La cirugía en establecimientos de salud de atención primaria: comentario desde Perú

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1lsmbEdclttdtpptcydrglpdilemsademyiLdcSCSLcbdqd3rdd72 CARTAS AL DIRECTORos sntomas cardacos obstructivos, fenmenos emblicosistmicos o pulmonares y sntomas constitucionales. Local-ente el tumor puede causar un deterioro hemodinmicoien por obstruccin al flujo o deformacin de la vlvula2.n ocasiones, la isquemia miocrdica puede ser el sntomae presentacin. Tambin puede haber pacientes que estnompletamente asintomticos si el crecimiento el tumor esento. Se ha descrito algn caso de hemorragia aguda den-ro del propio tumor, que lleva a un aumento brusco de suamano con deterioro clnico del paciente en caso de pro-ucir sntomas obstructivos3. En la auscultacin cardaca espica la presencia de un soplo mitral que se modifica con laosicin del paciente.La ecocardiografa juega un papel fundamental paraComo conclusin, podemos decir que es importantesospechar esta entidad en pacientes jvenes, fundamen-talmente mujeres, que se presentan con sintomatologa deinsuficiencia cardiaca aguda y no tienen factores de riesgocardiovascular, en los que la clnica del paciente no puedaexplicarse por otras entidades ms frecuentes como son lacardiopata hipertensiva o isqumica.Bibliografa1. Gonzalez-Juanatey C, Regueiro-Abel M, Lopez-Agreda H, Pena-Martnez F, Gonzalez-Gay MA. Giant left atrial myxomamimicking severe mitral valve stenosis. Int J Cardiol. 2008;127:e110---2.2. Brugts JJ, van den Bos EJ, Raap JB, van de Woestijne PC, KofflardMJ, Dirkali A. Obstructive giant cardiac tumour in a patient withchest pain and acute respiratory insufficiency. J Cardiovasc Med.2012;13:274---6.3. Sonker U, Kloppenburg GT, Knoop EA, Seldenrijk CA, Morshuis WJ.Emergency surgery for acute mitral valve obstruction resultingfrom hemorrhage within a left atrial myxoma. Ann Thorac Surg.2009;87:636---8.4. Jang KH, Shin DH, Lee C, Jang JK, Cheong S, Yoo SY. Left atrialmass with stalk: Thrombus or myxoma? J Cardiovasc Ultrasound.2014;201:154---6.5. Matsushita T, Huynh AT, Singh T, Hayes P, Armarego S, Seah PW.Mitral valve annular dilatation caused by left atrial myxoma.Heart Lung Circ. 2009;18:145---7.F.J. Garciprez de Vargas , M.V. Mogolln-Jimnez,CCC(http://dx.doi.org/10.1016/j.semerg.2013.12.001es iniciar con lo ms sencillo hacia lo ms complejo; parti-cularmente en ciruga significara partir analizando desde elestado quirrgico del primer nivel de atencin en salud.Contrario a lo que popularmente se piensa, la ciruga noes un servicio exclusivo de hospitales o institutos especia-lizados. Dentro de la cartera de servicio del primer nivelse tiene establecido la atencin de partos naturales4, sutu-ras y curacin de heridas. Es correcto afirmar que dichosprocedimientos son categorizados como ciruga menor,caracterizados por no requerir anestesia general, ni exis-tir un compromiso de la vida del paciente5. Sin embargo,ello no le quita la importancia al momento de planificar ydistribuir los recursos quirrgicos del Estado, conllevandoinevitablemente a preguntar: cuntos recursos materialesoder realizar un diagnstico precoz en estos pacien-es. Nos permite descartar otras entidades que cursanon disnea y soplo, como la miocardiopata hipertrfica las valvulopatas. Es importante hacer el diagnsticoiferencial con los trombos intracardiacos, dado la dife-ente estrategia teraputica en ambos casos. Como reglaeneral, los trombos suelen aparecer en pacientes con fibri-acin auricular, aurcula izquierda dilatada, estenosis ortesis mitral y tricuspdea, situacin de bajo gasto car-iaco y presencia de ecocontraste espontneo en aurculazquierda4.El tratamiento de los mixomas cardiacos consiste ena reseccin quirrgica. La ciruga debe ser urgente, paravitar complicaciones como los fenmenos emblicos o lauerte sbita. En ocasiones es necesario actuar tambinobre la vlvula mitral si existe dilatacin del anillo o estnfectados los velos o las cuerdas por el tumor5. El pronsticoe estos tumores es en general bueno. La ciruga es curativan la mayora de los casos, aunque hay que realizar un segui-iento peridico con ecocardiografa durante varios anos,a que existen casos de recidiva, la mayora debidas a unanadecuada reseccin quirrgica.a ciruga en establecimientose salud de atencin primaria:omentario desde Perurgery in primary health care clinics:omments from Perur. Director:a ciruga est adquiriendo cada vez mayor inters interna-ional como tema de la salud pblica1,2. La razn subyaceajo la desesperante necesidad de reunir esfuerzos en favore las familias en pases de bajos y medianos recursos (PBMR)ue estn inhabilitadas para recibir una atencin quirrgicaigna. Muestra de ello se encuentra en el hecho de que el,5% de las operaciones quirrgicas en todo el mundo sonealizadas en pases de bajos recursos3. La inequidad es evi-encia del desconocimiento en cuanto a los componentesel sistema quirrgico. Generalmente lo ms recomendablesgsle. Ortiz y R. PorroServicio de Cardiologa, Hospital San Pedro de Alcntara,ceres, EspanaAutor para correspondencia.orreo electrnico: fj.garci@hotmail.comF.J. Garciprez de Vargas).e necesitan para atender la demanda de atenciones quirr-icas en establecimientos de primer nivel de atencin?Desafortunadamente, muchos establecimientos dealud de atencin primaria no toman con importancia ellenado de registros de atenciones quirrgicas o, enl peor de los casos, no se tiene un sistema de