Se inaugura la Semana Enfermedades Digestivas 2011 en Sevilla‏

Hoy domingo 12 de junio se ha inaugurado en Sevilla la Semana de las Enfermedades Digestivas 2011, organizada por la Sociedad Española de Patología Digestiva (SEPD), con el XVIII Curso de Postgrado de la American Gastroenterological Associtation (AGA) y la Soceidad Española de Patología Digestiva (SEPD). El curso ha permitido conocer a los asistentes la evidencia científica más relevante a nivel internacional sobre 16 temas de gastroenterología y hepatología.

Los expertos han destacado especialmente que los casos de Esófago de Barrett se han multiplicado por cinco en los último 30 años. Recomiendan el uso de un tratamiento endoscópico, incluso en los casos de displasia de bajo grado, ya que permite sustituir con mejores resultados, en cuanto a morbilidad y mortalidad, las terapias quirúrgicas.

El Esófago de Barrett se produce por una complicación de la Enfermedad por Reflujo Gastroesofágico (ERGE).
Cuando el ácido del estómago asciende dentro del esófago durante un periodo de tiempo largo, puede modificar el tejido de revestimiento del esófago, produciendo lo que se conoce como Esófago de Barrett. Las últimas evidencias sitúan al tabaco, el hecho de dormir inmediatamente después de comer o la obesidad, como factores que aumentan el riesgo de padecerlo.

Important monitoring of heart performance is omitted in two-thirds of high-risk surgical operations

Only 35% of anaesthesiologists are carrying out a simple procedure during high-risk surgery that can make a significant impact on how well patients recover from their operations, according to new research presented today (Sunday 12 June) at the European Anaesthesiology Congress in Amsterdam. A survey of 463 randomly selected European and US anaesthesiologists found that although more than 95% of them knew that it was of major importance that enough oxygen reached all parts of the body during an operation and that this was determined by how well the heart was pumping blood around the body, 65% of them were failing to monitor the amount of blood the heart was pumping – a procedure known as cardiac output monitoring.
As a result of their findings, the authors of the study, led by Dr Maxime Cannesson, an Associate Professor of Anaesthesiology at the University of California, Irvine (USA), are calling for action at national and international level to ensure that cardiac output monitoring is carried out for all high-risk surgical operations.The numbers of operations affected are significant. High-risk surgery represents about 10-14% of all the 240 million surgeries performed each year worldwide, meaning that about 30 million patients in the world are undergoing high-risk surgery every year. Examples of high-risk surgery include operations on the liver, pancreas, aorta (the largest artery in the body), most cancer surgery, and orthopaedic surgery, for instance on the spine or for hip fractures.
Dr Cannesson said: “Several studies have shown that when anaesthesiologists measure and then set goals for cardiac output during high-risk surgery, their patients will have fewer postoperative complications, a shorter stay in the hospital after the surgery, and fewer of them will die in the postoperative period. The idea is very simple: since oxygen is of major importance to the body when it is experiencing stress, as in the case of high-risk surgery, it seems logical that setting goals for maximising the delivery of oxygen to the tissues would improve patients' care. Oxygen is used by the cells in order to produce energy and to fight the stress. If the cells and tissues do not receive oxygen during the surgery, they are going to produce toxins, which will eventually worsen the situation and increase postoperative complications such as infection, kidney failure, pneumonia, and so forth. It's like running a marathon at high altitudes where there is very little oxygen: you get short of breath very quickly and soon you'll develop chest pain and expose your body to high risk if you do not stop running.
” There are three main parameters that anaesthesiologists measure to check on oxygen delivery: levels of haemoglobin (the iron-containing, oxygen-carrying protein in red blood cells), oxygen saturation (how much oxygen the blood is carrying), and the cardiac output. Haemoglobin levels are usually checked regularly during high-risk surgery; continuous measuring of oxygen saturation is compulsory during anaesthesia in all European countries; but, as this study shows, cardiac output monitoring does not happen on a regular basis. “Yet, if cardiac output is not measured there is no way to know whether oxygen is delivered appropriately to the tissues or not,” said Dr Cannesson.
“Our study shows that there is a need for action by national and international professional societies to ensure that cardiac output monitoring is used in clinical practice for these patients. There should be a European and US task force that comes up with recommendations regarding all haemodynamic monitoring [monitoring of blood flow] during surgery in order to improve the care of patients,” he said. The main reasons given for not monitoring cardiac output were: the cardiac output monitors were too invasive; anaesthesiologists were using a surrogate for cardiac output monitoring such as checking variations in pulse pressure; and 30% of respondents believed that cardiac monitoring did not provide important information. Dr Cannesson said: “The last reason is interesting given that nearly all of them say that they know that oxygen delivery is of major importance and that cardiac output is involved in oxygen delivery!” He said that current cardiac output monitoring was no longer as invasive as it used to be when it involved a catheter inserted into the pulmonary artery. Nowadays, there were several, minimally invasive ways of doing it. Furthermore, using surrogates such as pulse pressure variations, could not substitute for cardiac output measurements.
“They have not been shown to improve patients’ outcome and can only be used in 40% of patients under anaesthesia. They are excellent adjuncts to cardiac output monitoring, and should be included in the clinical management wherever possible, but they should not replace it,” he said. Now Dr Cannesson and colleagues are running a multi-centre study in California focusing on the impact on patient care and postoperative outcome of the implementation of guidelines and checklists for monitoring blood flow during high-risk surgery. “Medical researchers are very good at finding the mechanisms underlying various conditions and developing research programmes aimed at developing better treatments. But our research shows that a crucial aspect of this is lacking: the delivery to the patient. Researchers and international professional societies should also be focusing on ensuring that when a treatment is appropriate for a condition or a situation, that this treatment is actually applied to the patient.”

