh and
Instead of ligaments, the spleen is attached by the anchoring it to the retroperitoneum (8). The extravascular pedicle. If the pedicle becomes twisted peritoneal space is created by using an inflatable
for any reason, the blood supply may be interrup- balloon device. The spleen is then introduced and
ted or blocked to the point of splenic infarction. positioned inside the created pocket. A laparoscoSymptoms and signs of splenic torsion are very pic “sandwich technique” has also been described
variable and non-specific. These include chronic where using two sheet of mesh the spleen is wraabdominal discomfort, intermittent pain, and seve- pped in its normal position in the left upper quare abdominal pain presenting as an acute abdo- drant (8).
men (1).
REFERENCES
Several imaging methods can be used to
diagnose splenoptosis. Ultrasonography with Do- 1.
G. Gayer, MD, R Zissin, MD, S Apter, MD, E Atar,
ppler may still be considered the most reliable me- MD, O Portnoy, MD, Y Itzchak, MD. CT findings in congenithod for diagnosis (2). CT scan and MRI can also tal anomalies of the spleen. British J Radiol 2001; 74:767–
be of valuable diagnostic help. Treatment of choice 772.
2.
Malak Hasan Alawi, MD, Ahmad Khalifa, MD, Sami
for splenoptosis is surgery, either splenopexy (sur- Hassan Bana, MD. Wandering Spleen: A challenging diaggically fixing an ectopic spleen) or splenectomy. nosis. Pak J Med Sci October-December 2005 Vol. 21 No.
A laparoscopic procedure is considered the “gold 4 482-484.
Sinha CK, Fisher R. Splenoptosis complicated by a
standard” for the removal or fixation of the spleen 3.
large
splenic
case report and discussion of combined
(4). Laparoscopic splenectomy has many advan- management.cyst:
Pediatr Surg Int. 2006 Jul;22 (7):605-7. Epub
tages in comparison to open splenectomy such as 2006 Apr 12.
less postoperative pain, faster recovery, improved 4.
Deborshi Sharma, MS, MRCS(Ed), FMAS, Vijay K.
pulmonary function, early return to normal bowel Shukla, MS, MCh. Laparoscopic Splenectomy 16 Years Sinfunction, decreased hospital stay, and impro- ce Delaitre With Review of Current Literature. Surg LapaEndosc Percutan Tech 2009; 19:190-194.
ved cosmesis (4). Disadvantages include longer rosc
5.
Frederick J. Rescorla, MD, Karen W. West, MD,
operative time and increased operative cost (5). Scott A. Engum, MD, Jay L. Grosfeld, MD. Laparoscopic
Preoperative vaccination against meningococcal, Splenic Procedures in Children Experience in 231 Children.
pneumococcal, and Haemophilus influenzae type Ann Surg 2007; 246: 683-688.
48
6.
B. Habermalz, S. Sauerland, G. Decker, B. Delaitre, JF. Gigot, E. Leandros, K. Lechner, M. Rhodes, G. Silecchia, A. Szold, E. Targarona, P. Torelli, E. Neugebauer.
Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery.
Surg Endosc (2008) 22:821-848
7.
Dahiya N, Karthikeyan D, Vijay S, Kumar T, Vaid
M. Wandering spleen: Unusual presentation and course
of events. Indian J Radiol Imaging 2002;12:359-62.
8.
Chinnusamy Palanivelu, MS, Muthukumaran
Rangarajan, MS, DipMS, Rangaswamy Senthilkumar,
MS, DNB, Ramakrishnan Parthasarathi, MBBS, Alfie J.
Kavalakat, MS, DNB. Laparoscopic Mesh Splenopexy
(Sandwich Technique) for Wandering Spleen. JSLS
(2007) 11:246-251.
Figure 1: Large infarcted spleen seen during the laparoscopic procedure.
RESUMEN
El bazo es un órgano solido en el cuadrante superior izquierdo del abdomen que se dedica
a filtrar y remover material extraño e innecesario,
producir células blancas, y eliminar las células
rojas desgastadas. Existen varias anomalías del
bazo; unas congenitas y otras adquiridas. Entre
ellas se encuentra una condición conocida como
esplenoptosis. Esplenoptosis congénita es una
condición donde el bazo no está anclado correctamente al mesenterio y solo está aguantado por
su pedículo vascular. Una torsión de ese pedículo
puede bloquear el flujo sanguíneo al bazo y como
consecuencia el órgano infartar. En este reporte
presentamos el caso de una paciente de 6 años
que es admitida al Hospital Pediátrico con historial
de dolor abdominal, fiebre y vómitos. En el exámen
físico se encontró una masa palbable debajo del
ombligo por el cual se le hizo un sonograma y tomografía abdominal computarizada. Los estudios
revelaron un bazo ectópico y agrandado a nivel de
L3 a L5-S1. Un estudio de sonografia con Doppler
mostró ausencia de flujo sanguíneo. La paciente
fue trasladada a la sala de operaciones para una
esplenectomía por laparoscopía. El tratamiento de
esplenoptosis es quirúrgico, ya sea esplenectomía
ó esplenopexía. La decisión se toma de acuerdo
a la viabilidad que tenga el bazo después de detorserlo. Si el bazo ha infartado, la esplenectomía
es el procedimiento a llevar a cabo. La esplenopexía es un procedimiento donde quirurgicamente
se posiciona el bazo en su localización anatómica
correcta. Este procedimiento es indicado cuando el
bazo aparenta estar viable luego de la detorsión.
Conéctese
Registros Electrónicos de Salud y mucho más
49
Rare Benign
Breast Tumor
Jaime Román-Díaz MD*
Diógenes Alayón-Laguer MD¥
Nelson Matos Fernández MD¥
Luis Báez MD¥
William Caceres-Perkins MD*
Daniel Conde-Sterling MD**
From the * VA Caribbean Healthcare System, HematologyOncology Program, the ** VA Caribbean Healthcare System,
Pathology Department, and ¥ Hematology-Oncology and Internal Medicine Departments, San Juan City Hospital.
Address reprints requests to: Jaime Román-Díaz, MD: VA
Caribbean Healthcare System, Hematology-Oncology program, 10 Calle Casia, San Juan, Puerto Rico 00921. Email:
[email protected].
ABSTRACT
We report the case of a female patient
with an incidental finding at routine mammography evaluation which consisted of a benign
spindle cell tumor, namely Breast Myofibroblastoma. It is arranged in fascicles with interspersed broad bands of hyalinized collagen
with variable immunohistochemical reactivity
to desmin, vimentin, smooth muscle actin and
CD 34. It is usually not reactive to cytokeratins
and S-100 as seen in the myoepitheliomas.
Recurrence of the lesion after excisional surgical procedure is not documented at medical literature. It is important to recognize the benign
nature of this neoplasm to prevent extensive
mutilating surgical procedures.
Index words: benign, breast, tumor
INTRODUCTION
Case History
Myofibroblastoma is a benign rare stromal
tumor seen mostly in elderly men. [1, 2] The gross
appearance is of a small well circumscribed nodule usually not exceeding more than 3 cm in size
(Figure-1). It is a spindle cell neoplasm of breast
exhibiting features of fibroblasts and smooth muscle cells. The myofibroblastic differentiation presents a discrete, firm, sharply circumscribed freely
movable mass with variable immunohistochemical reactivity to desmin, vimentin, actin and CD34.
This case report is of a breast myofibroblastoma
in a 51-years-old female discovered during routine
mammography evaluation.
This is a 51 years-old female, G5 P4 A1
and menarche at 10 years of age with past medical history remarkable only for gastroesophageal
reflux disease, hiatal hernia and asthma. Surgical
history remarkable for left oophorectomy with pathology reported as benign simple cyst and endometriosis. The patient was not using any medication but presents a positive toxic history of 39
pack–years tobacco abuse.
The patient presented with an incidental
finding of a left breast mass during routine mammography measuring 1.5 cm and localized at left
Figure 1: Myofibroblastoma - Lesions sharply circumscribed with adjacent compressed breast stroma results in a pseudocapsule.
50
upper external quadrant extending from the middle
to posterior third of the breast. It was described as
a well circumscribed heterogeneous in echotexture lesion with a fat content and associated halo
sign. The lesion was not palpable and there were
no axillary lymphadenopathies identified. The skin
over the lesion was smooth and intact without
evidence of lacerations, discoloration or hyperpigmentation. Patient denied tenderness, weight
loss, nipple discharge or constitutional symptoms.
Mass excision was performed in December 2008,
with report of clear surgical margins. The size of
the lesion was 2.8 cm x 2.6 cm x 2 cm. Pathology was reported as Myofibroblastoma (see Figure
1), CD 34 positive, smooth muscle actin positive,
HMWK negative, pankeratin negative and S-100
negative. The patient was followed closely for several months without clinical evidence of recurrence after the excisional biopsy procedure.
gen hormones [3,4]. Radiologically, the tumors are
homogenously lobulated and well circumscribed
and they lack micro calcifications [8].
Myofibroblastoma can express CD34 antigen with morphology similar to that of a solitary
fibrous tumor, for which a common origin of both
tumors has been suggested. However, there is
enough difference in the cytologic composition
and immunohistochemical profile to consider
them distinct entities. Solitary fibrous tumors have
been reported to have prominent hemangiopericytomatous vessels and a desmin negative immunohistochemistry [3, 5]. Moreover, some cases
of myofibroblastoma show a prominent adipositic
component resulting in similarity with spindle cell
lipoma (see Figure 3). Chromosomal rearrangements of 13q and 16q, characteristic of spindle cell
lipoma, have also been identified in some cases of
myofibroblastoma. The above supports a propoDISCUSSION
sition of relationship between these two tumors.
