Hiperlactatemia en la ablación quirúrgica de la fibrilación auricular y cirugía cardiaca. ¿Es un factor predictivo de morbimortalidad posoperatoria?

IntroductionIncreased serum lactate in postoperative cardiac surgery is very common and its pathogenesis is due to multiple factors. The elevation of serum lactate is associated with tissue hypoxia (hyperlactatemia type A) and non-hypoxic (hyperlactatemia type B) metabolic disorders. The aim of the study was to assess the evolution of postoperative lactate in surgical atrial fibrillation ablation during cardiac surgery, and to determine whether lactate levels could be predictors of morbimortality.Material and methodsA case-control study was conducted on 32 patients undergoing surgical atrial fibrillation ablation and cardiac surgery (Maze group) and 32 matched patients (Control group), operated on between 2011 and 2012. An analysis was made of the levels of postoperative lactate, perioperative morbimortality and hospital length of stay. A univariate and multivariate study was performed for a composite endpoint of morbimortality, and prolonged length of stay.ResultsLactate levels were significantly higher at 6, 12 and 24 h in the Maze group. The univariate analysis showed that being in the Maze group (OR 3.88; 95% CI 1.3-11.1; P = .01) and an elevated lactate at 12 h (OR 1.33; 95% CI 1.01-1.7; P = .04) were significant predictors of major complications, mortality, and longer hospital stays. In the multivariate analysis, surgical atrial fibrillation ablation (Maze group) was an independent predictor of major complications (OR 4.13; 95% CI 1.312.9; P = .015) for the morbimortality composite endpoint (OR 3.9; 95% CI 1.3-11.6; P = .01), and prolonged length of stay in the Intensive Care Unit (OR 5.7; 95% CI 2.01-15.7; P = .01).ConclusionsThe atrial fibrillation surgical ablation may be a not-yet-described cause of type B hyperlactatemia, with serum peak values being reached between 4-24 h after cardiac surgery. The predictive value of this elevation, its correlation with morbimortality, its sensitivity and specificity to discriminate the significant thresholds needs to be defined.     

Cirugía mínimamente invasiva y robótica en el tratamiento quirúrgico de las neoplasias de la unión esofagogástrica

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself.Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.     

Influencia de la fragilidad en el pronóstico de pacientes quirúrgicos mayores de 70 años con criterios de ingreso en UCI

IntroductionFrailty degree can influence more than age or severity in the outcome of patients older than 70 years undergoing surgery of the digestive system that require immediate postoperative control in the ICU.MethodsA prospective and observational study of patients over 70 years of age who were admitted to the surgical ICU of a third level hospital immediately after an elective or emergent surgical intervention on the digestive system from June 1, 2018 until June 1, 2019. The variables age, frailty Clinical Frailty Scale (CFS), and modified Frailty Index (mFI), severity (APACHE II), type of surgery, surgical pathology were recorded upon admission. A bivariate analysis was performed to assess the influence of frailty and severity on hospital morbidity and mortality and baseline situation of the patient (in terms of dependence) at 6 months.ResultsA total of 90 patients were recruited, 54.4% of whom were reoperated; 74.4% were initially discharged from the ICU, with 28.4% of readmission and directly associated to frailty (CFS and mFI: P<0.01). The overall mortality at 6 months was 44.5% being CFS (OR = 64.3; P<0.05, 95% CI: 12.3-333.9) and APACHE II (OR = 1.17; P<0.05; 95% CI: 1.04-1.32) the covariates that best related.ConclusionsThe estimation of frailty by CSF and mFI is directly associated to the surgical morbidity and readmission of elderly and severe patients admitted to the ICU. In addition, CFS and mFI has been efficient as a predictive of mortality at 6 months.     

Manejo de la presión arterial en pacientes neuroquirúrgicos y neurocríticos

The etiological and pathophysiological differences between diseases that may require a neurosurgical intervention or the establishment of neurocritical care make it impossible to talk about the control of blood pressure in the neurocritical or neurosurgical patient in a generic manner. With this reasoning in mind, we decided to review separately the control of blood pressure in some of the pathologies we most frequently faced in clinical practice. The topics reviewed are: cranial brain trauma, acute ischemic stroke, intracranial aneurysm surgery, cerebral arteriovenous malformation surgery, brain tumor surgery, spinal cord surgery and acute spinal cord injury.     