EL 70% DE LOS PACIENTES CON INSUFICIENCIA RENAL SUFRE DISFUNCION ERÉCTIL

Más de un 70% de los pacientes con insuficiencia renal crónica sufren disfunción eréctil (DE). “Se trata de una combinación de causas. Por un lado, por la propia enfermedad renal que va asociada a factores cardiovasculares, como hipertensión, diabetes y, por otro, a la propia diálisis y a la polimedicación a las que está sometido, sin olvidar el factor psicológico”. Así lo ha señalado el doctor Ignacio Moncada, coordinador del Grupo de Andrología de la Asociación Española de Urología (AEU), en el marco del LXXVI Congreso Nacional de Urología que estos días reúne a más de mil expertos en el Palacio de Ferias y Congresos de Málaga.

Dos millones de españoles entre los 40 y 50 años padecen esta alteración sexual, pero sólo entre un 35-40% de ellos consulta por este motivo al médico. En el caso de los pacientes con insuficiencia renal hay que añadir que, además, están preocupados por su enfermedad de base. Sin embargo, como señala este experto, “hay que tener en cuenta que la sexualidad es un problema de salud para el que existen tratamientos eficaces y seguros y es importante desterrar los falsos mitos asociados a esta alteración. Muchos de los pacientes con insuficiencia renal son jóvenes a los que les preocupa la DE y demandan una solución”.

El tratamiento de la DE de estos pacientes es similar al de aquellos que no tienen insuficiencia renal. El primer paso es identificar los factores de riesgo y tratarlos. Existen distintas opciones, que pueden comenzar por adoptar hábitos de vida saludables, como el abandono del tabaquismo y el alcohol, evitar el estrés y las comidas copiosas y realizar ejercicio físico. “En ocasiones”, señala el doctor Moncada, “no son suficientes estas medidas y se recurre a otros tratamientos, como los orales y la inyección intracavernosa. En el último eslabón estaría la cirugía de prótesis de pene”.

Los tratamientos menos invasivos, como son llevar unos hábitos de vida saludables y la terapia farmacológica, pueden resolver entre un 60-70% de los casos, pero todavía un 30-40% de los varones precisa recurrir a la cirugía, a las inyecciones intracavernosas y a los implantes de prótesis.

-Una solución muy eficaz
En los últimos años las prótesis han mejorado tanto mecánicamente, como en seguridad y eficacia “no se rompen ni se estropean y los fabricantes las garantizan de por vida. No hay que olvidar que se está implantando un cuerpo extraño que al principio daba problemas de infección, y que ya se han resuelto. Ahora mismo es excepcional que hubiera una infección o un fallo mecánico”, explica este experto.