This tumor differs in the area of presentation and
Mammary myofibroblastoma is a rare be- content of fat which is higher in spindle cell lipoma.
nign tumor first recognized by Wargotz et al. In Spindle cell lipoma also lack keratin like hyalinized
most cases, myofibroblastoma is composed of bands of collagen with negative response at imfascicles of spindle shaped cells separated by munohistochemical analysis for desmin and actin,
bundles of dense collagen (see Figure 2), immu- which are classically described findings of myofinoreactive to CD34, smooth muscle actin, vimen- broblastomas.
tin and with a variable focal positively for desmin.
It is usually negative for cytokeratin AE1/A3 and Histological and immunohistochemical feaS-100. Myofibroblastoma is the only mammary tures in this case are those of a myofibroblastoneoplasm more frequent in men than in women. ma. Microscopically myofibroblastoma can be diIts extra- mammary presentation is described to vided in different types as: classical, epithelioid,
be more frequent as well, in males than females. cellular collagenized and infiltrative. The clinical
Most cases display strong staining for androgen significance is the recognition as a distinctive bereceptor not seen in other spindle cell tumors. nign neoplasm. It is important to distinguish them
Upon correlation with several different reports, it from phylloides tumors, spindle cell carcinomas
seems to occur more commonly in patients under and myoepithelial proliferations; which is possible
androgen ablation therapy and older male pa- by morphology and immunohistochemistry [6, 7].
tients, which correlate with a decrease in andro- Virtually all patients were managed by excision
Figure 2: Myofibroblastoma - Fascicles of spindle cells separated by bundles of dense collagen.
51
biopsy. It is advised to follow up patient for signs
of recurrence or infiltration at contiguous structures. After revision of the medical literature, no recurrences have been reported after a follow-up of
three to 126 months.
Myofibroblastomas can mimic a malignant
neoplasm. The clinical significance of this entity
lies primarily in its recognition as a distinctive benign neoplasm. It would prevent unnecessary mutilating extensive surgical procedures or treatments
which can eventually harm patient’s health.
6) Maemura M, Iiono Y, Oyama T, Hikino T, Yokoe T, Takei
H, Horigushi J, Ohwada S, Nakajima T, Morishita Y. Spindle
Cell Carcinoma of the Breast. Japanese Journal of Clinical
Oncology 1997; 27 (1): 46-50.
7) Franceschini G, D'Ugo D, Masetti R, Palumbo F, D'Alba
PF, Mulè A, Costantini M, Belli P, Picciocchi A. Surgical
treatment and MRI in phyllodes tumors of the breast: our
experience and review of the literature. Ann Ital Chir. 2005
Mar-Apr; 76(2):127-40.
8) Greenberg JS. Kaplan SS, Grady C. Myofibroblastoma
of the breast in women: Imaging appearances. AJR Am J
Roentgenol 1998; 171:71-2.
Figure 3: Myofibroblastoma - Prominent adipositic component.
RESUMEN
REFERENCES
1) Schuseh W, Seemayer TA, Gabbiani G. The myofibroblast, A quarter century after its discovery. Am J Surg Pathol
1998; 22:141-7
2) Qureshi A, Kayani N. Myofibroblastoma of breast. Indian
J Pathol Microbiol 2008; 51: 395-6
3) Mc menemin M.E., Fletcher C.D. Mammary type myofibroblastoma of soft tissue: a tumor closely related to spindle cell lipoma. American journal surgical pathology 2001;
1022-1029.
4) Begin LR. Myogenic stromal tumor of the male breast (socalled myofibroblastoma). Ultrastruct Pathol 1991; 15: 61322.
5) Salomao D.R, Crotty T.B’ Nasciento A.G. Myofibroblastoma and Solitary fibrous tumor odf the breat: histopathologic
and immunohystochemical studies. The Breast 2001. 10
(1); 49-54.
Presentamos una paciente con un hallazgo incidental en un mamograma de rutina que
resultó en un tumor benigno, miofibroblastoma
mamario. Este tumor se arregla en fascículos
con bandas de colágeno hialinizado con inmunoperoxidasas que reaccionan de forma variable con desmina, vimentina, actina de músculo
liso y CD34. Usualmente no reacciona con citoqueratinas y S-100, como ocurre en los mioepiteliomas. No se ha documentado en la literatura
médica recurrencia de este tumor posterior a
escisión quirúrgica. Es importante reconocer la
naturaleza benigna de este tumor para prevenir
procedimientos quirúrgicos extensos que pudieran ser potencialmente mutilantes.
Los socios de la AMPR
obtienen el servicio de
eHr a precios más bajos
Atypical Presentation Of Basilar Artery
Thrombosis Due To Hypercoagulable
State And Incidental Patent Foramen
Ovale: A Case Report
Marie Bernadine Hidalgo MD *
Edwin Rodríguez MD **
Valerie Wojna MD***
From the *St. Lukes Episcopal Hospital, Ponce, PR, the
**Cardiovascular Center of Puerto Rico, and the ***Department of Internal Medicine, Neurology Division, UPR
School of Medicine.
Address reprints request to: Marie Bernadine Hidalgo, St.
Lukes Episcopal Hospital - Ponce School of Medicine Consortium, P.O. BOX 7004 Ponce, PR 00732. Email marie_
[email protected]
INTRODUCTION
Pregnancy precipitates a hypercoagulable
state associated with complications such as ischemic strokes and venous thromboembolism (1).
Maternal mortality is high in presence of strokes
and survivors may face long term neurologic sequelae. The presence of a patent foramen ovale
(PFO) increases the risk for ischemic stroke due
to paradoxical embolism without the presence of
deep venous thrombosis (DVT). It is imperative
to consider a PFO as risk factor of stroke in postpartum women (1). We propose to emphasize the
importance of recognizing risk factors of ischemic
stroke in pregnancy since early recognition and
diagnosis is crucial to prevent long term complications. The evaluation and follow-up of such patients and reviews of pertinent literature are discussed.
ABSTRACT
This is a case presentation of a 31
year old woman without history of any systemic illness and on her second pregnancy.
Three days after an elective cesarean delivery without complications presented with
neurological deficits mainly difficulty talking
that progressed to aphasia, dizziness, and
loss of vision. Neuro-images showed several
ischemic areas in the brain. A magnetic resonance angiogram revealed a thrombus in
the basilar artery. A transesophageal echocardiogram demonstrated a patent foramen
ovale (PFO). The early recognition and diagnosis of PFO is crucial in preventing longterm complications.
Index words: Stroke, Patent Foramen Ovale,
Pregnancy
The laboratory results were unremarkable
except for decreased hemoglobin (10.4g/dL) and
increased Factor VIII (214%, normal 60 – 150% of
nml). Work- up for a systemic etiology, and vasculitis were normal. (See Table 1). Brain imaging
showed ischemic strokes at cerebellum, bilateral
midbrain, and pons areas (See Figure 1). Magnetic Resonance Angiography (MRA) revealed
segmental occlusions of both right and left P1
segments of the posterior cerebral artery (PCA)
and basilar artery tip (See Figure 2). Electroencephalogram presented during sleep generalized
delta bursts (1Hz), otherwise was normal. Venous
Doppler ultrasound exam of the lower extremities
Case History
showed adequate compressibility, no DVT. Tran
A 31 year old woman Grava 2, Para 2, sesophageal Echocardiogram was performed reAbortion 0, underwent an uncomplicated cesarean vealing a PFO with right to left shunt.
section. Three days after developed dizziness,
Patient was treated with anticoagulation
nauseas, slurred speech, headache, and loss of with
a
gradual
neurological improvement after revision. Symptoms progressed to aphasia, hemipahabilitation.
resis, inability to follow commands, and eventually became stuporous. Initially the vital signs were
normal and the neurologic exam revealed right DISCUSSION
oculomotor nerve palsy, horizontal nystagmus,
Cardioembolic stroke is implicated in about
generalized decrease tone, resting tremor of all one-third
of all patients 40 years and younger (3).
extremities, and bilateral extensor response. Initial
Diagnosis
is based on the triad of identification of
working diagnosis of vertebrobasilar insufficiency
potential
cardioembolic
source, absence of other
was considered.
54
Figure 1. The Computed Tomography Scan shows bilateral cerebellar and midbrain lesions compatible
with acute ischemic infarcts.
midbrain
Cerebellar
lesions
Figure 2. Magnetic Resonance Angiogram showing features likely causes of stroke, and supportive
of basilar artery thrombosis and segmental occlusions of both clinical features such as decreased lePCA and non visualization of Superior cerebellar artery.
vel of consciousness, and neurological
symptoms (2).
ACA
LMCA
Tip Basilar
thrombosis
Segmental
occlusion L PCA
The PFO is a common congenital abnormality due to a remnant of the
fetal foramen ovale. PFO is implicated
in a number of disease processes, including cryptogenic stroke and migraine headaches (4). Frequently PFO
is diagnosed by echogardiography in
over 20% of normal adults. Thrombus formation due to stagnant blood
flow may also occur within the PFO
and susceptibility to atrial arrythmias
provides further potential mechanism
for cardioembolism. Emboli originating in the venous circulation, or right
heart circulation, may cause ischemic
strokes via paradoxical embolism (2).
Any conditions that increase right atrial
pressure more than left atrial pressure
can induce paradoxical flow and embolism (5). Paradoxical emboli is most
55
likely the etiology of cryptogenic stroke in young
patients (6).
Table 1. Laboratory and procedures performed results.
The American Maternal Mortality Collaborative reports that CVA is the 5th cause of maternal
deaths (7). Risks factors for stroke during pregnancy include: 35 years and older, hypertension, heart
disease, lupus erythematosus, cesarean delivery,
electrolytes disorders, thrombophilia, or multiple
gestations. In addition to these risks factor, PFO
during pregnancy can increase the possibility of
stroke. Warfarin and percutaneous transcatheter closure of the PFO are recommended in postpartum women after cryptogenic stroke believed
secondary to paradoxical embolism (1). Warfarin
should be avoided by pregnant women.
