Calidad de la recuperación después de la cirugía para el tratamiento del cáncer

Introduction

Assessment of quality of recovery is important as an end-point for outcome research. This study aims to determine the incidence and determinants of poor quality of recovery (PQR) after surgery in patients scheduled for curative neoplastic surgery.

Impacto del grado de cumplimiento de un protocolo ERAS en la recuperación funcional después de cirugía colorrectal

IntroductionCompliance to ERAS protocols is a process quality measure that is associated to better outcomes. The main objective of this study is to analyze the association between protocol compliance, surgical stress and functional recovery. The secondary objective is to identify independent factors associated to functional recovery.MethodsA prospective observational single-centre study was performed. Patients who had scheduled colorectal surgery within an ERAS program from January 2017 to June 2018 were included. We analysed the relationship between protocol compliance percentage and surgical stress (defined by C reactive protein [CRP] blood levels on postoperative 3^rd day), and functional recovery (defined by the proportion of patients who meet the discharge criteria on the 5^th PO day or before). Multivariate analysis was performed to asses independent factor associated to functional recovery.Results313 were included. For every additional percentage point of compliance to the protocol 3^rd day C reactive protein plasmatic level decreases 1,46 mg/dL and increases 7% the probability to meet the discharge criteria (p < 0.001 both). Independent factors associated to functional recovery were ASA III-IV (OR 0.26; 0.14-0.48), surgical CR-POSSUM score (OR 0.68; 0.57-0.83), early mobilization (OR 4.22; 1.43-12.4) and removal of urinary catheter (OR 3.35; 1.79-6.27), p < 0,001 each of them.ConclusionBetter compliance to ERAS protocol in colorectal surgery decreases surgical stress and accelerates functional recovery.     

Historia natural de la piuria y microhematuria después de la cirugía de próstata

ObjectiveUrinalysis alterations are common after prostatic surgery. However, time to normalization has not been established. Presence of pyuria and microhematuria can lead to unnecessary diagnostic procedures. The objective of this study is to determine the time to normalization for both parameters.Material and methodsWe reviewed medical records of patients who underwent prostatic surgery without infectious complications during follow-up. We included patients who underwent transurethral resection of the prostate (TURP) with either monopolar or bipolar energy, or open prostatectomy (OP). Kaplan-Meier curves were used to determine the time of persistence of both parameters. ANOVA was used to compare the 3 groups according to the type of surgery. We analyzed the impact of preoperative use of 5-α-reductase inhibitors, and searched for a correlation between the weight of resected tissue and persistence of both parameters.Results85 patients were analyzed: 44 underwent monopolar TURP, 27 bipolar TURP, and 14 OP. Persistence of pyuria was significantly longer than microhematuria with a median of 274 days vs. 176 days. Neither the use of monopolar or bipolar energy, nor the use of preoperative 5α-reductase inhibitors affected the persistence time. We found a positive correlation between the resected tissue weight and the persistence of leukocyturia after endoscopic surgery: 23 g was the best cut-off point.ConclusionsPyuria persists longer than microhematuria regardless of the type of surgery. There is a correlation between the resected tissue weight and the persistence of pyuria. The presence of pyuria and microhematuria after prostatic surgery is not always a pathological finding.     

La formación del residente en cirugía de la mama

Breast surgery training of residents varies greatly in Spain and depends on the specialty chosen and the centre where this is carried out. Training programmes have been changing and have been updated within the current trend for subspecialisation. The results from a survey show that, for residents, training in breast surgery is not very attractive as they think that they do not receive adequate training.     

Revisión sistemática del tratamiento activo de la fístula urinaria después de la nefrectomía parcial

IntroductionUrinary fistula is expected to become more frequent in urological practice as a result of expanding indication of partial nephrectomy given it?s oncological results equivalent to those of radical nephrectomy but at a lower risk of progression to chronic kidney disease, lower cardiovascular morbidity, and overall mortality.ObjectivesReview and compare different techniques of contemporary active management for urinary fistula after partial nephrectomy.MethodsA systematic literature search on the MEDLINE database was conducted in March 2020, combining the terms: «urine leak», «urine leakage», «urinary leak» and «urinary fistula», with: «partial nephrectomy», «nephron sparing surgery» and «renal sparing surgery». The review of the literature was performed accordingto the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only articles related to active treatment were eligible. Abstracts in English and Spanish from the last two decades were screened. No restriction based on study design nor the length of follow-up. Primary outcomes: 1) Leak resolution rate 2) Time course of leak resolution and 3) Number of interventions needed for resolution.ResultsMultiple studies were found. There were no randomized controlled trials. Urinary fistula can be solved in many ways with active treatment, with a high success rate (97.5%), an average of 1.4 intervention-per-patients and a mean time for leak resolution of 11 days (median of 3 days).ConclusionThere is a high risk of bias due to the study's methodology. There is a broad range of effective alternatives and various approaches to solve urinary fistula in an appropriate timing.     