El implante de prótesis, según este experto, es el método que da más satisfacción, según las encuestas, en las que “por supuesto, también participa la pareja, porque la sexualidad es un tema de ambos y no solo se busca la satisfacción de la persona que tiene problemas, también la de su pareja”, aclara el doctor Moncada.

Los criterios para recibir un implante de prótesis pasa porque la persona sea sexualmente activa y porque el problema orgánico que causa la DE no se haya resuelto con otros tratamientos. “El implante de prótesis resuelve el problema de una vez por todas, y el 90% de las personas implantadas volvería a operarse”. Se trata, eso sí, de un tratamiento irreversible.

La insuficiencia renal no sólo ocasiona problemas de sexualidad, sino también de fertilidad, “ya que se altera tanto el número como la movilidad de los espermatozoides. Con frecuencia estos pacientes tienen que recurrir a técnicas de reproducción asistida”, señala este experto.

Hypnosis/local anaesthesia combination during surgery helps patients and reduces hospital stays

Using a combination of hypnosis and local anaesthesia (LA) for certain types of surgery can aid the healing process and reduce drug use and time spent in hospital, anaesthesiologists have found. The combination could also help avoid cancer recurrence and metastases, according to new research to be presented today (Sunday) at the European Anaesthesiology Congress in Amsterdam.
Professor Fabienne Roelants and Dr. Christine Watremez, from the Department of Anaesthesiology at the Cliniques Universitaires St. Luc, UCL, Brussels, Belgium, studied the impact of using LA and hypnosis in certain kinds of breast cancer surgery and in thyroidectomy (removal of all or part of the thyroid gland). "In all of these procedures local anaesthesia is feasible but not, on its own, sufficient to ensure patient comfort," says Professor Roelants.
In the first study, 18 women out of 78 had hypnosis for a number of breast cancer surgical procedures – quadrantectomy (partial mastectomy), sentinel node biopsy (examination of the first lymph node or group of lymph nodes likely to be reached by metastasising cancer cells) and axillary dissection (opening the armpit to examine or remove some or all of the lymph nodes) – while the rest had general anaesthetic (GA) or the same operations. Although the patients who were hypnotised spent a few minutes more in the operating theatre, opioid drug use in the first group was greatly diminished, as was time in the recovery room and hospital stay.
In the thyroid study, the researchers compared the outcomes of 18 patients in the LA/hypnosis group with 36 who had GA. Both groups had video-assisted thyroidectomy, in an attempt to decrease the invasiveness of the procedure without reducing patient comfort. Once again drug use, recovery room and hospital stay times were greatly reduced among the LA/hypnosis group.
"In addition to reducing drug use and hospital stay time, being able to avoid general anaesthesia in breast cancer surgery is important because we know that local anaesthesia can block the body’s stress response to surgery and could therefore reduce the possible spread of metastases," Professor Roelants will say.
"Together with other anaesthesiologists at the hospital, we are specialised in hypnosis," says Dr. Watremez. "Although there are special precautions to be taken – for example, only the hypnotherapist should talk to the patient during the procedure and should avoid negatives, which unconsciousness cannot handle, and the surgeon needs to be gentle, avoid any tugging in his movements, and be able to remain cool in all circumstances – it is a straightforward procedure and appreciated by the patients.
"Imagine you are driving your car. You suddenly realise how far you have driven, but for a long time your mind has been elsewhere. This is extremely common, and is nothing more nor less than a mild hypnotic trance – a modified state of consciousness, with a different perception of the world. The principle of hypnosis is to focus one’s attention on one particular point," she says.
That point may be eye fixation, progressive muscle relaxation, or the retrieval of a pleasant memory. That hypnosis works in reducing the perception of pain has been shown by a number of studies, including by imaging the brain with position emission tomography (PET). Similar effects have been shown by using functional magnetic resonance imaging (MRI). Exactly how hypnosis works in this respect is still under discussion. Some researchers believe that it prevents information from reaching the higher cortical regions that are responsible for the perception of pain. Others believe that it permits a better response to pain by activating pain-inhibiting paths more effectively.
"There is still a lot of debate around the exact mechanism that allows hypnosis to reduce pain perception," says Professor Roelants," but what it absolutely clear is that it does so. The result is that one third of thyroidectomies and a quarter of all breast cancer surgery carried out at the UCL hospital are performed under local anaesthetic with the patient under hypnosis."
There are no sex or age differences relating to susceptibility to hypnosis, the researchers say. If the patient is motivated, ready to co-operate, and trusts the doctors, hypnosis will work. In addition to use in breast cancer surgery and thyroidectomy, the practice can be used in a number of other surgical procedures, for example carotid artery surgery, inguinal hernia, knee arthroscopy, gynaecological surgery, ophthalmology, ear nose and throat, plastic surgery and egg retrieval for fertility treatment.
"We believe that our studies have shown considerable benefits for the LA/hypnosis combination, and that such benefits are not only for patients, but also for healthcare systems. By using hypnosis combined with LA we can reduce the costs involved in longer hospital stays, remove the need for patients to use opioid drugs, and increase their overall comfort and satisfaction levels. To date there are few publications about the use of hypnosis in surgery, and we hope that, by contributing to the body of evidence on its efficacity, our research will encourage others to carry out this procedure to the advantage of all concerned," Dr. Watremez will conclude.