Laboratory
and
procedures
performed Patient’s result
The basilar artery, the largest artery in the
posterior circulation, forms the central core of this
vascular territory. Commonly is affected by atherosclerosis, embolism, dissections, aneurysms, migraine, and inflammatory conditions (9). Infarction
of the rostral brainstem and cerebral hemisphere
regions fed by the distal basilar artery causes a
clinically recognizable syndrome characterized by
visual, oculomotor, and behavioral abnormalities,
often without significant motor dysfunction (7).
Vascular imaging with magnetic resonance angiography is necessary to confirm the diagnosis of
basilar artery thrombosis. The incidence of acute
ischemic stroke related to basilar artery occlusion
in post partum women is unknown. However in
the general population approximately 27% of ischemic strokes are reported in the posterior circulation. The prognosis depends on the degree of
obstruction and early onset of medical therapy. If
not re-canalized, mortality exceeds 90% in spite of
anticoagulant and/or fibrinolytic therapy (2).
CONCLUSION
The case presented compiles one of the
possible complications of pregnancy, CVA. The
woman had several risk factors for the presence of
hypercoagulability: age, pregnancy, cesarean section, and increased Factor VIII. These risk factors
overlying with the presence of PFO made this woman at risk of a cardioembolic cerebral infarct. The
lodging of the emboli at the tip of the basilar artery
represented a life threatening event and marked
residual neurological deficits. The importance in
identifying these events early will minimize the
catastrophic outcome by administering early anticoagulant treatment.
REFERENCES
1.
Treadwell SD, Thanvi, Robinson TG. Stroke in pregnancy and the puerperium. Postgrad. Med. J. 2008;84;238245
56
Hemoglobin 10.4 g/dL
Factor VIII 214%
C3
complement 110 mg/dL
Anti-Nuclear
Antibody
<1:20
Protein C
Activity
104%
Protein S
Activity
84%
Prothrombin
time (PT)
11.4
Partial
thromboplastin
time (PTT) 23.0
Normal values
12.0 – 16.0g/dL
60-150%-of nml
75 - 161 mg/dL
<1:40
70 - 140% of nml
58 - 130% of nml
9 - 12.5 seconds
20 - 36 seconds
2.
Schneck M, Xu L, Palacio S. Cardioembolic stroke.
Emedicine http://emedicine.medscape.com/article/1160370overview 2008.
3.
Barinagarrementeria F, Amaya LE, Cantu C. Causes
and mechanisms of cerebellar infarction in young patients.
Stroke 1997; 28:2400-4.
4.
Daehnert I, Ewert P, Berger F, Lange PE. Echocardiographically guided closure of a patent foramen ovale during pregnancy after recurrent strokes. Case Reports. Journal Article, Journal of Interventional Cardiology. 14(2):191-2,
2001 Apr. UI: 12053303
5.
Lock, JE. Patent foramen ovale is indicated, but the
case hasn’t gone to trial. Circulation. February 29, 2000; 101
(8): 838 Medline.
6.
Messé SR, Silverman IE, Kizer JR, Homma S, Zahn
C, Gronseth G, Kasner SE. Practice Parameter: Recurrent
stroke with patent foramen ovale and atrial septal aneurysm.
American Academy of Neurology. Neurology 2004 Apr 13;
62(7):1042-50.
7.
Caplan L. "Top of the basilar" syndrome. NEUROLOGY 30: 72-79, January 1980 American Academy of Neurology.
8.
Schick P, Schick B. (2007). Hypercoagulability: Hereditary thrombophilia and lupus anticoagulants associated
with venous thrombosis and emboli. Emedicine. http://emedicine.medscape.com/article/211039-overview
9.
Voetsch B, DeWitt LD, Pessin MS, Caplan LR. Basilar Artery Occlusive Disease in the New England Medical
Center Posterior Circulation Registry Arch Neurol, April 1,
2004; 61(4): 496 - 504.
ACKNOWLEDGEMENTS
I would like to express my deep and sincere gratitude to Professor Edwin Rodriguez MD
and Professor Valerie Wojna MD for their extensive knowledge, ideals and concepts have had a
remarkable influence on my career in the field of
neurology research.
RESUMEN
Este es el caso de una paciente de
31 años de edad en su segundo embarazo,
sin ningún historial médico pasado. Tres días
después de una cesárea electiva, sin ninguna complicación, la paciente presenta déficits neurológicos que incluyeron mayormente
trastornos del habla que avanzó en afasia,
mareos, y pérdida temporal de visión. Neuroimágenes revelan zonas isquémicas en el
cerebro. Angiografía por resonancia magnética mostró una trombosis en la arteria basilar.
Un ecocardiograma transesofágico reveló un
foramen ovale permeable (FOP). El reconocimiento y el diagnostico temprano de un FOP
es crucial para la prevención de complicaciones a largo plazo.
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57
Intestinal
Endometriosis As
A Cause Of Rectal
Bleeding: A Case
Report
Jeannette A. Vergelí Rojas MD*
Lenny Pagán Rodríguez MD**
Carmen Santiago Muñoz MD¥, ¥
Sylvia Gutiérrez Rivera MD££
From the *Department of Internal Medicine, ** Department
of Obstetric and Gynecology, ¥ Department of Gastroenterology, and £ Department of Pathology, Saint Luke’s Memorial
Hospital, Ponce, Puerto Rico.
Reprints request to: Carmen Santiago, MD, FACG - Saint
Luke’s Memorial Hospital, Avenida Tito Castro 917, Ponce,
Puerto Rico, 00733-6810. E-mail: <carmensantiago3@aol.
com>.
INTRODUCTION
Endometriosis is defined as the presence
of endometrium-like tissue in sites outside the uterine cavity, primarily ovaries and peritoneal cavity
(1). Endometriosis is a common gynecologic disease that affects between four and 17% of women in their reproductive years (2). The estimated
prevalence of endometriosis in Puerto Rico is 4%,
comparable to what has been reported in other
populations (3). The presence of endometriotic
lesions in the sigmoid colon is a pathology that
is not frequently reported but may manifest with
symptoms in the form of intestinal occlusions, subocclusions and rectorrhagia (4,5). The prevalence of extra-pelvic endometriosis is currently unknown, but it has been estimated that this disease
affects the intestinal tract in 3-37% of all patients,
being the sigmoid colon and the rectum the most
commonly involved areas (4,6). As of yet, there is
insufficient data reported about the prevalence of
intestinal endometriosis in Puerto Rico.
ABSTRACT
Endometriosis is the presence of endometrial glands and stroma outside the uterine
cavity and musculature. The estimated prevalence of endometriosis in Puerto Rico is 4.0%.
The exact prevalence of extra-pelvic endometriosis is unknown. It has been reported that
affects the intestinal tract in 3-37% of all patients with pelvic endometriosis, with the sigmoid colon and rectum being the most commonly involved areas. It can mimic colorectal
cancer by producing an invasive abdominal
mass. We present the case of a 40 y/o female
patient with rectal bleeding that presented a
mass on a colonoscopy highly suggestive of
cancer. After all the studies and an exploratory laparotomy, the diagnosis was intestinal
endometriosis. Because of lack of published
data about intestinal endometriosis in Puerto
Rico, it is very important to show this condition
in order to properly assess young women with
rectal bleeding in light of a clinical suspicion of
endometriosis.
Index words: intestinal, endometriosis, rectal,
bleeding
We present a case report of a large concentric mass in the sigmoid area of a young patient with infertility problems who was presenting
daily rectal bleeding (9). The first impression based on the clinical presentation was colon carcinoma. After the diagnostic work up for malignancy
was done, the pathology report showed that the
resected mass was polypoid intestinal endometriosis. This report demonstrates the importance of
taking in consideration intestinal endometriosis as
a differential diagnosis in young women with rectal
bleeding.
Case History
This is a case of a 40- year old female patient nulligravid, without toxic habits, with past medical history of endometriosis for eight years. The
patient was visiting her gynecologist frequently
Intestinal endometriosis is sometimes diffi- due to inability to conceive and for follow up of
cult to be distinguished from malignancies, Infla- abnormal pap smears with chronic cervicitis. Her
mmatory Bowel Disease or ischemic colitis due only medication at the time was clomiphene for
to similarities in clinical manifestations (7,8). It is long standing infertility. Family history was unreof great importance to deeply explore the clinical markable for colon cancer. Previously, a complete
manifestations of extra-pelvic endometriosis, es- workup of laboratories and imaging studies were
pecially the intestinal ones, in light of its clinical done to both the patient and her husband for the
resemblance with gastrointestinal malignancies. cause of their infertility without satisfactory finThis knowledge will help to promptly reach a co- dings. On 2001 the patient had a diagnostic laparrect diagnosis such that appropriate clinical ma- roscopy where Revised American Fertility Society (rAFS) stage 1 endometriosis was diagnosed.
nagement strategies can be applied.
58
Despite the fact that the patient was diagnosed Figure 1: Colonoscopy showing the Polypoid enwith endometriosis, she denied having pelvic pain dometrioma occluding approximately 90% of the
or any other physical complains except for inferti- lumen.
lity prior to this. She also never had any medical
treatment targeted to the endometriosis. She had
two cryosurgeries due to abnormal Pap smear
exams and hysteroscopy to evaluate the uterine
cavity due to the mentioned inability to conceive.
On June 2009, she went through dilation
and curettage due to the abnormal pap results and
on her follow up visit on July 2009 she decided to
tell her physician about the recurrent rectal bleeding episodes she was experiencing. The rectal
bleeding, which started approximately on December 2008, was intermittent but not cyclical, and
described as bright red blood mixed in the stools.