registro.dx.doi.org/http://www.elsevier.es/semergenhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.semerg.2013.11.002&domain=pdfhttp://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010mailto:estefanol@yahoo.comdx.doi.org/10.1016/j.semerg.2013.11.002http://crossmark.crossref.org/dialog/?doi=10.1016/j.semerg.2013.12.001&domain=pdfhttp://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0005http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.com/S1138-3593(13)00277-3/sbref0010http://refhub.elsevier.c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AL DIRECTOR 173Es comn ver estos casos en zonas remotas de PBMR. Eldilema est en campo de la epidemiologa. Es necesarioestablecer acciones de control epidemiolgico eficaces,comprometidos con la ciruga y la descentralizacin de susservicios a travs de inversin en redes de comunicacin. LaOrganizacin Mundial de la Salud (OMS) muestra su apoyomediante un llamado para trabajar sinrgicamente en eldesarrollo de la epidemiologa quirrgica6.El llamado incluye a todos los profesionales involucradosen ciruga, sin excepcin. En el primer nivel de atencinencontramos a enfermeras, tcnicos de laboratorio, mdi-cos, internos y obstetras. Los gobiernos, a travs de losministerios de salud, no parecen mostrar mucha disposi-cin en consolidar la ciruga en su personal de primer nivelde atencin. Universidades y organizaciones no guberna-mentales de pases desarrollados han tomado la iniciativaa travs de viajes de asistencia quirrgica, los cuales hansido aprovechados para capacitar a diversos profesionalesde la salud de PBMR. tica en ciruga7, capacitacin te-rica y prctica en procedimientos quirrgicos8,9 son algunasde las actividades que se han desarrollado con un enfoquemultidisciplinario.Muchos pases han promulgado el sistema bidireccionalde referencia y contrarreferencia (RC) con el propsito deintegrar los establecimientos de salud de diferentes niveles.Entonces, por qu aun as muchos hospitales nacionales einstitutos especializados se ven sobrecargados de pacien-tes? El motivo se puede fundamentar en el aumento de lademanda inducida e incremento de la demanda espontnea.Nos referimos a demanda inducida a aquella que segenera por el establecimiento de salud de menor nivel;en cambio, la espontnea se refiere a la demanda que elpropio paciente emite al acudir en primera instancia al esta-blecimiento de mayor nivel. Ambas demandas motivan aun desequilibrio del sistema de RC. Mientras la demandainducida puede deberse a una escasa contrarreferencia, lademanda espontnea puede verse motivada por una des-confianza en la atencin en el primer nivel de atencin.El panorama no lo comparten todos los pases. En Brasil,Gaio et al. mencionan una disminucin en costes de servi-cio, mayor disponibilidad de camas y reduccin de tiempo deinternamiento10. Sera interesante reproducir la experienciaen PBMR.En conclusin, la atencin quirrgica en establecimien-tos de salud de atencin primaria es un tema que requieretomar mayor protagonismo dentro de la salud pblica. Mayo-res esfuerzos son necesarios para comprender las fortalezasy limitaciones con respecto a la epidemiologa, educacincontinua del personal quirrgico y el sistema de referenciay contrarreferencia que estn involucrados en ciruga.Bibliografa1. Surgery----a call for papers: The Lancet Internet [consultado 1Ag 2013]. Disponible en: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60066-5/fulltext#articleupsell2. Global surgery----the final frontier? The Lancet Internet [consul-tado 1 Ag 2013]. Disponible en: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60083-X/fulltext3. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, LipsitzSR, Berry WR, et al. An estimation of the global volume ofsurgery: a modelling strategy based on available data. Lancet.2008;372:139---44.4. Ministerio de Salud del Per. Norma Tcnica de Salud. Catego-ras de establecimiento de salud MINSA 2011;546 [consultado13 Jun 2013]. Disponible en: http://www.dgiem-minsa.info/wp-content/uploads/2013/01/pw48 rm546-2011-minsa-nts021.pdf5. Earl R. Definition of major and minor surgery. Ann Surg. 1917;65:799.6. Thind A, Mock C, Gosselin RA, McQueen K. Surgical epi-demiology: A call for action. Bull World Health Organ.2012;90:239---40.7. Ramsey KM, Weijer C. Ethics of surgical training in developingcountries. World J Surg. 2007;31:2067---9.8. Ozgediz DWJ. Surgical training and global health: Initial resultsof a 5-year partnership with a surgical training program in alow-income country. Arch Surg. 2008;143:860---5.9. Qureshi JS, Samuel J, Lee C, Cairns B, Shores C, Charles AG.Surgery and global public health: The UNC-Malawi surgical ini-tiative as a model for sustainable collaboration. World J Surg.2011;35:17---21.10. Fratini JRG, Saupe R, Massaroli A. Referncia e contra refern-cia: contribuico para a integralidade em sade. Cincia,Cuidado e Sade. 2008;7:65---72.S.B. Shu-Yipa,b, y D.A. La Torre-Rodriguezaa Facultad de Medicina Alberto Hurtado, UniversidadPeruana Cayetano Heredia, Lima, Perb Sociedad Cientfica de Estudiantes de Medicina CayetanoHeredia (SOCEMCH), Lima, PerAutor para correspondencia.Correo electrnico: sebastian.shu.y@upch.pe(S.B. 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ciruga en establecimientos de salud de atencin primaria: comentario desde PerBibliografaInsuficiencia cardiaca aguda en paciente con mixoma auricular simulando estenosis mitral severaBibliografaLa cirugia en establecimientos de salud de atencin primaria: comentario desde PerBibliografa

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