3-D movie shows, for the first time, what happens in the brain as it loses consciousness

For the first time researchers have been able to watch what happens to the brain as it loses consciousness. Using sophisticated imaging equipment they have constructed a 3-D movie of the brain as it changes while an anaesthetic drug takes effect.
Brian Pollard, Professor of Anaesthesia at The University of Manchester (UK), told the European Anaesthesiology Congress in Amsterdam that the real-time 3-D images seemed to show that losing consciousness involves a change in electrical activity deep within the brain, changing the activity of certain groups of nerve cells (neurons) and hindering communication between different parts of the brain. He said the findings appear to support a hypothesis put forward by Professor Susan Greenfield, of the University of Oxford, about the nature of consciousness itself. Prof Greenfield suggests consciousness is formed by different groups of brain cells (neural assemblies), which work efficiently together, or not, depending on the available sensory stimulations, and that consciousness is not an all-or-none state but more like a dimmer switch, changing according to growth, mood or drugs. When someone is anaesthetised it appears that small neural assemblies either work less well together or inhibit communication with other neural assemblies.
“Our findings suggest that unconsciousness may be the increase of inhibitory assemblies across the brain’s cortex. These findings lend support to Greenfield’s hypothesis of neural assemblies forming consciousness,” said Prof Pollard. The team use an entirely new imaging method called “functional electrical impedance tomography by evoked response” (fEITER *), which enables high speed imaging and monitoring of electrical activity deep within the brain and is designed to enable researchers to measure brain function. The new device was developed by a multidisciplinary team drawn from the Schools of Medicine and Electrical and Electronic Engineering at The University of Manchester (UK) led by Professor Hugh McCann and with support from a Wellcome Trust Translation Award.
The machine itself is a portable, light-weight monitor, which can fit on a small trolley. It has 32 electrodes that are fitted around the patient’s head. A small, high-frequency electric current (too small to be felt or have any effect) is passed between two of the electrodes, and the voltages between other pairs of electrodes are measured in a process that takes less than one thousandth of a second. An “electronic scan” is thus carried out and the machine does this whole procedure 100 times a second. By measuring the resistance to current flow (electrical impedance), a cross sectional image of the changing electrical conductivity within the brain is constructed. This is thought to reflect the amount of electrical activity in different parts of the brain.
The speed of the response of fEITER is such that the evoked response of the brain to external stimuli, such as an anaesthetic drug, can be captured in rapid succession as different parts of the brain respond, thus tracking the brain’s processing activity.“We have looked at 20 healthy volunteers and are now looking at 20 anaesthetised patients scheduled for surgery,” said Prof Pollard. “We are able to see 3-D images of the brain’s conductivity change, and those where the patient is becoming anaesthetised are most interesting.” “We have been able to see a real time loss of consciousness in anatomically distinct regions of the brain for the first time. We are currently working on trying to interpret the changes that we have observed. We still do not know exactly what happens within the brain as unconsciousness occurs, but this is another step in the direction of understanding the brain and its functions.” The team at Manchester is one of many worldwide teams investigating electrical impedance tomography (EIT), but this is its first application to anaesthesia.
Prof Pollard said that a huge amount of research still needed to be done to fully understand the role EIT could play in medicine. “If its power can be harnessed, then it has the potential to make a huge impact on many areas of imaging in medicine. It should help us to better understand anaesthesia, sedation and unconsciousness, although its place in medicine is more likely to be in diagnosing changes to the brain that occur as a result of, for example, head injury, stroke and dementia. “The biggest hurdle is working out what we are seeing and exactly what it means, and this will be an ongoing challenge,” he concluded.