Before the onset of bleeding the patient had experienced constipation and changes in the stool’s
consistency, “pencil-like”. As time went by, the patient started to present intractable, colicky abdominal pain of 7/10 intensity (based on the Visual
Analogue Scale), early satiety, bloating, increase
in the abdominal girth, and rectal tenesmus. The
physical examination was unremarkable including
a pelvic and digital rectal examination which was
negative for melena, port wine or bright red blood.
No masses were palpable. At that moment a stool
for occult blood was ordered with positive findings.
She was referred to a community’s gastroenterologist who performed a colonoscopy on August
2009. A “large concentric mass in sigmoid that begins at 18 cm and extend up to 5 cm proximal,
occluding 90% of the lumen” was described on the
endoscopic report (see Figure 1). The rest of the
colon was normal and biopsies were taken. The
pathology reported Polypoid Endometriosis with a
Periodic Acid Schiff and mucin stains contributory
to the given diagnosis (see Figure 2). The patient
was immediately admitted and scheduled for surgery which was done the next day. Serum colon
cancer marker Carcinoembryonic Antigen levels
were assayed and reported as less than 0. 50 ng/
ml. Of note, prior to surgery, the abdomino-pelvic
computed tomography (CT scan) did not show any
colonic mass, although it indeed showed free fluid
in the cul-de-sac with bilateral ovarian cysts.
Figure 2: Endometrial stroma present in the colonic mucosa.
Figure 3: Endometrial glands invading submucosa of the colon.
The patient underwent an exploratory laparotomy where a partial sigmoid hemicolectomy
with end-to-end anastomosis and left ovarian mass
excision were done. The gross appearance of the
colonic specimen was a fungating light-brown tan
soft to rubbery tumor mass that measured 4.5 x 3
x 2.5 cm. The pathology report was confirmatory
of the initial diagnosis with the left ovarian tumor
being an endometrioma and the resected sigmoid
area, polypoid endometriosis involving the submucosa and smooth muscle of the colonic wall (see
Figure 3). She had a successful and uneventful
59
recovery. Currently the patient denies any gastro- endometriosis is laparoscopy or laparotomy fointestinal complaints including rectal bleeding. Her llowed by histological confirmation of endometrial
problem of infertility continues but remains asymp- glands and stroma.
tomatic without any medication.
Treatment options for intestinal endometrioDISCUSSION
sis include surgery or hormonal therapy, depending
on the patient’s age and desire to maintain fertility,
Endometriosis is a common gynecologic and also on the severity and complications of the
condition afflicting women during their reproduc- disease. Recently, laparoscopic treatment of colotive years (2). It has been estimated that this di- rectal endometriosis, even in advanced stages, has
sease affects the intestinal tract in 3-37% of all pa- been proven feasible and effective in nearly all patients, as in the present case. The most common tients. Some studies have demonstrated that surgisites of intestinal endometriosis are the sigmoid cal management not only improves pain symptoms
and rectum, responsible for up to 90% of all cases but also fertility in young patients with a history of
(4,6,10,11).
inability to conceive (24-27). If the surgery is not
feasible there are medical treatments for endome
There are several theories that try to explain triosis which include: danazol, high dose progesthe pathogenesis of the extra-pelvic endometrio- tins and Gonadotropin releasing hormone agonists
sis, including retrograde menstruation (Sampson’s with almost equivalent efficacy (28).
theory), altered immunity, metaplasia, or “the implantation theory” (12-16). It is difficult to know This patient represents a case of lower gaswhich one of these hypothesis may explain the trointetinal bleeding in a young female with history
seeding of this patient’s sigmoid endometrioma, of endometriosis. Her symptoms of bloating, interbut the most widely accepted one is the retrograde mittent hematochezia, early satiety, “pencil-like”
of endometrial tissue through the fallopian tubes. stools, in addition to the colonoscopy findings, sugA substantial proportion of patients with endome- gested a bowel malignancy. On the other hand, her
triosis commonly report gastrointestinal-related history of infertility, which was her main complaint
symptoms including abdominal upsets (e.g., diarr- (and not dysmenorrhea), and the negative CEA lehea, constipation) and dyschezia (31). Symptoms vels, did not support a diagnosis of a malignancy.
can be cyclical in about 40% of patients, and can It is well established in the literature that intestialso include crampy abdominal pain, distention, te- nal endometriosis can mimic colorectal cancer by
nesmus and hematochezia (20). This is contrary to producing an invasive abdominal mass associated
the presentation of this patient who did not present with abdominal pain, bleeding or ulcers (6,29-30).
cyclical (i.e., related to menses) rectal bleeding as
would be expected when endometriosis is suspec- In addition, studies conducted in an animal
ted. It must be recognized that the symptoms of model of endometriosis have shown that ectopic
intestinal endometriosis vary according to the site lesions growing in the peritoneal area can draof involvement (17). Rectosigmoid endometriosis matically affect the function, inflammatory status
causes alterations in bowel habits and bleeding and transcriptome of the gastrointestinal tract of
that resemble symptoms of colorectal cancer. It affected rats, which may explain the often severe
may present with rectal bleeding, bowel obstruction GI-related symptoms (32,33). These observations
and, rarely, with perforation or malignant transfor- highlight the importance of considering the myriad
mation (18,19). Barclay and Langlois reported in of clinical presentations that may be associated
their publications that the clinical manifestations of with intestinal endometriosis such that patients
intestinal endometriosis are sometimes difficult to could be promptly and correctly diagnosed and
distinguish from malignancy, inflammatory bowel managed.
disease, or ischemic colitis and that in the case of
mucosal involvement, a bleeding-polypoid mass In conclusion, there is few data reported
may be present (7,8).
about the extra-pelvic manifestations of endometriosis, especially when affecting the GI tract.
Radiologic imaging (CT scans, Magne- Because intestinal endometriosis can mimic the
tic Resonance Imaging or MRI) and endoscopic clinical presentation of a GI malignancy, it is very
(colonoscopy) examinations are essential for the important to rule out this possibility first. In view of
diagnosis of intestinal endometriosis, which may a young woman with signs and symptoms of enbe confused with malignancies, particularly in dometriosis, intestinal extension must be ruled out
patients with mucosal involvement (21,22). MRI as well. It is our recommendation to publish more
seems to be the most sensitive imaging technique data about this fairly common complication of enfor intestinal endometriosis (23). However, eva- dometriosis in order to assess better our patients
luations based on imaging are not diagnostic. The and provide them with prompt and appropriate
gold standard diagnostic procedure for intestinal treatment for their symptoms.
60
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C: Self-reported prevalence of endometriosis and its symptoms
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passage of intestinal endometriosis, Dig Dis Sci. 2001; 46:1963–
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(10) Coronado C, Franklin RR, Lotze EC et al. Surgical treatment
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411-416.
(11) Bailey HR, Ott MT, Hartendorp P: Aggressive surgical management for advanced colorectal endometriosis, Dis Colon Rectum
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(12) Vinatier D, Orazi G, Cosson M, Dufour P: Theories of endometriosis. Eur J Obstet Gynecol Rep Biol. 2001;96:21-34
(13) Sampson JA: Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J
Obstet Gynecol.1927;14:422-469.
(14) Olive DL, Henderson DY: Endometriosis and Mullerian anomalies, Obstet Gynecol. 1987; 69: 412.
(15) Steele RW, Dmowski WP, Marmer DJ: Immunologic aspects of
human endometriosis, Am J Reprod Immunol 1984; 6: 33.
(16) Schenken R: Pathogenesis In Endometriosis: Contemporary
Concepts in Clinical Management, Schenken, RS (Ed), JB Lippincott Company,1989. p.1.
(17) Giudice LC, Kao LC: Endometriosis, Lancet 2004; 364:17891799.
(18) Varras M, Kostopanagiotou E, Katis K, Farantos Ch, Angelidou-Manika Z, Antoniou S: Endometriosis causing extensive intestinal obstruction simulating carcinoma of the sigmoid colon: a case
report and review of the literature. Eur J Gynaecol Oncol. 2002;
23: 353–357.
(19) Yantiss RK, Clement PB, Young RH. Neoplastic and pre-neoplastic changes in gastrointestinal endometriosis: a study of 17 cases. Am J Surg Pathol. 2000; 24: 513–524.
(20) Jubanyik K, Comite F: Extrapelvic endometriosis, Obstet Gynecol Clin North Am. 1997; 24: 411–440.
(21) Dimoulios P, Koutroubakis IE, Tzardi M, Antoniou P, Matalliotakis IM, Kouroumalis EA: A case of sigmoid endometriosis difficult to
differentiate from colon cancer, BMC Gastroenterol. 2003; 3:18.
(22) Bergamini V, Ghezzi F, Scarpero S, Raffaelli R, Cromi A,
Franchi M: Preoperative assessment of intestinal endometriosis:
a comparison of Transvaginal Sonography with Water-Contrast in
the Rectum, Transrectal Sonography, and Barium Enema. Abdom
Imaging. April, 2010.
(23) Brosens I, Puttemans P, Campo R, Gordts S, Brosens J: Noninvasive methods of diagnosis of endometriosis, Curr Opin Obstet
Gynecol. 2003;15:519–522.
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K, Agic A: 94 months follow-up after laparoscopic assisted vaginal
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deep infiltrating endometriosis. Arch Gynecol Obstet. May, 2010.
(27) Dousset B, Leconte M, Borghese B, Millischer AE, Roseau
G, Arkwright S, Chapron C: Complete surgery for low rectal endometriosis: long-term results of a 100-case prospective study. Ann
Surg. May, 2010; 251(5):887-895.
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50.
