Tromboelastometría como guía de administración de hemoderivados en cirugía cardiaca

Objective

Thromboelastometry is a viscoelastometric method for haemostasis testing in a whole blood sample. The aim of this study was to assess the results of using thromboelastometry as guidance for blood management in cardiac surgery, postoperative adverse events and ICU stay.

Protocolo de manejo de la vía aérea difícil. Implicación de la Declaración de Helsinki

The “Helsinki Declaration on Patient Safety in Anesthesiology” highlights the management of the difficult airway. A difficult airway management protocol includes a set of organized strategies to aid the choice of the ventilation and intubation techniques with the greatest chance of success and the lowest risk of causing injury to the patient. The aim is to guarantee oxygenation in potentially life-threatening and rapidly changing situations that require agile decision-making, thus reducing the number and severity of critical incidents and complications.     

Guía clínica del carcinoma urotelial de vejiga no músculo-invasivo de la Asociación Europea de Urología. Actualización de 2011

Context and objectiveTo present the 2011 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer (NMIBC).Evidence acquisitionLiterature published between 2004 and 2010 on the diagnosis and treatment of NMIBC was systematically reviewed. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned.Evidence synthesisTumours staged as Ta, T1, or carcinoma in situ (CIS) are grouped as NMIBC. Diagnosis depends on cystoscopy and histologic evaluation of the tissue obtained by transurethral resection (TUR) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TUR is essential for the patient's prognosis. Where the initial resection is incomplete or where a high-grade or T1 tumour is detected, a second TUR should be performed within 2-6 wk. In papillary tumours, the risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients into low-, intermediate-, and high-risk groups (separately for recurrence and progression) is pivotal to recommending adjuvant treatment. For patients with a low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is recommended. Patients with an intermediate or high risk of recurrence and an intermediate risk of progression should receive one immediate instillation of chemotherapy followed by a minimum of 1 yr of bacillus Calmette-Guérin (BCG) intravesical immunotherapy or further instillations of chemotherapy. Papillary tumours with a high risk of progression and CIS should receive intravesical BCG for 1 yr. Cystectomy may be offered to the highest risk patients, and it is at least recommended in BCG failure patients.ConclusionsThese abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice.     

Guía clínica de la Asociación Europea de Urología sobre tecnologías láser

ContextThe European Association of Urology (EAU) Guidelines Office has set up a guideline working panel to analyse the scientific evidence published in the world literature on lasers in urologic practice.ObjectiveReview the physical background and physiologic and technical aspects of the use of lasers in urology, as well as current clinical results from these new and evolving technologies, together with recommendations for the application of lasers in urology. The primary objective of this structured presentation of the current evidence base in this area is to assist clinicians in making informed choices regarding the use of lasers in their practice.Evidence acquisitionStructured literature searches using an expert consultant were designed for each section of this document. Searches were carried out in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Medline and Embase on the Dialog/DataStar platform. The controlled terminology of the respective databases was used, and both Medical Subject Headings and EMTREE were analysed for relevant entry terms. One Cochrane review was identified.Evidence synthesisDepending on the date of publication, the evidence for different laser treatments is heterogeneous. The available evidence allows treatments to be classified as safe alternatives for the treatment of bladder outlet obstruction in different clinical scenarios, such as refractory urinary retention, anticoagulation, and antiplatelet medication. Laser treatment for bladder cancer should only be used in a clinical trial setting or for patients who are not suitable for conventional treatment due to comorbidities or other complications. For the treatment of urinary stones and retrograde endoureterotomy, lasers provide a standard tool to augment the endourologic procedure.ConclusionsIn benign prostatic obstruction (BPO), laser vaporisation, resection, or enucleation are alternative treatment options. The standard treatment for BPO remains transurethral resection of the prostate for small to moderate size prostates and open prostatectomy for large prostates. Laser energy is an optimal treatment method for disintegrating urinary stones. The use of lasers to treat bladder tumours and in laparoscopy remains investigational.     

Infusión errónea de paracetamol por vía epidural

A 45-year-old woman was accidentally administered an epidural infusion of paracetamol instead of levobupivacaine for postoperative pain therapy during the postoperative period of abdominal hysterectomy under general anesthesia combined with epidural analgesia.The patient had no neurological symptoms at any time, although a slight tendency to arterial hypotension that did not require treatment was observed. No rescue analgesia was necessary until 8 h after the start of epidural infusion.The incidence of these types of errors is probably underestimated, although there are several cases reported with various drugs.     