Sesión en directo de la SEPD en Sevilla

Hoy se ha celebrado en Sevilla el Curso práctico de avances en endoscopia, ecoendoscopia y ecografía digestiva, en el marco de la SED 2011, el encuentro científico de referencia en el campo de la gastroenterología a nivel nacional. Organizado por la Sociedad Española de Patología Digestiva (SEPD), celebra su LXX Congreso Anual, que tendrá lugar desde hoy 11 de junio en Sevilla hasta el próximo martes 14. Durante esta sesión en directo, los asistentes han podido observar y opinar a tiempo real acerca de las técnicas más novedosas en cuanto a cirugía gastrointestinal, realizadas paralemente en el quirófano del Hospital Virgen Macarena.

Entre otras, han podido asistir a la La Embolización de las varices gástricas con Endocoil, una técnica para el tratamiento de las varices gástricas que se realiza de forma pionera en nuestro país en el Hospital Universitario Virgen Macarena de Sevilla, desde hace cuatro años.

Otra de las técnicas pioneras mostradas en directo durante la SED 2011 es el Drenaje de un pseudoquiste pancreático, que permite eliminar una infección en el páncreas sin recurrir a la cirugía y que evita el fallecimiento en el caso de los pacientes que tienen un pseudiquiste infectado

La SEGO y MSD inician el primer ciclo formativo en Ginecología y Obstetricia a través de videoconferencia

La Sociedad Española de Ginecología y Obstetricia (SEGO) ha presentado elprimer ciclo de videoconferencias en Ginecología y Obstetricia 2011-2013. Esta propuesta formativa, dirigida a especialistas de toda España, aprovecha las nuevas tecnologías de la información y será difundida a través del portal de formación médica de MSD www.univadis.es. La iniciativa ha sido presentada por el profesor Josep María Lailla, actual presidente de la SEGO, y por su antecesor en el cargo, José Manuel Bajo Arenas. En su opinión, en la actualidad existe en la profesión una aportación continua de conocimientos novedosos que son difíciles de abarcar por lo que “apostar por la formación ‘on line’ es apostar por el futuro”.
Ante el continuo cambio de conceptos y las nuevas aportaciones de la especialidad, ambos han manifestado que “esta iniciativa marca el inicio de un proceso que será seguramente el futuro de la docencia y de la formación continuada en nuestra especialidad y en todas”. Este programa formativo, que se impartirá a lo largo de dos años, consta de cuatro módulos (Anticoncepción y Menopausia, Obstetricia y Ecografía, Endoscopia y Oncología Ginecológica, y Suelo Pélvico) y se desarrollará a través de retransmisiones ‘on line’ y en directo. Bajo Arenas explica que “podrán acceder a él todos aquellos profesionales médicos socios de la SEGO además de todos aquellos que soliciten a nuestra sociedad su interés por participar”.
Tras las videoconferencias “se abrirá un chat en el que los especialistas que participen podrán plantear cuestiones de su interés a un coordinador que canalizará sus preguntas al ponente”.“El objetivo -declara Josep María Lailla es aprovechar los avances tecnológicos y la posibilidad de dar formación a los ginecólogos sin que éstos tenga necesidad de desplazarse. Buscamos ofrecer un método asequible y fácil al que el profesional tenga acceso cómodamente desde su casa para ponerse al día”.
Para el doctor Bajo Arenas, “toda mujer de cualquier rincón de España tiene que tener acceso a una Obstetricia y a una Ginecología de la máxima calidad posible. Para ello, desde la SEGO seguiremos poniendo en marcha acciones de formación continuada para nuestros especialistas, aportándoles guías de actuación, documentos de consenso o protocolos, además de toda clase de documentación actualizada continuamente”. En opinión del doctor Lailla Vicens “con este ciclo de videoconferencias la SEGO pretende aportar un programa a través del que se puedan filtrar nuevos conocimientos, mostrarlos y que el profesional pueda recibirlos fácilmente”.

**Publicado en "EL MEDICO INTERACTIVO"