Utilidad del bloqueo interpectoral continuo como técnica analgésica en cirugía oncológica de mama

Objective

To compare the analgesic efficacy of continuous interpectoral block (CIPB) compared to intravenous analgesia (IV) after breast surgery.

Aplicación de la técnica ROLL como método de biopsia excisional en patología oncológica

ObjectiveTo evaluate the utility of the ROLL (Radioguided Occult Lesion Localization) technique as a method of excisional biopsy in hypermetabolic lesions suspected of malignancy evidenced in [¹⁸F]Fluordeoxiglucose PET/CT scans.Material and methods33 patients were retrospectively evaluated referred for metabolic studies due to tumoral pathology or suspected neoplastic process and presenting hypermetabolic adenopathies with high probability of malignancy. The group consisted of 19 women and 14 men, ranging from 23 to 77 years old. Patients were performed a ROLL technique for localization and removal the selected adenopathies, through the injection of [99mTc] macro-aggregates of albumin guided by ultrasound or CT. A detection probe and a portable gamma camera were used during the surgical procedure.ResultsIn 31 patients (94%) the location and removal of the radiolabeled adenopathies was achieved. In one patient the location of the lesion was not possible and a second patient was not operated due to inadequate dose injection confirmed by gammagraphy study. The result of the anatomopathological study of adenopathies resulted in 23 tumor affections and 8 benign processes, including a granulomatous process.ConclusionThe ROLL technique proved its utility as a radioguided excisional biopsy method for the study of lesions suspected of malignancy evidenced in patients undergoing PET/CT studies. The technique allowed to confirm the persistence of oncological process in some cases and the existence of false positives from the imaging study in others, modifying the patients therapeutic management.     

Manejo anestésico en la cirugía de epilepsia con electrocorticografía intraoperatoria

Epilepsy surgery is a well-established treatment for patients with drug-resistant epilepsy. The success of surgery depends on precise presurgical localisation of the epileptogenic zone. There are different techniques to determine its location and extension. Despite the improvements in non-invasive diagnostic tests, in patients for whom these tests are inconclusive, invasive techniques such intraoperative electrocorticography will be needed.Intraoperative electrocorticography is used to guide surgical resection of the epileptogenic lesion and to verify that the resection has been completed. However, it can be affected by some of the anaesthetic drugs used by the anaesthesiologist. Our objective with this case is to review which drugs can be used in epilepsy surgery with intraoperative electrocorticography.     

Procedimiento radioguiado en la cirugía mínimamente invasiva del hiperparatiroidismo primario

Minimally invasive parathyroidectomy, of choice in most cases of primary hyperparathyroidism, shows a high detection rate, based on precise preoperative localization by MIBI scintigraphy (SPECT/CT) and neck ultrasound. Radio-guided minimally invasive parathyroidectomy is an even more effective technique, which shortens surgical times, maintains minimal incision and few complications, allows immediate verification of parathyroid adenoma removal and is especially interesting in patients with ectopic lesions or cervical surgical history. In this paper, the indications, protocols and differences between the two available radio-guided parathyroid surgery procedures (MIBI and ROLL) are exposed.     

Tratamiento anestésico mediante bloqueo del plexo braquial costoclavicular con analgesia controlada por el paciente en Pediatría: caso clínico

Anesthetic management using costoclavicular brachial plexus block with patient-controlled analgesia in pediatrics: a case report Abstract The costoclavicular brachial plexus block (CBPB) has been receiving increasing attention as an effective technique for upper arm surgery conducted without phrenic paralysis. However, studies in children are lacking. CBPB was applied to a 10 year-old girl undergoing scheduled radial and ulnar osteotomy due to multiple cartilaginous exostoses and ulnar lengthening. CBPB was performed with a bolo administration of 10 mL of 0.25% levobupivacaine, and the catheter was sequentially replaced in the right costoclavicular space. After surgery, a continuous infusion of 0.17% levobupivacaine through a catheter was initiated at 2 mL/h, along with patient-controlled analgesia (PCA) of 3 mL 0.17% levobupivacaine with a 60-minute lock out. The patient complained of 5/10 pain on the numerical rating scale (NRS) 2 hours after surgery, which improved immediately after bolus administration. The analgesia induced by CBPB was otherwise effective (NRS ≤ 2). CBPB with PCA may provide adequate analgesia in pediatric cases.     

Clevidipino como antihipertensivo en la cirugía de feocromocitoma

Pheochromocytoma is a catecholamine-producing tumour and laparoscopic adrenalectomy is its treatment of choice. During pneumoperitoneum insufflation and tumour handling there is a high risk of massive catecholamine release and hypertensive crisis. After tumour excision, severe arterial hypotension is a common effect, due to relative vasodilation and the residual effect of antihypertensive drugs. We report the case of a patient with pheochromocytoma who was treated with laparoscopic adrenalectomy. During surgical manipulation there was a sudden hypertensive peak that could be controlled quickly with clevidipine infusion. After tumour resection, clevidipine perfusion was stopped and there were no arterial hypotension episodes. Clevidipine is a new intravenous calcium antagonist with rapid onset of action and short half-life that has no residual effect and does not produce arterial hypotension after tumour resection. For these reasons, it can be a first-choice drug for this kind of surgery.     