(29) Keighley MRB, Williams NS.: Miscellaneous inflammatory disorders. In: Keighley MRB, Williams NS, eds. Surgery of the Anus,
Rectum and Colon. London: WB Saunders: 1993: 1226-30.
(30) Rowland R, Langman JM: Endometriosis of the large bowel: a
report of 11 cases, Pathology 1989; 21: 259-65.
(31) Fourquet J, Gao X, Zavala D, Orengo JC, Abac S, Ruiz A,
Laboy J, Flores I: Patient’s report on how endometriosis affects
health, work, and daily life. Fertil Steril. November, 2009.
(32) Appleyard CB, Cruz ML, Rivera E, Hernandez GA and Flores
I: Experimental endometriosis in the rat is correlated with colonic
motor function alterations but not with bacterial load. Reprod Sci
Dec. 2007; 14(8):815-24.
(33) Rojas-Cartagena C, Appleyard C B, Santiago O I, Flores I:
Experimental endometriosis is characterized by increased levels of
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gene expression. Biol Reprod. 2005; Dec 73(6):1211-1218.
ACKNOWLEDGEMENTS
Special thanks to Dr. Idhaliz Flores, Ph.D
who helped us in the preparation of this presentation. Also, we are very grateful for the help of Dr.
Rafael Bredy, MD, MBE, MScCR.
RESUMEN
La endometriosis es la presencia de
glándulas endometriales y estroma fuera de
la musculatura y cavidad uterina. La prevalencia estimada de la endometriosis en Puerto Rico es de 4.0%. La prevalencia exacta
de la endometriosis extra-pélvica es desconocida. Se ha reportado que afecta el tracto
intestinal en 3-37% de todos los pacientes
con endometriosis pélvica, siendo el sigmoide y el recto las áreas más comúnmente
afectadas. Puede imitar al cáncer colorectal
presentándose como una masa abdominal
invasiva. Presentamos el caso de una fémina de 40 años con sangrado rectal que presenta una masa muy sugerente de cáncer
por medio de una colonoscopía. Después de
todos los estudios y una laparotomía exploratoria, el diagnóstico final fue de endometriosis intestinal. Debido a la falta de datos
publicados sobre la endometriosis intestinal
en Puerto Rico, es muy importante mostrar
esta condición para poder evaluar correctamente pacientes jόvenes con sangrado rectal con sospecha clínica de endometriosis.
61
“Caduet es una pastilla* para mi
presión arterial alta ...
®
y para mi
colesterol elevado.”
Caduet® combina dos medicamentos comprobados en una sola pastilla:
Norvasc® (besilato de amlodipina) para la presión arterial alta y
Lipitor® (atorvastatina cálcica) para reducir el colesterol elevado.
"Caduet hace más fácil manejar mis dos condiciones.” Caduet es
una pastilla que, conjuntamente con la dieta y el ejercicio,
reduce efectivamente tanto la presión arterial alta como el colesterol elevado. Caduet viene en una variedad de dosis de manera
que su médico puede elegir la dosis adecuada para usted.
Pregunte a su médico sobre Caduet.
Caduet. Dos medicamentos, una pastilla.
Aprenda más en www.Caduet.com
*Caduet puede usarse solo o en combinación con
otros medicamentos antihipertensivos.
Por favor vea el resumen sobre información
al paciente en la siguiente página.
INFORMACION IMPORTANTE: Caduet® es un medicamento
para venta con receta que combina 2 medicamentos, Norvasc y
Lipitor. Norvasc se usa para tratar la presión arterial alta
(hipertensión), el dolor de pecho (angina) o las arterias cardiacas
bloqueadas (enfermedad de las arterias coronarias). Lipitor se usa,
junto con la dieta y el ejercicio, para reducir el colesterol elevado.
Se usa también para reducir el riesgo de ataques cardiacos y
derrames en personas con factores múltiples de riesgo de
enfermedad cardiaca, como historial familiar, presión arterial alta,
edad, HDL-C bajo o fumar.
Caduet no es para todo el mundo. No es para personas con
problemas del hígado ni para mujeres que lactan, que están
embarazadas o que puedan quedar embarazadas. Si usa Caduet,
infórmele a su médico si siente algún dolor o debilidad muscular
nuevos. Esto podría ser señal de efectos secundarios musculares
poco comunes, pero graves. Informe a su médico sobre todas las
medicinas que usa para ayudar a evitar interacciones graves de
fármacos. El médico debe ordenarle exámenes de sangre para
verificar su función hepática antes del tratamiento y durante el
mismo y podría ajustar la dosis. Si tiene algún problema cardiaco,
asegúrese de informárselo a su médico. Los efectos secundarios más
comunes son edema, dolor de cabeza y mareo. Éstos tienden a ser
leves y, a menudo, desaparecen.
Caduet es una entre varias opciones para tratar la presión arterial
alta y el colesterol elevado, además de la dieta y el ejercicio, que
usted y su médico pueden considerar.
Le exhortamos a notificar a la Administración de Drogas y Alimentos (FDA) sobre los efectos secundarios negativos de los medicamentos con receta.
Visite www.fda.gov/medwatch o llame 1-800- FDA-1088.
©2006 Pfizer Inc. Todos los derechos reservados. CTU00211PR
(CAD-oo-et)
DATOS IMPORTANTES
PARA DISMINUIR LA PRESIÓN ARTERIAL
ALTA Y EL COLESTEROL ELEVADO.
La presión arterial alta y el colesterol elevado son más que simples
números. Son factores de riesgo que no deben ignorarse. Si su médico
le informó que tiene la presión arterial alta y el colesterol elevado, usted
puede estar expuesto a un riesgo mayor de sufrir un ataque cardiaco o
un accidente cerebrovascular. Sin embargo, la buena noticia es que
usted puede tomar los pasos necesarios para disminuir su presión arterial
y su colesterol.
Con la ayuda de su médico y medicamentos como CADUET,
conjuntamente con dieta y ejercicio, usted podría estar en vías de
disminuir su presión arterial y su colesterol. ¿Está listo para comenzar
una alimentación adecuada y ejercitarse un poco más? Hable con su
médico y visite la página en Internet de la Sociedad Americana del
Corazón, www.americanheart.org.
¿PARA QUIÉN ES CADUET?
Quién puede tomar CADUET:
• Los adultos que necesitan disminuir su presión arterial alta Y que
no pueden reducir suficientemente su colesterol con dieta y ejercicio
Quién NO debería tomar CADUET:
• Mujeres que están embarazadas o piensan que puede estarlo o tiene
planes de quedar embarazadas. CADUET puede perjudicar a su bebé
por nacer. Si queda embarazada, deje de tomar CADUET y llame de
inmediato a su médico.
• Mujeres que están lactando. CADUET puede pasar a la leche
materna y perjudicar a su bebé.
• Personas que tienen problemas del hígado.
• Personas alérgicas a algún ingrediente de CADUET.
POSIBLES EFECTOS SECUNDARIOS DE CADUET
Efectos secundarios graves en un número pequeño de personas:
Problemas musculares que pueden conducir a problemas renales,
incluso insuficiencia renal.
Usted tiene una mayor probabilidad de tener problemas musculares si está tomando otros medicamentos junto con CADUET.
Problemas hepáticos. Su médico puede hacerle análisis de sangre
para verificar la función del hígado antes de comenzar a tomar
CADUET y mientras lo está tomando.
Los síntomas de problemas musculares y hepáticos incluyen:
• Debilidad, sensibilidad o dolor que ocurre sin una buena razón,
especialmente si también tiene fiebre o se siente más cansado que
de costumbre
• Náuseas, vómitos, dolor estomacal
• Orina de color marrón o de tonalidad oscura
• Se siente más cansado que de costumbre
• La piel o la parte blanca de los ojos se torna amarilla
Dolor de pecho. A veces el dolor de pecho no desaparece o
empeora o puede sufrir un ataque cardiaco. Si esto sucede, llame
al médico o vaya de inmediato a la sala de emergencia.
Los efectos secundarios más comunes de CADUET incluyen:
• dolor de cabeza
• cansancio
• dolor estomacal
• gases
• estreñimiento
• mareos
• somnolencia extrema
• náuseas
• erupción
• diarrea
• hinchazón de las piernas o los tobillos (edema)
• sensación de calor en la cara (ruborización)
• latidos irregulares del corazón (arritmias)
• latidos bien rápidos del corazón (palpitaciones)
• dolor en los músculos y en las articulaciones
Hable con su médico o con su farmacéutico sobre los efectos
secundarios que le molestan o que no desaparecen. Hay otros
efectos secundarios de CADUET. Pida una lista completa a su
médico o a su farmacéutico.
CÓMO TOMAR CADUET
ANTES DE TOMAR CADUET
Háblele a su médico:
• Acerca de todos los medicamentos que está tomando, incluso
medicamentos con y sin receta, las vitaminas y los suplementos
herbáceos.
• Si ha sufrido enfermedades cardiacas
• Si ha tenido dolor o debilidad muscular
• Si toma más de dos bebidas alcohólicas al día
• Si tiene diabetes o problemas de los riñones
• Si ha tenido problemas de la tiroides
INFORMACIÓN SOBRE CADUET
CADUET es un medicamento con receta que combina Norvasc®
(besilato de amlodipina) para tratar la presión arterial alta y Lipitor®
(atorvastatina cálcica) que se usa para disminuir el colesterol elevado,
en una pastilla. CADUET, conjuntamente con dieta y ejercicio, trata
tanto la presión arterial alta (hipertensión) como el colesterol elevado.
CADUET puede disminuir el riesgo de un ataque cardiaco o accidente
cerebrovascular en pacientes con factores de riesgo de enfermedades
cardiacas como: historial familiar de enfermedades cardiacas, presión
arterial alta, HDL-C bajo, diabetes, fumar o ser mayor de 55 años.
