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.     

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.     

Comparación entre tomografía computarizada y resonancia magnética en la evaluación de quistes renales complejos empleando la clasificación de Bosniak

Introduction and objectivesThe Bosniak classification of cystic renal lesions was first published in 1986 based on computed tomography (CT). In the present study, we aimed to investigate the effect of magnetic resonance imaging (MRI) on Bosniak category compared with CT, and to determine how this effect changed the treatment modality in the evaluation of complex renal cysts.Material and methodsData of 144 patients were collected retrospectively. After exclusion criteria, 102 cystic renal lesions with a Bosniak category of at least IIF on CT or MRI between 2013 and 2016 were evaluated by 2 abdominal radiologists. The demographic data, Bosniak category, interobserver agreement, and pathologic data of patients who underwent surgery were recorded.ResultsThe coherence between MRI and CT was 75.5%. The Bosniak classification of 17 patients was upgraded with MRI, and the treatment modality changed in 10 patients, and they underwent surgery. The Bosniak category was downgraded from III to IIF in 6 patients out of 8 whose Bosniak category was downgraded with MRI and the treatment modality changed. Surgery was performed in one patient out of these 6 patients, and the pathology was reported as benign. Progression was detected in the follow-up at month 18 of 1 patient out of 5, and surgery was performed. The pathology was reported as renal cell carcinoma. The pathology result was reported as RCC in 35 (68.6%) patients out of 51 who underwent surgery. Progression was detected in 7 patients out of 51 who were followed up (13.7%), and the pathology results were reported as RCC. The majority of the malignant tumors were low stage and grade.ConclusionsMRI may be successfully used in the evaluation of renal cystic lesions. In particular, the challenging Bosniak IIF and all Bosniak III lesions must be evaluated using MRI before making the decision for surgery. The upgrading of Bosniak category with MRI is more possible compared with CT due to its high-contrast resolution, therefore further studies are required to identify whether it was the cause of overtreatment of Bosniak III lesions.     

Correlación de hallazgos preoperatorios en la tomografía axial computarizada con la presencia de vía aérea difícil en pacientes intervenidos mediante cirugía otorrinolaringológica de cabeza y cuello

Objectives

To establish a correlation between 4 measurements made on preoperative computed axial tomography and the presence of difficult airway, as well as its clinical prediction in patients undergoing otorhinolaryngological surgery.

Guía clínica de la Asociación Europea de Urología sobre la evaluación y el tratamiento no quirúrgico de la incontinencia urinaria

ContextThe previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology.ObjectiveWe present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination.Evidence acquisitionEvidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on 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 guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice.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 such evidence does not exist, they present a consensus of expert opinion.     

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.     

Tinción de Gram intraoperatoria en bilis para la prevención de complicaciones infecciosas en la duodenopancreatectomía

IntroductionInfectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications.MethodsA retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days.ResultsThe incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p<0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p<0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively).ConclusionIntraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications.     

Aplicación de la medicina regenerativa y la bioimpresión 3D en urología

In the last two decades, a new purpose has collected great efforts from scientists in all branches of medicine. It is about the possibility to make the body regenerate ill tissues and organs by itself with de right artificial stimuli or the construction of new functional organs to replace the damaged ones. This process comprises various interdisciplinary approaches to healthcare, such as tissue engineering, molecular medicine, biotechnology, and three-dimensional printing. Urologists have been remarkably active in this field of medicine called Regenerative Medicine. The searching of the different requirements like suitable and compatible biomaterials, versatile cells, adequate techniques to construct tissues, available biomolecules, and the knowledge of all these minimizing risks, are some of the aims and the approximations until now. Despite many obstacles, in vitro and in vivo studies are already showing encouraging options. We will review the advances related to the bladder, urethra, ureter, and kidneys. Difficulties such as ethical issues, time investment and high costs, have been some of the drawbacks encountered. Further studies are still required for its clinical application in daily life.     

Consenso de la sección de cirugía mayor ambulatoria de la Asociación Española de Cirujanos sobre el papel de la cirugía mayor ambulatoria en la pandemia SARS-CoV-2

The current situation of the SARS-CoV-2 pandemic has paralyzed non-urgent and/or oncological surgery in many hospitals in our country with what it means for the health of citizens who are awaiting a surgical procedure. Outpatient Surgery can afford more than 85% of the surgical procedures that are performed in a surgical department and is presented as a feasible and safe alternative at the present time since it does not require admission and decreases clearly the risk of infection. In addition, it is the tool that should be generalized to solve the accumulation of patients on the waiting list that the pandemic is generating, so it seems appropriate that the Ambulatory Surgery section of the Spanish Association of Surgeons present a series of recommendations for the implementation of outpatient surgery in these exceptional circumstances that we have to live.     

Terapia de presión negativa en cirugía de la pared abdominal

Negative pressure wound therapy (NPWT) is widely known in surgical practice. The initial indications for NPWT were chronic wounds, especially diabetic foot, vascular and decubitus ulcers, and infected traumatic wounds. Nowadays, the use has been widely increased. Although in the field of abdominal wall surgery, it has mainly been used in the treatment of surgical wound complications after hernia repair, other indications have been added after years of experience in the management of NPWT.Therefore, the aim of this article is to analyze and review the main indications of NPWT in abdominal wall surgery, as well as the advantages obtained with its application.     

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.     

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.     

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.     

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 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.