Contribución de la neuroestimulación a la seguridad en la extubación traqueal tras tiroidectomía total. Estudio prospectivo con electrodos de aguja

Introduction and objectivesBilateral laryngeal paralysis cause serious respiratory complications. In thyroid surgery, neuromonitoring helps in identifying the recurrent laryngeal nerve, reports on its functioning at the end of surgery, supports decision making, and may reduce the risk of bilateral paralysis. Our objective was to estimate the influence of neuromonitoring in operative strategy and extubation safety in total thyroidectomy.MethodsA non-randomized prospective study was conducted on 210 patients undergoing total thyroidectomy (420 laryngeal nerves stimulated included). We collected qualitative neuromonitoring variables (presence or absence of final signal after stimulation of the vagus nerve), and postoperative indirect laryngoscopy (normal motility or paralysis), performed until 3rd day after the surgery.ResultsThe accuracy of the test was 99.5% (95% CI 98.3 to 99.9). The positive predictive value was 100% (95% CI 99.1 to 100), which showed the high ability of neuromonitoring to predict paralysis in case of loss of signal, and the negative predictive value was 99.5% (95% CI 98.3 to 99.9), which indicated its predictive capacity for normal motility when there is a normal signal.ConclusionsIn our group of patients, recurrent laryngeal nerve monitoring was useful in total thyroidectomy as it provided information on the prognosis of laryngeal motility, and helped in making decisions during surgery when there was signal loss. Due to the risk of serious respiratory complications due to bilateral recurrent laryngeal nerve paralysis, we opted for the performing of the 2-stage total thyroidectomy in case of signal loss in the first lobectomy. Thereby, neuromonitoring contributed to the safety of the airway in tracheal extubation, aiding in the prevention of a possible bilateral laryngeal paralysis.     

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.     

Estudio de las infecciones relacionadas con la asistencia sanitaria tras la realización de cistectomía radical

Introduction and objectiveRadical cystectomy is a complex surgery with a high rate of complications including infections, which lead to increased morbidity and mortality, longer hospital stay and higher costs. The aim of this work is to evaluate health care-associated infections (HAIs) in these patients, as well as associated microorganisms, antibiotic resistance profiles and risk factors.Material and methodsProspective study from 2012 to 2017. Epidemiologic variables, comorbidities and surgical variables are collected. The microorganisms involved and antibiotic susceptibility patterns are analyzed.Results122 patients. Mean age 67 (SD:18,42). Mean hospital stay 23.5 days (18.42). HAIs rate of 45%, with predominant urinary tract infections (43%) and surgical wound infections (31%). Positive cultures in 78.6% of cases. Increased isolation of Enterococcus (18%) and Escherichia coli (13%). Forty-three percent of microorganisms were resistant to amoxicillin/ampicillin, 23% to beta-lactamases and 36% to quinolones. Empirical treatment was adequate in 87.5%. Hospital stay is increased (17 days, p< 0.05) due to HAIs. Lower rate of infectious complications in the laparoscopic vs. open approach (p< 0.001) and in orthotopic vs. ileal conduit diversion (p = 0.04)ConclusionsWe found a high rate of HAIs in our radical cystectomy series, with predominant urinary tract and surgical wound infections. E.coli and Enterococcus spp. are the most frequently isolated microorganisms, with high rates of resistance to some commonly used antibiotics.     

Medidas de prevención de la infección de localización quirúrgica en cirugía general. Documento de posicionamiento de la Sección de Infección Quirúrgica de la Asociación Española de Cirujanos

Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30-60 minutes before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.     

Programa de Reducción de la Infección Quirúrgica del Observatorio de Infección en Cirugía (PRIQ-O). Documento de priorización y consenso Delphi de recomendaciones para la prevención de la infección de localización quirúrgica

Surgical site infection is the most frequent and avoidable complication of surgery, but clinical guidelines for its prevention are insufficiently followed. We present the results of a Delphi consensus carried out by a panel of experts from 17 Scientific Societies with a critical review of the scientific evidence and international guidelines, to select the measures with the highest degree of evidence and facilitate their implementation. Forty measures were reviewed and 53 recommendations were issued. Ten main measures were prioritized for inclusion in prevention bundles: preoperative shower; correct surgical hand hygiene; no hair removal from the surgical field or removal with electric razors; adequate systemic antibiotic prophylaxis; use of minimally invasive approaches; skin decontamination with alcoholic solutions; maintenance of normothermia; plastic wound protectors-retractors; intraoperative glove change; and change of surgical and auxiliary material before wound closure.     