CTU00211PR
Qué hacer:
• Tome CADUET una vez al día, exactamente como le indique el médico.
• Intente ingerir alimentos saludable para el corazón mientras toma CADUET.
• Tome CADUET todos los días a cualquier hora del día, con o sin
alimentos.
• Si olvida una dosis, tómela tan pronto se acuerde. Pero si han
transcurrido más de 12 horas desde que olvidó la dosis, espere. Tome la
próxima dosis a la hora establecida.
Qué no hacer:
• No parta las tabletas de CADUET antes de tomarlas.
• No deje de tomar nitroglicerina si la toma para el dolor de pecho (angina).
• No cambie o deje de tomar su dosis sin hablar antes con su médico.
• No comience a tomar medicamentos nuevos o deje de tomar cualquier
medicamento que esté tomando sin antes hablar con su médico.
¿NECESITA MAYOR INFORMACIÓN?
• Pregúntele a su médico, proveedor de servicios de salud o farmacéutico.
Este documento es sólo un resumen de la información más relevante.
• Vaya a www.caduet.com.
CADUET está incluido en el programa de ahorros en
medicamentos con receta “Together RX Access™”,
Para información adicional llame al 1-800-444-4106 o visite
www.TogetherRxAccess.com
Rx únicamente
Fabricado por Pfizer Ireland Pharmaceuticals, Dublin, Irlanda
Distriubido por Pfizer Labs, División de Pfizer, Inc. Nueva York, NY 10017
© 2008 Pfizer, Inc. Todos los derechos reservados. Impreso en los Estados Unidos de Norteamérica.
CTIF Rev. 1, 01.08
CME Credits
Boletin Asoc Med PR Vol 102 No 02,
2010
a)
b)
c)
d)
e)
ha aumentado
ha disminuido
se ha quedado estatica
no se sabe
ninguna de las anteriores
Questions from article: “LAPAROSCOPIC LIVER
RESECTIONS: INITIAL EXPERIENCE IN PUERTO RICO”, by David H. Solís Lopez MD, Carlos M. Questions from article: “CENTRAL NERVOUS
SYSTEM INVOLVEMENT BY FOLLICULAR LYMClaudio MD, Diego R. Solís Lopez MD.
PHOMA: A Case Report”, by Liza Paulo Malavé
1.
Benefits from laparoscopic liver surgery in- MD, William Cáceres MD.
clude:
7. The following statement is correct about central
a.
Early postoperative recovery
venous involvement by non-Hodgkin’s lymphoma:
b.
Less pain medication
c.
Less fluid retention
a.
It is usually present in all types of nond.
All of the above
Hodgkin’s lymphoma
It is more common in Hodgkin’s lymphoma
2.
True or False: Liver tumor malignancy sta- b.
tus is a contraindication for laparoscopic liver re- than Non-Hodgkin’s.
c.
It is more common in Burkitt’s and lymphosections.
blastic lymphoma than follicular lymphoma
a.
True
d.
Never occurs in lymphoma
b.
False
3.
Risks and concerns still present with laparoscopic liver surgery might include:
a.
Hemorrhage
b.
Venous gas embolism
c.
Ability to resect and achieve oncologic safe
margins
d.
All of the above
8. Involvement of central venous system by NonHodgkin’s lymphoma occurs approximately in:
Preguntas sobre el articulo: “VALIDACION DE UNA
ESCALA DE ACTITUDES HACIA LA SEXUALIDAD EN UNA MUESTRA DE ANCIANOS PUERTORRIQUENOS”, por Rosa Janet Rodríguez
Benítez PhD, José Rodríguez Gómez MD, Sean
Sayers Montalvo, PhD.
9. Nuchal rigidity, disorientation and seizures:
a.
b.
c.
d.
50% of cases
100% of cases
25% of cases
8% of cases
a.
Could be a sign of central nervous involvement by lymphoma
b.
Always is due to bacterial meningitis
c.
In patients with lymphoma it is always secondary to chemotherapy toxicity
Prophylaxis with chemotherapy avoids this
4.
Aspecto del envejecimiento que afectan el d.
desarrollo sexual en la “etapa dorada” de la vida complication in all patients with follicular lymphoma
incluyen:
a)
aislamiento
Questions from article: “ADULT EVANS SYNDROb)
pobreza
ME: COMPLETE HEMATOLOGIC RECOVERY
c)
incapacidad fisica
WITH STEROIDS AND RITUXIMAB: A Case Red)
consumo de medicamentos
port”, by Karen J. Santiago-Ríos MD, Omayra Ree)
todas las anteriores
yes MD, Alexis Cruz MD, Nydia Rodríguez-Pabón
5.
Un aumento en la frecuencia sexual en per- MD, William Cáceres MD.
sonas mayores de 60 años:
a)
aumenta la satisfacción
b)
disminuye los sentimientos de depresión, 10. Evans syndrome is characterized by:
ansiedad, coraje, y vergüenza hacia la actividad
a.
Autoimmune hemolytic anemia and autoimsexual
c)
disminuye los sentimientos de abandono y mune thrombocytopenia
b.
Autoimmune hemolytic anemia and renal
soledad
failure
d)
todas las anteriores
c.
Autoimmune hemolytic anemia and throme)
ninguna de las anteriores
bocytosis
Autoimmune thrombocytopenia and renal
6.
La transmisión heterosexual del HIV en los d.
failure
envejecidos:
64
11.
Rituximab:
16. The following statements are TRUE about the
spleen:
a. solid organ located in the left upper quaa.
Causes depletion of T-cells expressing the drant
surface antigen CD30
b. largest collection of lymphoid tissue in
b.
Causes depletion of B-cells expressing the the
body
c. filters and removes foreign material
c.
Causes depletion of B-cells expressing the d. eliminate worn our red blood cells
e. all of the above
d.
Causes depletion of B-cells and T-cells
Therapy for autoimmune hemolytic ane- 17. Splenoptosis means:
a. absence of the spleen
b. multiple spleens
c. absence of fixation of the spleen
a.
Include splenectomy as first line
d. infarcted spleen
b.
Should begin with steroids
e. none of the above
c.
Should begin with blood transfusion
d.
None of the above
18. The most reliable method to diagnosed spleQuestions from article: “GUILLAIN-BARRE SYN- noptosis is:
a. UGIS
DROME AFTER INFLUENZA VACCINE ADMI- b. Barium enema
NISTRATION: TWO ADULT CASES”, by Valerie
c. CT Scan
Bedard Marrero MD, Ramón L. Osorio Figueroa
d.
US
with
Doppler
MD, Orlando Vázquez Torres MD.
e. MRI
13. Treatment of Guillain-Barré syndrome inQuestions from article: “RARE BENIGN BREAST
cludes all of the following EXCEPT:
TUMOR”, by Jaime Román-Díaz MD, Diógenes
a)
Either intravenous immune globulin or plas- Alayón-Laguer MD, Nelson Matos Fernández MD,
Luis Báez MD, William Caceres-Perkins MD, Dama exchange.
niel Conde-Sterling MD.
b)
Corticosteroids.
c)
Respiratory and cardiovascular monitoring. 19. Myofibroblastoma of the breast is more fred)
Venous thrombosis prophylaxis.
quently encountered in:
e)
Physical and occupational therapy.
a)
elderly males
b)
elderly females
14. The trivalent inactivated influenza vaccine c)
young males
should be avoided in:
d)
young females
e)
none of the above
a) Immunosuppressive patients.
b) Pregnant women.
20. This type of tumor is characterized by the
c) Patients allergic to eggs.
following immunohistochemistry:
d) Patients allergic to sulfa.
a)
positive immunostaining for vimentin,
e) Patient with Chronic Obstructive Pulmonary smooth-muscle actin, and fibronectin
Disease.
b)
Negative results for desmin, laminin, and
type IV collagen
15. There has been some concern that certain c)
Positive for CA 19-9
immunizations might trigger GBS in susceptible d)
Positive for CEA
individuals some of the hypothesis are:
e)
None of the above
21. The management and prognosis of patients
a) Immunological predisposition among the is:
patients
a)
Poor prognosis after surgery
b) Molecular mimicry
b)
Good prognosis after surgery
c) Endotoxin concentration in the content of c)
High recurrence rate after surgery
the vaccine
d)
All of the above
d) All of the above
e)
None of the above
12.
mia:
Questions from article: “LAPAROSCOPIC SPLENECTOMY FOR INFARCTED SPLENOPTOSIS
IN A CHILD: A Case Report”, by Jorge Carmona
MS, Humberto Lugo Vicente MD.
Questions from article: “INTESTINAL ENDOMETRIOSIS AS A CAUSE OF RECTAL BLEEDING: A
Case Report”, by Jeannette A. Vergelí Rojas MD,
Lenny Pagán Rodríguez MD, Carmen Santiago
Muñoz MD, Sylvia Gutiérrez Rivera MD.
65
22. What is the estimated prevalence of endometriosis in Puerto Rico?
a.
3%
b.
4%
c.
10 %
d.
17 %
e.
none of the above
23. Which is the most accepted hypothesis for
intestinal endometriosis?
Acredite su actividad
de Educación Médica
Continuada en
ACCME a través de
nuestra Asociación
Médica de Puerto
Rico, representante
exclusiva de ACCME
en Puerto Rico
a.
Sampson’s theory (retrograde menstruation through fallopian tubes)
b.
c.
d.
e.
Altered immunity
Implantation theory
All of the above
None of the above
24. Which of the following can be caused by an
intestinal endometrioma?
a.
Rectal bleeding
b.
Bowel Obstruction
c.
Perforation
d.
Altered bowel habits
e.