Infección del sitio quirúrgico en cirugía hepatobiliopancreática y su relación con la concentración sérica de vitamina D

IntroductionWhile several studies have examined the correlation between vitamin D concentrations and post-surgical nosocomial infections, this relationship has yet to be characterized in hepatobiliary surgery patients. We investigated the relationship between serum vitamin D concentration and the incidence of surgical site infection (SSI) in patients in our hepatobiliary surgery unit.MethodsParticipants in this observational study were 321 successive patients who underwent the following types of interventions in the hepatobiliary surgery unit of our center over a 1-year period: cholecystectomy, pancreaticoduodenectomy, total pancreatectomy, segmentectomy, hepatectomy, hepaticojejunostomy and exploratory laparotomy. Serum vitamin D levels were measured upon admission and patients were followed up for 1 month. Mean group values were compared using a Student's T-test or Chi-squared test. Statistical analyses were performed using the Student's T-test, the Chi-squared test, or logistic regression models.ResultsSerum concentrations >33.5 nmol/l reduced the risk of SSI by 50%. Out of the 321 patients analyzed, 25.8% developed SSI, mainly due to organ-cavity infections (incidence, 24.3%). Serum concentrations of over 33.5 nmol/l reduced the risk of SSI by 50%.ConclusionsHigh serum levels of vitamin D are a protective factor against SSI (OR, 0.99). Our results suggest a direct relationship between serum vitamin D concentrations and SSI, underscoring the need for prospective studies to assess the potential benefits of vitamin D in SSI prevention.     

Actividad física y fragilidad como indicadores de reserva cardiorrespiratoria y predictores del pronóstico quirúrgico: caracterización de la población quirúrgica en cirugía general y digestiva

Introduction

Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes.

Papel de la impresión 3D para la protección de los profesionales del área quirúrgica y críticos en la pandemia de COVID-19

Background and objectiveThere is a shortage of supplies for the protection of professionals during the COVID-19 pandemic. 3D printing offers the possibility to compensate for the production of some of the equipment needed. The objective is to describe the role of 3D printing in a health service during the COVID-19 pandemic, with an emphasis on the process to develop a final product ready to be implemented in the clinical environment.MethodsA working group was formed between the healthcare administration, clinicians and other public and private institutions in Cantabria, Spain coordinated by the Valdecilla Virtual Hospital. The process included receiving the printing proposals, learning about the printing resources in the region, selecting the devices, creating a team for each project, prototyping, evaluation and redesign, manufacturing, assembly and distribution.ResultsThe following supplies are produced: 1) devices that help protect providers: face protection screens (2,400 units), personalized accessories for photophores (20 units) and ear-protection forks for face-masks (1,200 units); 2) products related to the ventilation of infected patients: connectors for non-invasive ventilation systems; and 3) oral and nasopharyngeal swabs (7,500 units) for the identification of coronavirus carriers with the aim of designing action protocols in clinical areas.Conclusions3D printing is a valid resource for the production of protective material for professionals whose supply is reduced during a pandemic.     

Sutura laparoscópica mecanizada con FlexDex Surgical System® para ubicaciones anatómicamente difíciles

The field of laparoscopic surgery has experienced an exponential growth in recent years. Despite great progress in this field, standard laparoscopic tools have not been optimally developed and still has some deficiencies when it comes to mobility and ergonomics.Robotic surgery has attempted to solve these problems by improving the articulation of surgical instruments. However, it presents a series of disadvantages, among which are its high cost, low availability and the need of a specific training, which conditions its profitability and hinders a widespread use.We present the results of a prospective clinical series of 20 cases in which the safety, efficacy and ergonomics of FlexDex® have been tested for performing laparoscopic intracorporeal sutures. The result is a safe and functional tool that offers both control and precision in its handling, while improves the ergonomics of the surgeon. This device represents an alternative that combines the precision and range of movements of robotic surgery with the greater availability of conventional laparoscopy.     

Variabilidad en la práctica de la cirugía mamaria en mujeres participantes en el programa de cribado poblacional de cáncer de mama

Introduction

Currently, variability in surgical practice is a problem to be solved. The aim of this study is to describe the variability in the surgical treatment of breast cancer and to analyze the factors associated with it.