Los factores causantes del acortamiento de pene después de la cirugía con plicatura en pacientes con incurvación peneana congénita

ObjectiveCongenital penile curvature is defined as the non-straightness of the penis without any urethral or penile pathology. We aimed to evaluate the factors that cause penile shortening after plication surgery in patients with congenital penile curvature.MethodsBetween November 2010 and December 2020, we retrospectively reviewed patients with CPC undergoing tunica albuginea plication surgery. Before the procedure, patients’ age, curvature location and degrees, as well as penile length were recorded. After the treatment, penile lengths were measured and recorded again. Early and late period results were recorded.ResultsPlication surgery was performed in 130 patients. The median age was 24 years.Seventy-six patients had ventral curvature, 22 had dorsal curvature, 32 had lateral curvature. Average shortening of penile length in patients with curvature below 30° was: ventral 8-16 mm, dorsal 6-13 mm, lateral 5-12 mm. Patients with curvatures above 30° were: ventral 12-22 mm, dorsal 8-20 mm, lateral 2-12 mm.ConclusionPenile length shortening after plication is inevitable. Curvature degree and direction are factors affecting penile length after surgery. Therefore, patients and relatives should be informed in more detail about this complication.     

Neumoencéfalo,coma y convulsiones después de una cirugía de descompresión lumbar

We describe a patient with pneumocephalus following lumbar decompression surgery who presented altered mental status at time to awake of anesthesia and the patient was admitted in intesive care unit in mechanical ventilation. The patient has not eye-opening response, no verbal response and motor response only withdraw in response to pain (7 points on Glasgow coma scale). Then, the patient experienced a generalized tonic-clonic seizure. Immediate cranial computed tomography (CT) images were performed. Cerebral pneumocephalus was present in CT, imaging revealed a voluminous pneumocephalus responsible for a significantspace-occupying effect on the frontal and parietal lobes, lateral ventricles and quadrigeminal plate cistern.Anti-epileptic therapy (diazepam and levetiracetam) and neurological monitoring were initiated. At 12 postoperative hours repeat CT scanning showed pneumocephalus were completely improved to minimal quantity and only limited to frontal lobe. The consciousness is impaired, and a generalized tonic-clonic seizure was present. Electroencephalogram showed continuous epileptiform activity and phenytoin IV was administered in continuous infusión. Four hours later the level of consciousness gradually improved, and the patient was right in eye opening, verbal and motor responses. A few hours later the patient was extubated, and no neurological deficits were present. Pneumocephalus should be considered in the differential diagnosis when evaluating a patient with altered mental status following lumbar surgery.     

Hemorragia de la pared abdominal después de prostatectomía radical asistida por robot: ¿es una complicación de la cirugía robótica?

ObjectiveRobotic-assisted radical prostatectomy (RARP) is the minimally invasive surgical treatment for patients with localized prostate cancer. Perioperative or postoperative complications following RARP have been reported in some studies and severe postoperative bleeding after RARP is rare, but hemodynamic instability may necessitate open surgical exploration and be associated with considerable morbidity. We reported postoperative bleeding cases, which is a kind of complication associated with robotic surgery and requiring massive transfusion after RARP.Patients and methodsFrom August 2009 to May 2012, 317 consecutive patients who underwent RARP performed at our institution were analyzed. Patients with serious postoperative bleeding that caused hemodynamic instability after surgery were enrolled.ResultsA total of 5 among 317 (1.6%) patients had bleeding requiring postoperative transfusion. In these cases, mean operative time was 114 minutes. The mean estimated blood loss was 110 ml during operation. In these patients, hematocrit (Hct) levels gradually fell after surgery and ecchymosis was detected on the side and posterior walls of the abdomen on the second day. The mean preoperative Hct was 44.3% and mean lowest Hct was 23.1%. All patients were successfully treatment without surgical exploration.ConclusionsRobotic radical prostatectomy has proven to be a safe surgical treatment with low morbidity. However, postoperative bleeding can reach serious problems. This is the first study to explain haemorrhage, associated with possible risk of robotic surgery.     