All of the above
ANSWERS
1- 2- 3- 4- 5- 6- 7- 8- 9- 10-
11- 12- 13- 14-
15-
16- 17- 18- 19-
20-
21- 22- 23- 24-
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(A)
(B)
(B)
(B)
(B)
(B)
(B)
(B)
(B)
(B)
(B)
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(B)
(B)
(B)
(B)
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(B)
(B)
(B)
(B)
(B)
(B)
(B)
(B)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(C)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(D)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
(E)
CME Credits
Boletin Asoc Med PR Vol 102 No 02, 2010
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texto justificado, espacio simple, doble espacio entre parrafos. Titulos en
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We will accept works sent by e-mail, only, to:
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Deberá incluirse lo siguiente: título, nombre de autor(es) y su grado (ej.: MD,
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El articulo debe comenzar con una breve introducción en la cual se
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• Nomenclatura
Deben usarse los nombres genéricos de los medicamentos. Podrán usarse
también los nombres comerciales, entre paréntesis, si así se desea se
usará con preferencia el sistema métrico de pesos y medidas.
• Resumen
Un abstracto no mayor de 250 palabras en estudios clínicos y no mayor
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escrito en inglés y en español.
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aparición en el texto. Los números deben aparecer en paréntesis al nivel
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“Cumulative Index Medicus" que publica la Asociación Médica Americana.
Las referencias deben seguir el patrón que se describe a continuación.
1. Para artículos de revistas: Apellido(s) e iniciales del nombre del autor(es),
título del artículo, nombre de la revista, año, volumen, páginas. Por ejemplo:
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73: 479-87. Si hay más de 7 autores, incluir los primeros 3 y añadir et al.
2. Para citación de libros donde el autor(es) del capítulo citado es a su
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número de edición, ciudad, casa editora, año y página. Por ejemplo: Keith
JD, Rowe RD, Vlad P: Heart disease in infancy and childhood, 3d. Ed., New
York, MacMillan, 1978: 789
3. Para citación de libros donde el editor(es) no es el autor(es) del capítulo
citado se añade el autor(es) del capítulo y el título del mismo. Por ejemplo:
Olley PM: Cardiac arrythmias; In: Keith ID, Rowe RD, Vlad P Eds. Heart
disease in infancy and childhood, 3d Ed., New York, MacMillan, 1978: 275301
[email protected]
Abstract in Spanish and English.
Should include the following: title, authors and their degrees (e.g. MD,
FACP), city where the work was done, hospital or academic institutions,
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meeting the place and date should be given.
The article should start with a brief introductory paragraph or paragraphs
which should state its purpose. The main sections (for example, Materials
and Methods) should be identified by heading in bold capital letters.
Articles reporting the results of clinical studies or laboratory investigation
should be organized under the following headings: Introduction, Materials
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• Nomenclature
Generic names of drugs should be used; trade names my also be given
in parenthesis, if desired, metric units of measurement should be used
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• Abstract
An abstract not longer than 250 words for clinical studies and no longer than
150 words for case reports and reviews. It must include the main points that
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results, and conclusions. The Abstract should be written both in Spanish
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1. For periodicals: Surname and initials of author(s), title of article, name
of journal, year, volume, pages. For example: Villavicencio R.: Soplos
inocentes en pediatría. Bol Asoc Med P Rico 198 1; 73: 479 87. If there are
more than 7 authors list only 3 and add et al.
2. For books when the authors of the cited chapter is at the same time the
editor: Surname and initials of author(s), title, edition, city, publishing house,
~ear and page. For example: Keith JD, Rowe RD, Vlad P: Heart disease in
infancy and childhood, 3d Ed., New York, MacMillan, 1978: 789
3. For chapter in book when the author of the chapter is not one of the Olley
PM: Cardiac arrythmias: In: Keith JD, Rowe RD, Vlad P. Eds. Heart disease
in infancy and childhood, 3d Ed. New York, MacMillan, 1978, 275-301
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mí sinceramente me gustaba
“ Afumar,
y en realidad jamás
pensé que lo dejaría.
”
ex fumadora desde ‘07
Lisa dejó de fumar con CHANTIX y con apoyo.
Con CHANTIX puedes fumar durante la primera semana de tratamiento. Además, es una pastilla sin nicotina
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nicotina antes de que llegue a los receptores. En los estudios, el 44% de los usuarios de CHANTIX había
dejado de fumar durante la 9ª a 12ª semana del tratamiento (comparado con 18% que tomaron placebo). Para
saber más acerca de CHANTIX y escuchar a otros ex fumadores, visite www.chantix.com.
Hable
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paraque
verusted
si CHANTIX
el medicamento
apropiado
para usted.
CHANTIX
es unacon
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y su médicoes
pueden
considerar. Llame
al 1-877-CHANTIX
(242-6849).
CHANTIX es una opción de tratamiento que usted y su médico pueden considerar. Llame al 1-877-CHANTIX (242-6849).
Información Importante de Seguridad:
Algunas personas han tenido cambios en el comportamiento, hostilidad, agitación, estado de ánimo deprimido,
pensamientos o conducta suicida mientras están usando CHANTIX para ayudarlas a dejar de fumar. Algunas personas
han tenido estos síntomas cuando comenzaron a usar CHANTIX, mientras otras los manifestaron luego de varias
semanas de tratamiento o después de que dejaron de usar CHANTIX. Si usted, su familia o la persona que le cuida
observan agitación, hostilidad, depresión o cambios de comportamiento, pensamiento o estado de ánimo, que no son
típicos en usted, o si manifiesta pensamientos o conducta suicida, ansiedad, pánico, agresión, coraje, manía,
sensaciones anormales, alucinaciones, paranoia o confusión, deje de tomar CHANTIX y llame a su médico
inmediatamente. Dígale también a su médico si tiene un historial de depresión u otros problemas de salud mental,
antes de tomar CHANTIX, puesto que estos síntomas se pueden agravar mientras toma CHANTIX.
Algunas personas pueden tener reacciones cutáneas graves mientras están tomando CHANTIX, algunas de las cuales pueden ser
potencialmente mortales. Estas pueden incluir erupción, hinchazón, enrojecimiento y descamación de la piel. Algunas personas pueden
tener reacciones alérgicas a CHANTIX, algunas de las cuales pueden ser potencialmente mortales e incluyen: hinchazón de la cara,
boca y garganta, las cuales pueden causar problemas respiratorios. Si tiene estos síntomas o tiene una erupción con piel descamada o
ampollas en la boca, deje de tomar CHANTIX y busque ayuda médica de inmediato.
Los efectos secundarios más comunes son náuseas, problemas para dormir, estreñimiento, gases y vómitos. Si tiene efectos
secundarios que le incomodan o persisten, llame a su médico.
Los pacientes también informaron que tuvieron problemas para dormir y sueños demasiado intensos, inusuales o extraños. Tenga
cuidado al manejar u operar maquinaria hasta que sepa cómo CHANTIX le puede afectar.
Puede que necesite una dosis más baja de CHANTIX si tiene problemas renales o recibe diálisis. Antes de comenzar a tomar
CHANTIX, infórmele a su médico si está embarazada, espera quedar embarazada, o si toma insulina, medicamentos para el asma o
anticoagulantes.
Medicamentos como estos pueden funcionar de manera distinta cuando deje de fumar. CHANTIX no se debería tomar con otros
medicamentos para dejar de fumar. Si tiene una recaída y vuelve a fumar, siga intentando dejar de fumar.
CHANTIX es un medicamento con receta para ayudar a adultos de 18 años o más a dejar de fumar.
Por favor véase el resumen del paciente de "Important Facts about Chantix” en la próxima página.
Le exhortamos a informar al FDA sobre efectos secundarios adversos de los medicamentos recetados.
Visite www.fda.gov/medwatch or call 1-800-FDA-1088.
CHU01195SP © 2009 Pfizer Inc. Todos los derechos reservados.
“Qué manera
de despertar, tuve
un infarto cardiaco
a los 57 años”
~John E.
Lafayette, CA
Infarto cardiaco:
16 de agosto de 2007
“Debí haber hecho algo más sobre mi colesterol. Aprendí mi lección de la manera
más difícil. Ahora le confío mi corazón a Lipitor. Hable con su médico acerca de
su riesgo y acerca de Lipitor.”
●
Cuando la dieta y el ejercicio no son suficientes, añadir Lipitor puede ayudar. A diferencia de otros
medicamentos para reducir el colesterol, Lipitor está aprobado por la Administración de Drogas
y Alimentos (FDA por sus siglas en inglés) para reducir el riesgo de ataques cardiacos y eventos
cardiovasculares en pacientes con múltiples factores de riesgo como historial familiar, presión arterial
alta, bajo nivel de HDL (colesterol “bueno”), edad y fumar.
●
LIPITOR es uno de los medicamentos más estudiados con más de 16 años de investigaciones. Lipitor está
respaldado por más de 400 estudios continuos y completados.
INFORMACIÓN IMPORTANTE: LIPITOR es un
medicamento con receta. Se le administra a pacientes con
múltiples factores de riesgo de enfermedad cardiaca, como
historial familiar, presión arterial alta, edad, bajo nivel de HDL
(colesterol “bueno”) o ser fumador para reducir el riesgo de
infartos cardiacos, accidentes cerebrovasculares y ciertos tipos
de cirugías del corazón. Cuando la dieta y el ejercicio solos no
son suficientes, se usa LIPITOR junto con una dieta baja en
grasas y ejercicios para disminuir el colesterol.