Cirugía en directo: estudio de seguridad tras 17 ediciones de cirugía retroperitoneoscópica

IntroductionLive surgery has become an excellent tool for medical training. Despite this, there is controversy about the safety of the patients involved.ObjectiveTo analyze the results of live surgeries performed in 17 consecutive retroperitoneoscopy courses organized in our center. Procedures performed were partial nephrectomy (PN), radical nephrectomy (RN) and nephroureterectomy (NU).Material and methodsReview from January 2010 to October 2017 of all live surgeries carried out by an expert surgical team in the retroperitoneoscopy courses, compared with a control group of surgeries performed in standard conditions. A matching (1:1 for each RN and 1:2 for each PN and NU) according to age, body mass index and comorbidities was performed.ResultsTwenty-one live surgeries were analyzed (eight PN, seven RN and six NU) with a global median follow-up of 38 months. No significant differences were observed between both groups in terms of perioperative variables (operative time, operative bleeding and intraoperative complications) or of postoperative complications and length of hospital stay. Likewise, there were no differences between recurrence rates (PN: 0% vs. 6.3%, p = 0.47, NU: 33.3% vs. 66.7%, p = 0.180, RN: 0% vs. 28.6%, p = 0,127).ConclusionsLive surgery in the hands of expert surgeons in a suitable environment and with well-selected patients does not increase the risk of complications and allows maintaining the same oncological outcomes.     

Monitorización de la oximetría cerebral en el manejo de la hipoxemia severa asociada a la transposición de grandes arterias mediante atrioseptostomía con balón

Transposition of the great arteries (D-TGA) is one of the most common congenital heart diseases requiring neonatal surgical intervention. In the desperately ill neonate with TGA and the resultant hypoxaemia, acidemia, and congestive heart failure, improvement is often obtained with balloon atrial septostomy (BAS). Current methods employed to evaluate oxygen delivery and tissue consumption are frequently nonspecific. Near infrared spectroscopy (NIRS) allows a continuous non-invasive measurement of tissue oxygenation which reflects perfusion status in real time. Because little is known about the direct effect of BAS on the neonatal brain and on cerebral oxygenation, we measured the effectiveness of BAS in two patients with D-TGA using NIRS before and after BAS. We concluded BAS improves cerebral oxygen saturation in neonates with D-TGA.     

Diagnóstico intraoperatorio de red de Chiari basado en ecocardiografía

We report a case of a Chiari network as a possible cause of intraoperative supraventricular tachycardia with potential cardiac flow obstruction and hemodynamic collapse. The intraoperative diagnostic analysis considered detects cardiac abnormalities associated to this congenital remnant and discard common intraoperative causes of hemodynamic alterations.     

Cirugía laparoscópica a través de incisión única

One of the aims of the new technologies and techniques in minimally invasive surgery (MIS) is to achieve a surgery without or with minimal visible scars.Natural orifice transluminal endoscopic surgery (NOTES) might be considered to be a paradigm of this development but it has not yet been possible to implement this universally.Nevertheless, the resultant innovation of research into NOTES has enabled “bridge technologies" to be introduced that allow MIS to be developed with the required standards of efficiency and safety.The aim of this paper is to review the concept of single incision surgery and to classify the available tools for its development and implementation.     

Fístulas rectoneovaginales en pacientes tras cirugía de reasignación de sexo. Descripción de nuestra experiencia y revisión de la literatura

Male-to-female reassignment surgery or vaginoplasty includes those surgical procedures that aim to recreate a functional and cosmetically acceptable female perineum with minimal scarring. The technique of choice at our center is penile inversion vaginoplasty with or without scrotal skin grafts. We present 4 cases diagnosed with rectoneovaginal fistulas treated at our center with favorable evolution. The first patient was diagnosed in the late postoperative period during dilation. She underwent 2 failed vaginal repair attempts. Finally, a temporary colostomy and a rectal flap were performed. The second patient was diagnosed 2 weeks after the initial surgery due to aggressive dilation and was treated with a temporary colostomy and secondary wound closure. The third patient was diagnosed on the fifth post-operative day after removal of the vaginal packing. Dietary restriction was indicated, and a rectal flap was performed. A fourth patient was diagnosed within the late postoperative period; she was submitted to surgical exploration and a rectal wall flap was created. Rectoneovaginal fistulas after sex reassignment surgery has an incidence of about 2-17% and they are the most common type of fistula after this procedure. In most cases, it is secondary to rectal injury during the initial surgery. The management of these fistulas ranges from primary closure, diverting colostomies, conservative management, or the performance of flaps. A multidisciplinary team approach is recommended for the diagnosis and treatment of this complication.     