Abordaje del uréter distal en la nefroureterectomía laparoscópica

IntroductionNephroureterectomy is one of the procedures for which a laparoscopic approach is more clearly indicated. However, despite the long experience available, management of the distal ureter is still difficult.Materials and methodsThirty-two laparoscopic nephroureterectomies were performed from November 2004 to December 2008. The procedure used was endoscopic resection of distal ureter and earlier ligation of the ureter in the laparoscopic time in 13 patients, a laparoscopic bladder cuff in 13 patients, and an open bladder cuff in 3 patients.ResultsMean operating time was 221.53 min (125-315 min), and mean postoperative stay of 27 patients was 4.6 days. Conversion to open surgery and discontinuation of the procedure for local tumor progression were required in one patient each. Mean patient follow-up was 17.8 months. No local relapse or metastasis occurred in the ports.ConclusionThe most common procedures continue to be endoscopic resection and the open bladder cuff depending on indication. Any laparoscopic approach to upper urothelial tumors must strictly comply with oncological principles. The reported procedure is in our experience the fastest, most simple, and most effective for this purpose. In our opinion, the therapeutic algorithm provided is adequate for management of the distal ureter in laparoscopic nephroureterectomy.     

Manejo anestésico del síndrome del ligamento arcuato medio

Median arcuate ligament syndrome, also known as celiac artery compression syndrome, is a rare and unusual clinical disorder. Its symptoms are non-specific, which complicates its diagnosis, and a multidisciplinary approach is required to treat the disorder. The ligament is circumferentially cleared by laparoscopy. Selective angiography and endovascular techniques may be used after laparoscopy. Vital organs and important vascular structures can be injured during the surgery. The combination of different procedures, as well as the high risk of damage, make this process a significant challenge for the anaesthetist. During corrective surgery for median arcuate ligament syndrome, general anaesthesia must be adapted to the various haemodynamic and ventilatory requirements, and strict control of pain established, as oral tolerance is a key factor in the post-operative recovery of these patients     

Estudio comparativo entre bloqueo paravertebral torácico,bloqueo de los nervios pectorales y bloqueo del músculo erector de la columna ecoguiados para el manejo del dolor en cirugías de cáncer de mama. Estudio controlado aleatorizado

ObjectivesAchieving adequate perioperative analgesia can be challenging in patients undergoing breast surgeries due to the complex nerve supply of the breast and axilla. The study aims to investigate the efficacy of ESPB in comparison to conventional regional anesthesia techniques (TPVB and PECS).MethodsEighty female patients who were scheduled for elective MRM, with ASA score I-II, and aged between 18 and 60 years, were included in the study. Patients were randomized into four groups: the TPVB, PECS, ESPB, and the control group. All patients in either block groups received 25 ml bupivacaine 0.25% with ultrasound guidance. The control group received only opioids for perioperative pain management. The patients were observed for 48 hours after surgery for the duration of analgesia (primary outcome)ResultsESPB has a shorter duration of analgesia than PECS block with no significant statistical difference compared with group TPVB. Morphine consumption is increased in ESPB compared to the PECS group, with an insignificant difference compared to group TPVB. There was an insignificant difference between the groups concerning hemodynamics and complications, with one pneumothorax case reported in the TPVB group.ConclusionPECS and ESPB represent a good alternative to TPVB for post-mastectomy analgesia with a superior analgesic effect of PECS block regarding opioid consumption, duration of the analgesia, and VAS score.     

La cirugía transanal como herramienta en la dehiscencia de la anastomosis colorrectal

The treatment of anastomotic leakage after oncological surgery for rectal cancer is a surgical challenge. The goal of this study is to show how transanal surgery combined with the abdominal approach is a very useful tool to decide on individualized treatment depending on the degree of dehiscence and to assist us in its local management. We present three cases of patients with colorectal anastomotic dehiscence. In two, we demonstrate the treatment of acute colorectal leakage and how transanal surgery allows us to confirm its viability and rule out any underlying ischemia. Furthermore, it facilitates good drainage of the adjacent collection as well as the placement of a vacuum system, if necessary, and its subsequent replacements. The last case is a delayed dehiscence with chronic presacral sinus, and its treatment by transanal access for fenestration.     