LIPITOR no es para todo el mundo. No es para aquellas
personas con problemas de hígado ni para mujeres que
estén lactando, estén embarazadas o que puedan quedar
embarazadas. Si toma LIPITOR, infórmele a su médico sobre
cualquier dolor o debilidad muscular nuevos. Esto pudiera
ser señal de efectos secundarios musculares raros, pero
serios. Infórmele a su médico sobre todos los medicamentos
que usa. Esto puede ayudar a evitar interacciones serias entre
medicamentos.Su médico debe hacerle pruebas de sangre para
verificar su función hepática antes y durante el tratamiento y
podría ajustar su dosis. Los efectos secundarios más comunes
son gases, estreñimiento, dolor estomacal y acidez. Estos
tienden a ser leves y, a menudo, desaparecen.
Cuando la dieta y el ejercicio no son suficientes, añadir
LIPITOR puede ayudar. LIPITOR es una de muchas
opciones de tratamiento para reducir el colesterol que usted
y su médico pueden considerar.
Sírvase ver información adicional importante en la próxima
página.
Hable de corazón a corazón con su médico acerca de su riesgo. Y sobre Lipitor.
Llame al 1-888-LIPITOR (1-888-547-4867) o visite www.lipitor.com/john
Le exhortamos a notificar a la Administración de Drogas y Alimentos (FDA)
sobre los efectos secundarios negativos de los medicamentos con receta.
Visite www.fda.gov/medwatch o llame al 1 800 FDA 1088.
2008 Pfizer Inc. Todos los derechos reservados. LPU01085
DATOS IMPORTANTES
PARA DISMINUIR SU NIVEL
ALTO DE COLESTEROL
El nivel alto de colesterol es más que un simple número.
Es un factor de riesgo que no se debería ignorar. Si su
médico le dijo a usted que tiene un nivel alto de colesterol,
podría estar en riesgo de sufrir un infarto cardiaco; pero la
buena noticia es que usted puede tomar medidas para
disminuir su colesterol.
Con la ayuda de su médico y un medicamento para
disminuir el colesterol como LIPITOR, y junto con una
dieta y ejercicios, usted podría estar en camino a disminuir
su colesterol.
¿Listo para comenzar a comer bien y ejercitarse más?
Hable con su médico y visite la página Web de la
Asociación Americana del Corazón,
www.americanheart.org.
POSIBLES EFECTOS
SECUNDARIOS DE LIPITOR
Serios efectos secundarios en un pequeño número de
personas:
• Problemas musculares que pueden conducir a problemas
renales, incluso fallo renal. Su probabilidad de tener
problemas musculares es mayor si toma otros
medicamentos específicos con LIPITOR.
• Problemas hepáticos: Su doctor puede hacerle pruebas de
sangre para verificar su hígado antes de tomar LIPITOR y
mientras lo está tomando.
Los síntomas de problemas musculares o hepáticos incluyen:
• Debilidad o dolor muscular inexplicable, especialmente si
tiene fiebre o siente mucho cansancio
• Náusea, vómitos o dolor estomacal
• Orina de color marrón u otro color oscuro
• Siente más cansancio de lo usual
• Su piel y la parte blanca de sus ojos se ponen amarillas
Si tiene estos síntomas, llame a su médico de inmediato.
Los efectos secundarios más comunes de LIPITOR
son:
¿PARA QUIÉN ES LIPITOR?
Quién puede tomar LIPITOR:
• Personas que no pueden disminuir su colesterol lo
suficiente con dieta y ejercicio
• Adultos y niños mayores de 10 años
Quién NO debería tomar LIPITOR:
• Mujeres embarazadas, que pueden estar embarazadas o
pueden quedar embarazadas. LIPITOR puede hacerle
daño al bebé por nacer. Si usted queda embarazada, pare
de tomar LIPITOR y llame a su médico de inmediato.
• Mujeres que están lactando. LIPITOR puede pasar a la
leche materna y puede hacerle daño a su bebé.
• Personas con problemas hepáticos.
• Personas alérgicas a cualquier ingrediente de LIPITOR.
• Dolor de cabeza • Estreñimiento
• Diarrea, gas
• Malestar o dolor estomacal
• Erupción cutánea • Dolor muscular y articular
Por lo general, los efectos secundarios son leves y pueden
irse por sí solos. Menos de 3 personas en 100 dejaron de
tomar LIPITOR debido a los efectos secundarios.
CÓMO TOMAR LIPITOR
Qué hacer:
• Tome LIPITOR según recetado por su médico.
• Intente comer alimentos saludables para el corazón
mientras toma LIPITOR.
• Tome LIPITOR en cualquier momento del día, con o sin
comida.
• Si se olvida de tomar una dosis, tómesela tan pronto se
acuerde, pero espere si han pasado más de 12 horas desde
que olvidó la dosis. Tómese la próxima a su hora
establecida.
Qué no hacer:
ANTES DE TOMAR LIPITOR
Háblele a su médico :
• Acerca de todos los medicamentos que está tomando,
incluso medicamentos con receta, medicamentos sin
receta (OTC, por sus siglas en inglés), vitaminas y
suplementos herbáceos
• Si tiene dolores o debilidad muscular
• Si ingiere más de dos bebidas alcohólicas al día
• Si tiene diabetes o problemas renales
• Si tiene un problema de la tiroides
ACERCA DE LIPITOR
LIPITOR es un medicamento con receta. Disminuye, junto
con la dieta y el ejercicio, el colesterol “malo” en la sangre.
También puede aumentar el colesterol “bueno” (HDL-C,
por sus siglas en inglés).
LIPITOR puede disminuir el riesgo de infartos cardiacos o
accidentes cerebrovasculares en pacientes que tienen
factores de riesgo de enfermedad cardíaca, tales como:
• Edad, ser fumador, presión arterial alta, bajos niveles
de HDL-C, enfermedades cardíacas en la familia
• DiabetesLP278791-A
con un factor de riesgo como problemas
oculares y renales, ser fumador o presión arterial alta
• No cambie su dosis ni pare de tomársela sin antes hablar
con su médico.
• No comience a tomar nuevos medicamentos sin antes
hablar con su médico.
• No le dé su medicamento LIPITOR a otras personas. Esto
puede hacerles daño aún si tienen los mismos problemas
que usted.
• No rompa la tableta.
¿NECESITA MÁS INFORMACIÓN?
• Pregúntele a su médico o proveedor de servicios de
salud.
• Hable con su farmacéutico.
• Vaya a www.lipitor.com o llame al 1-888-LIPITOR
Lipitor está incluido en el programa de ahorros en
medicamentos con receta “Together RX Access™”.
Para información adicional llame al 1-800-444-4106
o visite www.TogetherRxAccess.com
Sólo con
receta
Fabricado por Pfizer Ireland Pharmaceuticals
Dublín, Irlanda
Distribuido por Parke-Davis, Division de Pfizer, Inc.
Nueva York, NY 10017 USA
© 2005 Pfizer Ireland Pharmaceuticals
Todos los derechos reservados. Impreso en los EUA.
LPIF Rev 2, Dic. 2005
LPU01085
Corporación de Servicios
Tecnológicos Médicos, inc.
Creada por la Asociación Médica de Puerto Rico para asistir a
los profesionales de salud en el desafío tecnológico de la era.
Empresas aliadas
Software
Tecnología Informática Médica
Conexión
www.cstmpr.net
eHr - eRx - eBilling
Total Office Solution
Software y hardware
Conexión banda ancha
Asesoramiento gratuito
Instalación y configuración
Educación y entrenamiento
Soporte tecnológico continuo
Oficinas Centrales:
Ave. Fernández Juncos 1305
Santurce, PR 00908
Tel: (787) 721-6969 - Email: [email protected]
(In vitro data; clinical significance unknown.
Full course of therapy is complete in 7 days.)1,2
n
ZYMAR® ophthalmic solution rapidly eradicates
key pathogens in vitro, including:
S aureus: eradicated in 15 minutes1,*
S epidermidis: eradicated in 30 minutes1,*
S pneumoniae: eradicated in 10 minutes2,*
H influenzae: eradicated in 5 minutes2,*
* Time to reach kill threshold. 10 CFU/mL is the lower limit of detection and is
indistinguishable from complete kill.
ZYMAR® ophthalmic solution is indicated for the treatment of bacterial conjunctivitis caused by susceptible strains
of the following organisms: Corynebacterium propinquum,† Staphylococcus aureus, Staphylococcus epidermidis,
Streptococcus mitis,† Streptococcus pneumoniae, and Haemophilus influenzae. (†Efficacy for this organism was studied
in fewer than 10 infections.)
Important Safety Information: NOT FOR INJECTION. ZYMAR® ophthalmic solution should not be injected
subconjunctivally, nor should it be introduced directly into the anterior chamber of the eye. As with other antiinfectives, prolonged use may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection
occurs, discontinue use and institute alternative therapy. Patients should
be advised not to wear contact lenses if they have signs and symptoms of
bacterial conjunctivitis.
®
The most frequently reported adverse events occurring in approximately 5%
to 10% of the overall study population were conjunctival irritation, increased
lacrimation, keratitis, and papillary conjunctivitis.
Please see brief prescribing information on adjacent page.
1. O’Brien TP. Antimicrobial efficacy of ZYMAR® and Vigamox® against Staphylococcus species. Refract Eyecare Ophthalmol. 2003;7(12):15-18. 2. Novosad BD, Callegan MC.
Killing of Streptococcus pneumoniae, methicillin-resistant Staphylococcus aureus (MRSA), and Haemophilus influenzae ocular isolates by fourth-generation fluoroquinolones.
Poster presented at: 78th Annual Meeting of the Association for Research in Vision and Ophthalmology; April 30-May 4, 2006; Fort Lauderdale, FL.
©2009 Allergan, Inc., Irvine, CA 92612 www.allergan.com ® marks owned by Allergan, Inc.
ZYMAR® is licensed from Kyorin Pharmaceutical Co., Ltd., Tokyo, Japan. APC50TC09 803807

Asociación Médica de Puerto Rico - Asociacion Medica de Puerto

Transcription

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