Hipogonadismo prolongado tras la suspensión de tratamiento hormonal en pacientes con cáncer de próstata

ObjectivesTo study the levels of LH, testosterone and PSA after suspending prolonged treatment with LH-RH analogs.Materials and MethodHormonal evolution was studied in 29 patients from whom treatment had been withdrawn. The patients had previously been receiving treatment with LH-RH analog for more than one year, and with LH< 2 mUI/mL and testosterone <2.8 ng/mL. LH, testosterone and PSA were determined monthly, together with clinical assessment. The treatment was re-initiated and the period of monitoring ended before the presence of clinical progression and/or PSA ? 10 ng/mL. The cohort was described and survival was calculated using Kaplan-Meier and Cox regression.ResultsThe mean period of time without treatment for the series was 35 months (CI 95%, 15.7-54.2 months). Prolonged hypogonadism (> 24 months) was presented by 17% of the patients. The recovery of the LH-T-PSA axis, when it occurred, followed the expected sequence. The variables that influenced the period of recovery of the PSA were the PSA pretreatment and the association of an antiandrogen.ConclusionsAfter withdrawing the prolonged treatment with LH-RH analogs, most of the patients recovered the levels of LH-T-PSA, although a subgroup remained hypogonadic for more than 24 months.     

Consecuencias renales de la hipertensión intraabdominal en modelo porcino. Búsqueda de la técnica indirecta de elección de la medida de la presión intraabdominal

ObjectiveTo study the effects on the renal system in a porcine model of intraabdominal hypertension, and to determine the indirect technique of choice for determination of the intraabdominal pressure.Material and methods30 pigs were used divided in two groups according with increased intraabdominal pressure values (20 mm Hg and 30 mm Hg). In both groups pressures were registered 8 times, summing up to 3 hours, with a CO₂ insufflator. Three different measures of the intraabdominal pressure were taken: a direct transperitoneal measure, using a catheter of Jackson-Pratt connected to a pressure transducer, and two indirect measures, a transvesical by means of a Foley to manometer system, and a transgastric by introducing in the stomach a catheter connected to a pressure monitor with electronic hardware. Mean arterial pressure was calculated, along with the cardiac index, production of urine and serum creatinine.ResultsThere was a greater correlation between the transvesical and the transperitoneal intraabdominal pressures (R² = 0,95). Average transgastric intraabdominal pressure was inferior to the transperitoneal indicator in all taken measurements. The average arterial pressure descended in both groups, with earlier significant differences observed at 30 mm Hg (p < 0,020). Urine production was lower at 30 mm Hg compared with the 20 mm Hg group (9,63 ± 1,57 versus 3.26 ml ± 1,73). Serum creatinine increased in both groups being pathological at 30 mm Hg after 1 h 20 min, with existing differences between early pressures (p < 0,027).ConclusionsThis study revealed marked renal affectation with higher severity at 30 mmHg pressures. The transvesical technique showed a greater correlation with the direct measurement technique used, defining this as the method of choice for determination of intraabdominal pressure.     

Psicoterapia: una pieza que falta en el puzle de la rehabilitación de la disfunción eréctil tras prostatectomía radical

ObjectivesTo measure the impact of psychotherapy associated to the use of Tadalafil in the improvement of erectile function after radical prostatectomy.MethodsFrom 132 patients surgically treated for prostate cancer, thirty sequential patients with bilateral nerve sparing, low risk controlled disease and post-surgery erectile dysfunction (ED) took Tadalafil 20 mg and underwent psychotherapy sessions, both weekly for three months. Patients were interviewed to establish the quality of erection using the instrument IIEF-5 and to measure psychological features impacting erectile function, aspects related to function, dysfunction, physical and emotional discomfort were evaluated with the help of an intensity scale.ResultsThe average age was 62.5 (46 to 77 years), 96.7% had a stable relationship, 56.6% of the patients accepted the diagnosis and 43.2% exhibited defense mechanisms (3.3% negation, 6.6% revulsion, 33.3% concern). A positive correlation was observed between erectile function and time exposed to treatment (IIEF-5 - 9.7 to 13.3, p = 0.0006), with increased satisfaction with life in general (2.1 to 2.7, P = .028) and sexual life (3.1 to 3.7, P = .028), added to facilitation of expressing feelings/emotions (1.8 to 3.0, P = .0008). Satisfaction with relationship and intimacy with partner did not present significant improve (P = .12 and P = .61, respectively).ConclusionsA holistic patient care with more complete ED rehabilitation includes psychotherapy with a positive correlation between erectile function and treatment exposition. Psychotherapy allowed the identification of important spouse related factors in this scenario.     