Predicción de hipocalcemia postiroidectomía mediante determinación de PTH rápida

IntroductionHypocalcemia is the most frequent complication after thyroidectomy. The aim of this work is to identify biochemical risk factors of hypocalcemia using quick perioperative (pre and post-thyroidectomy) intact parathyroid hormone (PTHi) and postoperative calcemias.MethodsIn a consecutive series of 310 total thyroidectomies, samples of quick PTHi at the anaesthetic induction and 10 minutes after surgery, together with serum calcemias every 12 hours were obtained. The sensitivity, specificity, positive and negative predictive value are analyzed and related to hypocalcemia. A control group of hemithyroidectomies is also analyzed to compare the effects of surgery on PTH secretion.ResultsOf the 310 patients, 202 (65.1%) remained normocalcemic and asymptomatic (group A), 108 (34.9%) presented hypocalcemia (Group B), requiring oral calcium (79 symptomatic). After analysis of several cut-off points, combining a PTHr drop gradient of 60% or calcemia inferior to 7.4 mg/dl at 24 hours, a sensitivity of 100% is achieved without leaving false negatives. Compared to the control group, there is a significant difference with respect to the post-operative calcemias and PTHr, p < 0.001.ConclusionsTotal thyroidectomy affects parathyroid function with evident decrease in rPTH and risk of hypocalcemia. The combination of PTHr decrease of 60% or less than 7.4 mg/dl calcemia at 24 hours gives a 100% sensitivity for predicting patients at risk of hypocalcemia.     

Optimización de un programa de alta precoz tras prostatectomía radical laparoscópica

ObjectiveTo assess the safety of hospital discharge 24 hours after laparoscopic radical prostatectomy and to identify possible factors associated with longer hospital stays.Material and methodsRetrospective study of patients diagnosed with localized prostate cancer underwent to laparoscopic radical prostatectomy consecutively between May of 2007 and December of 2010. Those patients who met the following requirements were discharged in less than 24 hours: absence of complications, drainage debit minor than 50cc, normal oral tolerance, no significant bladder haematuria and good functional recovery. Logistic regression analysis was conducted in order to assess the possible associated variables with longer hospital stays.ResultsA total of 266 patients were analysed. The follow-up median was 34 months. Eighty patients (30.1%) were discharged in less than 24 hours. Average stay (SD) of all series was 2.9 days (3.08). Solely HTA, neurovascular bundles sparing and the development of lymphadenectomy were statistically significant between both groups in univariate analysis (discharge<24 hours vs. discharge>24 hours). In multivariate analysis, only HTA (OR = 1.98 [CI 95%:1.13-3.47], P = .016) and lymphadenectomy performance (OR = 2.56 [CI 95%:1.18-5.56] P = .017) were independent predictive variables of hospital stays longer than 24 hours.ConclusionsEarly hospital discharge of patients underwent to LRP is feasible and safe. In our series, the lymphadenectomy performance and the HTA were associated factors to longer hospital stay.     

Guía clínica de la Asociación Europea de Urología sobre el tratamiento quirúrgico de la incontinencia urinaria

ContextThe European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology.ObjectiveWe present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience.Evidence acquisitionEvidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.Evidence summaryThe full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report.ConclusionsThese new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion.     

Duodenopancreatectomía en ancianos. Evaluación de resultados

IntroductionWith the increase in life expectancy, more and more resectable periampullary tumours are being diagnosed in the geriatric population. Despite the decrease in post-operative mortality, there continues to be a debate on the risk-benefit of cephalic duodenopancreatectomy (CPD) in the elderly.ObjectiveTo analyse the morbidity and mortality of CPD in patients over 70 years-old.DesignProspective observational study.PatientsA total of 54 duodenopancreatectomies were performed between January 2005 and December 2010. Two groups of patients were compared: Group 1 (patients > 70 years-old, n: 24), and Group 2 (patients < 70 years-old, n: 30). The morbidity and mortality, transfusion, reinterventions, mean hospital stay, and survival were analysed.ResultsThe > 70 years group included more ASA 2 and 3 patients (P=.010), and had a higher number of previous medical problems per patient (P=.037). The post-operative mortality was higher in the older age group, although the difference was not significant (8.3 vs 3.3%). There were also no significant differences in post-operative morbidity (45.8 v. 46.6%), reintervention rate (16.6 vs 13.3%), length of hospital stay (18 vs 13%), and survival at 6 and 12 months (84 and 72% vs 90 and 86%).ConclusionsAge, in itself, does not seem to be a contraindication for CPD, but the elderly do have a higher risk of complications due to the physiological changes associated with ageing. The disparity of results demonstrates the need for more population studies at national level that may give an overall view of morbidity and mortality in CPD.     

Metodología de una revisión sistemática

Context

The objective of evidence-based medicine is to employ the best scientific information available to apply to clinical practice. Understanding and interpreting the scientific evidence involves understanding the available levels of evidence, where systematic reviews and meta-analyses of clinical trials are at the top of the levels-of-evidence pyramid.

Adenomectomía laparoscópica: 10 años de experiencia

Introduction

Lower urinary tract symptoms secondary to increased prostate volume are associated with ageing and are becoming more prevalent due to increased life expectancy. We present our experience with transperitoneal laparoscopic adenomectomy for the management of bladder outlet obstruction caused by benign prostatic enlargement.