Rehabilitación multimodal en cirugía electiva colorrectal: evaluación de la curva de aprendizaje con 300 pacientes

IntroductionThe aim of this paper is to assess the learning curve on compliance to the application of a multimodal rehabilitation program (MMRP) protocol and patient recovery after elective colorectal surgery.Material and methodsA comparative prospective study of 3 consecutive cohorts of 100 patients (P1, P2 and P3) who had colonic or rectal surgery. The same MMRP protocol was applied in all cases. Compliance to the protocol, tolerance to the diet and walking have been analysed. The percentages of early hospital discharges have also been compared.ResultsCompliance gradually improved, reaching statistical significance between P1 and P3. Starting the diet on day 1 post-surgery was 52% vs 86% (p=0.0001) and the removal of drips was 21% vs 40% (p=0.005). This difference remained during days 2 and 3. Tolerance to the diet on day 1 (P1: 34% vs. P3: 66%; p=0.0001) and walking on day 2 (P1: 41% vs. P3: 68%; p=0.0002) were also better in the third period. No differences in morbidity were found between the three periods. The percentage of hospital discharges on day 3 P1: 1% vs. P3: 15%; p=0.0003), day 4 (P1: 12% vs. P3: 32%; p=0.001) and day 5 (P1: 30% vs. P3: 50%; p=0.002) was higher in the third period.ConclusionsThe compliance to the protocol and the results of applying the MMRP improved significantly with the greater experience of the professionals involved.     

Función eréctil después de cistectomía con preservación neurovascular

ObjectivesTo study the utility of neurovascular preservation for postoperative erection in radical cystectomy.Materials and methodsRetrospective analysis of 44 cystectomies performed at our center between January 2006-December 2009 in men < 65 years. In 11 cases a neurovascular preservation was done. We analyzed age, BMI, indication for surgery, urinary diversion, use of i-PDE5 or alprostadil, and daytime and nighttime continence. Erection Hardness Score (EHS) was used to assess erectile function.ResultsSpontaneous postoperative erectile function in preservation group was 44,4% EHS 4, 33,3% EHS 3 and 22,3% EHS 1 (achieving EHS 3 or 4 with alprostadil). In the non preservation group, 4,5% achieved EHS 4 spontaneously. The other 95,5% had EHS 0 (4,5% achieved EHS 3 with tadalafil 20 mg and 9% with intracavernous injections). Variables age (P = .001) and nerve-sparing surgery (P < .001) were related to postoperative erectile function recovery. In the multivariate analysis, nerve-sparing surgery remained statisticaly significant.ConclusionsThe functional results in preserving cystectomy are promising. The preservation should be considered in young patients without erectile dysfunction.     

Revisión del manejo de la vía aérea díficil en cirugía torácica

The management of difficult airway (DA) in thoracic surgery is more difficult due to the need for lung separation or isolation and frequent presence of associated upper and lower airway problems. We performed an article review analysing 818 papers published with clinical evidence indexed in Pubmed that allowed us to develop an algorithm.The best airway management in predicted DA is tracheal intubation and independent bronchial blockers guided by fibroscopy maintaining spontaneous ventilation. For unpredicted DA, the use of videolaryngoscopes is recommended initially, and adequate neuromuscular relaxation (rocuronium/sugammadex), among other maneuvers. In both cases, double lumen tubes should be reserved for when lung separation is absolutely indicated.Finally, extubation should be a time of maximum care and be performed according to the safety measures of the Difficult Arway Society.     

Síndrome de Rett: doble catéter epidural para control del dolor postoperatorio tras cirugía de escoliosis. Revisión de la bibliografía

Rett syndrome is a severe and incapacitating neurological disease caused by a structural defect in the short arm of the X chromosome (Xq28). It affects females and consists of multiple and progressive neurological impairments that start from a young age, leading to lifelong disability and dependency.Scoliosis appears in more than 50% of patients and requires surgical correction in cases where the curvature is severe. Pre-anaesthetic assessment is essential in order to identify the risk factors and thus reduce the morbidity and mortality associated with the surgical procedure.We present the case of a patient affected by this syndrome and scoliosis, who was scheduled to have an instrumented thoracolumbar spine arthrodesis with general anaesthesia, which passed without incident. We evaluate the specific details of this syndrome, its potential complications, and its management from an anaesthetic point of view, emphasising the control of postoperative pain using a double epidural catheter with an infusion of local anaesthetics and fentanyl.     

Utilidad de la hemoperfusión en el tratamiento del paciente séptico grave. Actualización

Haemoperfusion is an extracorporeal technique that removes endotoxin and/or inflammatory mediators by means of an adsorptive mechanism during the passage of the blood through a porous filter. Most of the studies in the literature use polymyxin B as the adsorptive agent. This treatment is based on the assumption that the removal of endotoxin and inflammatory mediators from the circulation attenuates the inflammatory response in sepsis. This review summarizes the theoretical basis, and the experimental and clinical results published to date with the use of haemoperfusion. Although most of the studies show positive results, some doubts have arisen about the suitability of the methods described (small number of cases, low quality of the experimental design, and excessive mortality in the control groups). There are also some inconsistencies regarding the theoretical basis of its use (lack of positive effects after the removal of endotoxin from the circulation using alternative mechanisms, discrepancies regarding the best moment to initiate the therapy, unexplained beneficial effects in the absence of increased endotoxin levels). It is the opinion of the authors that haemoperfusion represents a promising therapy for the treatment of sepsis, but consider that its usefulness requires confirmation in well designed studies before being included in protocols.