Relación de la velocidad preoperatoria de PSA con los hallazgos histopatológicos de la pieza quirúrgica y la supervivencia tras prostatectomía radical

ObjectiveTo assess whether PSA velocity (PSV) is related to pathological findings in surgical specimen, biochemical recurrence-free survival (BRFS), cancer-related survival (CRS), and overall survival (OS).Materials and methodsA retrospective and prospective observational cohort study on 265 patients with prostate cancer (PCa) who underwent radical prostatectomy (RP) from 2000 to 2008. PSAV was calculated arithmetically and by linear regression analysis, using PSA values in the year prior to diagnosis. A multivariate logistic regression analysis was performed to detect variables associated to extracapsular disease (ECD). Variables related to BRFS, CRS, and OS were analyzed using Kaplan-Meier methodology (PSAV ≤3 vs. >3 ng/mL/year) and a multivariate Cox regression analysis. The ability of PSA velociy to predict BRFS, CRS, and OS was evaluated by c-index.ResultsMedian follow-up was 56.16 months (9.14–106.75). Median PSAV was 0.65 and 0.63 ng/ml/year using the arithmetic and regression methods respectively. ECD was detected in 74 specimens (27.92%), and biochemical recurrence in 50 patients (18.87%). Cancer-related mortality was seen in 4 patients (1.52%) and overall mortality in 16 (6.08%). In the multivariate analysis, PSAV was not related to ECD. PSAV was an independent predictor for BRFS (RR: 1.06, 95% CI: 1.02–1.13, p=0.008), CRS (RR: 1.22, 95% CI: 1.00–1.50, p=0.048), and OS (RR: 1.35, 95% CI: 1.18–1.55, p<0.001) in the multivariate Cox regression analysis.ConclusionsPSAV is a preoperative parameter that predicts for BFRS, CRS, and OS in patients undergoing RP. No association was found between PSA velocity and presence of ECD.     

Impacto de la resección no planificada y la reintervención de sarcomas de partes blandas en su pronóstico

IntroductionUp to 40% of all initial operations for soft tissue sarcoma (STS) are unplanned, which would leave residual macroscopic tumor in more than 50% of the cases. The effect this has on local recurrence rate, metastases rate and survival has never been fully established, due to the lack of randomized studies.MethodsRetrospective review of patients with STS treated in our unit between January 2001-January 2016. We classified them whether they had been treated by initial planned or unplanned operation. Outcomes were compared in both groups globally and stage-matched. Endpoints were local recurrence and distant metastases.ResultsTwenty-three patients of STS underwent a planned excision and 16 an unplanned excision, 13 of them underwent further re-excision. 40% of patients with planned excision had an advanced stage in regard to the unplanned excision group which presented earlier stages. 77% of patients with unplanned excision had residual tumor identified after surgical re-excision. Local recurrence rate in the unplanned excision group was considerably higher 73,5% vs. 43,8%. Metastases rate was lower in planned excision group, 45,5% vs 56,3% (P > .05). The recurrence pattern in the unplanned excision group was unstable, with worse outcomes in earlier stages.ConclusionThe unplanned excision of a soft tissue sarcoma may compromise disease local control, with higher rates of local recurrence and metastases, and worse functional out- comes, despite further oncological treatment. We need to recognize the clinical features for malignancy risk in soft tissue lumps for a safe diagnosis to avoid inadequate resections.     

Dislocación testicular. aportación de 2 nuevos casos y revisión de la literatura

We report 2 new cases of testicular luxation. A review of current literature is made. Testis was located inguinal after scrotal trauma in both cases. Early close reduction was unsuccessfully. A delayed reduction was found in one case at the moment of surgery. A surgical replacement of the testis was carried out in the other patient. Follow-up control revealed a benign course in bothTesticular dislocation is a rare complication after scrotal trauma (only 152 cases reported). Physician have to be aware of this possibility following perineal trauma. Oftenly a surgery reduction is required