Bloqueos del plano fascial ecoguiados,como única técnica anestésica para mastectomía total en la era de la COVID-19: caso clínico

IntroductionRegional anesthesia techniques were recently introduced to provide analgesia for breast surgery. These techniques are rarely used as the primary anesthesia due to the complexity of breast innervation, with numerous structures that can potentially be disrupted during breast surgery.Case reportA female patient in her sixties diagnosed with invasive ductal carcinoma on her left breast was scheduled for a simple mastectomy. After anesthetic evaluation, identification of high risk perioperative cardiovascular complications, it was proposed to perform the surgery only with regional anesthesia. A combination of pectoral nerve block (Pecs II), pecto-intercostal fascial block (PIFB) and supraclavicular nerve block ultrasound-guided were successfully performed.ConclusionThis is the first case reporting a novel approach in a patient with severe cardiopulmonary disease who underwent breast surgery in a COVID-19 era.     

Calcitonina como agente analgésico: revisão dos mecanismos de ação e das aplicações clínicas

Background and objectivesCalcitonin is a polypeptide hormone regulating the metabolism calcium in the body. For many years calcitonin has been used to maintain and improve bone mineral density and to reduce the fracture rate. Many studies showed that calcitonin had analgesic role in several painful circumstances. This pain‐ameliorating effect is irrelevant to its osteoclastic inhibitory effect and mechanisms like altering Na+ channel and serotonin receptor expression or hypothesis including the endorphin‐mediated mechanism were used to explain this effect. In this study we performed a thorough review on the role of calcitonin as an analgesic agent in different scenarios and investigated the fact that calcitonin can be a feasible medication to relieve pain.MethodMany studies focused on the analgesic effect of calcitonin in several painful circumstances, including acute pains related to vertebral fractures, metastasis, migraine and reflex sympathetic dystrophy as well as neuropathic pains related to spinal injuries or diabetes, and phantom pain. Also, calcitonin was showed to be a useful additive to local anesthesia in the case of controlling postoperative pain or trigeminal neuralgia more effectively. However we faced some contradictory data for conditions like lumbar canal stenosis, complex regional pain syndrome, phantom pain and malignancies.ConclusionThis study showed that calcitonin could be helpful analgesic agent in different painful situations. Calcitonin can be considered an eligible treatment for acute pains related to vertebral fractures and a feasible alternative for the treatment of the acute and chronic neuropathic pains where other medications might fail.     

Factores que condicionan la sensibilidad de la ecografía y la gammagrafía en la localización del adenoma paratiroideo

IntroductionThe treatment of choice for primary hyperparathyroidism (PHPT) when there is proper preoperative localization of the adenoma is minimally invasive parathyroidectomy. However, imaging techniques are not always able to provide the exact location. The objective is to identify potential factors that might influence the sensitivity and concordance of ultrasound (US) and 99mTc-methoxy-isonitrile parathyroid scintigraphy (MIBI-PS) and the actual location of the adenoma.MethodsWe reviewed the data of patients who underwent parathyroidectomies for PHPT. All patients had undergone ultrasound and 99mTc-MIBI scintigraphy as a preoperative location study. Multiple endocrine neoplasms, other hyperplasias and non-cervical ectopic adenomas were excluded. The sensitivity, PPV and concordance have been estimated for the location of the gland in both tests compared with the intraoperative location, using a multivariable analysis of the factors that might influence their localization capacity.Results139 patients (82% women) have been analysed. The US sensitivity was 56.7%, concordance (Kappa index) 0.387 and PPV 96.3%. The MIBI-PS sensitivity was 81.6%, the concordance (Kappa index) 0.669 and the PPV 97.4%. The factor that improved localization of the glands by US in the multivariable analysis was the absence of a concomitant thyroid pathology. The factor that improved the MIBI-PS results was a gland weight greater than 600 mg.ConclusionsUS sensitivity improves when there is no concomitant thyroid pathology. MIBI-PS sensitivity improves when the gland weight is greater than 600 mg.     

Experiencia en manejo anestésico para cirugía no cardiaca en pacientes con asistencias ventriculares

Heart failure (HF) is a syndromic condition with a high incidence in current medicine. When the symptoms of HF progress, and become refractory, cardiac transplant is the best therapeutic option. However, due to the shortage of donors and the long waiting lists, many of those patients are candidates for implantation of ventricular assist devices as a bridge to the cardiac transplant, or when this is not an option, as a definitive therapy. A series of four clinical cases of patients with ventricular assist devices that required surgical intervention, is presented. Three of them were assisted with long-term care: two EXCOR (pulsatile and para-corporeal) and one HEARTWARE (non-pulsatile and intra-corporeal), and the last one with short-term assistance; CentriMag biventricular Levitronix. There is no significant literature on the peri-operative implications of these patients when they undergo urgent or scheduled surgery. The experience in our centre leads us to raise the need to determine a series of aspects: operation of each device, emphasising the correct placement of the cannulas during the surgery; the proper management of any medication, emphasising the importance of anticoagulant and anti-platelet therapies; the Pathophysiological changes at cardiopulmonary level due to the implantation of these devices; and the importance of the administration of a correct antibiotic therapy. Given the complexity of these cases, the limited experience in this field, and the few cases that exist in these situations, it is recommended to create protocols to ensure their proper management.