SEVE project (Surgical Expertise Validity Evaluation) risk adjusted quality by standard data

The SEVE project (Surgical Expertise Validity Evaluation) is a collaborative effort of the AEC (Spanish Association of Surgeons) and the Section of Surgery of the European Union of Medical Specialists (UEMS) that aims to develop a model and an on line application that can be used to evaluate surgical complications. The aim is to identify the optimal results that can be obtained in each intervention, in order to present them as a reference for our usual practice (benchmarking).     

Proyectos de estandarización del tratamiento del cáncer de la unión esofagogástrica: centralización,registros y formación

Surgical treatment of oesophagogastric junction adenocarcinomas is based on total gastrectomies or oesophagectomies, which are complex procedures with potentially high morbidity and mortality. Population-based registers show a considerable variability of protocols and outcomes among different hospitals and regions. One of the main strategies to improve global results is centralization at high-volume hospitals, a process that should take into account the benchmarking of processes and outcomes at referral hospitals. Minimally invasive surgery can improve postoperative morbidity while maintaining oncological guaranties, but is technically more demanding than open surgery. This fact underlines the need for structured training and mentorship programs that minimize the impact of surgical teams’ training curves without affecting morbidity, mortality or oncologic radicality.     

Resultados de morbimortalidad en cáncer colorrectal en paciente quirúrgico frágil. Implementación de un Área de Atención al Paciente Quirúrgico Complejo

Introduction

Advanced age and comorbidity impact on post-operative morbi-mortality in the frail surgical patient. The aim of this study is to assess the impact of a comprehensive, multidisciplinary and individualized care delivered to the frail patient by implementation of a Work Area focused on the Complex Surgical Patient (CSPA).

Incidencia de infección de sitio quirúrgico y factores de riesgo en cirugía de recto. Estudio de cohortes prospectivo

Introduction

Surgical site infection (SSI) is the main cause of nosocomial infection in Spain. The aim of this study was to analyze the incidence of SSI and to evaluate its risk factors in patients undergoing rectal surgery.

El ambiente de la herida,la virulencia microbiana y la infección postoperatoria: lecciones prácticas para el cirujano

For the practicing surgeon, the development of a postoperative wound infection represents a major complication that can be both costly and disabling. As a result, surgeons apply multiple methods of prevention including skin decontamination, use of antibiotics, irrigation with or without antiseptics and meticulous use of technique. In elective surgery, however, most wound infections cannot be predicted.In this review we discuss emerging concepts in wound infection pathogenesis and include a discussion on how the wound environment may directly activate bacteria to express a more harmful or virulent phenotype. Based on these emerging concepts, we provide the practicing surgeon with molecular level evidence to explain why some methods of wound infection protection may be useful while others are not.     

Resección robótica del lóbulo hepático caudado: descripción técnica y consideraciones iniciales

Introduction

Firstly described in 2002, the robotic liver surgery has not spread widely due to its high cost and the lack of a standardized training program. Still being considered as a ‘development in progress’ technique, it has however a potential to overcome the traditional limitations of the laparoscopic approach in liver interventions.

Care burden and outcome of the surgical management of ulcerative colitis: A retrospective analysis of the last 20 years in a tertiary hospital in Spain

AimTo analyze the surgical burden of UC care in the last two decades, analyzing the characteristics of the patients, surgical indications along with the short and long-term results.MethodSingle-center retrospective cohort analysis of UC patients undergoing abdominal and anorectal surgery between January 2000 and December 2020. The care burden, clinical data and results were analyzed according to distribution by decades.Results128 patients, 37% female, underwent 376 surgical interventions (296 intestinal procedures and 80 anorectal). Mean follow-up for the cohort was 106 ± 64 months. Timing from diagnosis to first surgery was under 5 years in 53.3%. In the second decade of the study there were fewer operated patients (73 vs. 48) as well as the total number of interventions per patient (2.7 vs. 2.0). The proportion between elective and urgent surgery was reversed in the second decade, observing an increase in laparoscopic surgery (70% vs. 8%) together with a decrease in major postoperative morbidity (Clavien-Dindo ≥ IIIa) (20% vs 8.4%). 80 patients underwent a restorative proctocolectomy, with a failure of 5% at 1 year but 23.7% in the long term. 37 patients required anorectal surgery, of which 26 (71%) were serial interventions, most due to septic complications of the pouches.ConclusionsThe number of colectomies and interventions per patient decreased in the last decade, while there were improvements in morbidity and surgical approach. The need for sequential surgeries and long-term active instrumental surveillance for possible functional deterioration constitutes a significant clinical burden.