Abordaje ecoguiado a nivel antecubital para cirugía del síndrome del túnel del carpo

IntroductionThere are various anaesthetic techniques for ambulatory surgery of carpal tunnel release. The ultrasound-guided nerve blocks offer advantages compared to other techniques. The purpose of this study was to evaluate the efficacy using ultrasound-guided block at the antecubital fossa, as well as to evaluate complications, patient satisfaction and surgeon satisfaction with the block.Materials and methodsProspective observational study with 32 elective patients for carpal tunnel release in a one-day case unit. An ultrasound-guided block with mepivacaine 1% was performed at the antecubital fossa, aiming for the median, ulnar and the lateral and medial cutaneous nerves of the forearm. The measurements of the anteroposterior and laterolateral diameters of the median and ulnar nerves were recorded, before and after injection. Motor and sensory levels were evaluated for the median and ulnar nerves at 5 and 30 min post injection, and compared with the contralateral hand. Pain from the surgical incision time and recovery were recorded, together with complications, and patient and surgeon satisfaction with the block.ResultsThe antecubital fossa ultrasound-guided block was successful in 93.7% of the patients. No patients needed rescue analgesia in recovery and no complications were recorded. Patient satisfaction was 93.7% and surgeon satisfaction was 97%.ConclusionsA selective block of the medial, ulnar and medial and lateral cutaneous nerves of the forearm are effective and satisfactory anaesthetic techniques for carpal tunnel release in a one-day case unit. It allows early mobilization, minimises risks and amount of local anaesthetic used.     

Pediatric Liver Transplantation Experience and Outcome in Chile

IntroductionIn 1994 our group began its experience with pediatric liver transplantation. The experience gained during this period is the largest in the country, positioning the Hospital Luis Calvo Mackenna and Clinica Las Condes as major referral centers in the public and private sectors. The aim of this study was to report our experience of our pediatric liver transplantation program during this period.MethodsThe liver transplantation database of Hospital Luis Calvo Mackenna and Clinica Las Condes between January 1994 and July 2011 was reviewed recording age, gender, indications for transplantation, surgical technique, complications, and survival. Survival rates were calculated using Kaplan-Meier analysis.ResultsDuring the period described 230 transplantations were performed in 189 pediatric patients. Fifty-five percent were male patients. The average age was 5 years. The main causes of transplantation were biliary atresia (50%), fulminant hepatic failure (25%), and other cholestatic diseases by 10%. Vascular and biliary complications were the leading cause of graft loss and retransplantation. The overall rate of retransplantation at 5 years was 20%. The technique of living donor was used in 28% of the cases. The 1-year patient actuarial survival rate was 80%, 73% at 5 years, and 68% at 10 years. In the last 3 years the survival rate at 1 year exceeds 90%.DiscussionOur program includes more than 90% of the national liver experience. The incorporation of living donor is a milestone that has enabled us to save many patients who previously died while waiting for an organ. Its use in cases of full acute liver failure has allowed us to dramatically reduce mortality on the waiting list. Our results in the last 3 years reflect the experience that results in a significant decrease in mortality, comparing favorably to other series published in the international literature.     

Combined Liver-Kidney Transplantation: Survey of a Single Center in Spain

BackgroundRenal dysfunction is a common complication of advanced liver failure and liver transplantation. Since the introduction of the MELD criteria the proportion of patients with advanced chronic kidney disease and need for liver transplantation has increased. One alternative is the combined liver-kidney transplant (CLKT). The aim of this study was to evaluate the outcome of this type of transplant in our center.MethodsWe retrospectively analyzed all combined simultaneous or sequential transplants from 1989 to 2012. We studied demographic and clinical variables. Survival analysis was performed by Kaplan-Meier method.ResultsIn the study period, 1,265 kidney and 1,050 liver transplantations were performed; 34 were CLKT (to 29 adults and 5 children); 13 of these were simultaneous and 12 sequential liver-kidney. We also carried out 4 triple liver-pancreas-kidney transplantations, 3 simultaneous and 1 sequential. The mean age was 44.1 ± 15 years, and 27 were male (93.1%); 9 (37.5%) were diabetic. The main causes of liver disease were viral (n = 11 [41.3%; hepatitis virus B, C, or both] and alcoholism (9 [31%]). The renal disease etiology was unknown in 16 (55.1%), IgA nephropathy in 2 (6.8%), membranoproliferative glomerulonephritis in 2 (6.8%), and calcineurin inhibitor toxicity in 4 (13.6%). Transjugular renal biopsy was performed in 6 sequential transplants. Survival of patients who received a CLKT was excellent: 91%, 51%, and 40%, at 1, 5, and 10 years, respectively. No significant difference was found between sequential and simultaneous transplants (log rank 0.5).ConclusionsOur results of CLKT show results similar or superior to those of other series and are an alternative to consider in candidates for liver transplantation with chronic kidney disease. Transjugular biopsy is an alternative to study the etiology of renal disease in patients with hepatic dysfunction before or after liver transplantation.     

Exactitud de la urotomografía computarizada para detectar tumores vesicales en pacientes con hematuria microscópica

ObjectiveOur objective was to evaluate the sensitivity, specificity, predictive value, and accuracy of computed tomographic urography for the detection of bladder tumors in patients with microscopic hematuria.Material and methodsPatients with microscopic hematuria initially evaluated with computed tomography and cystoscopy from January 2006 to December 2009 were evaluated. Computed tomography detecting a bladder lesion suspicious of malignancy was considered positive. Cystoscopy was classified as positive when a lesion requiring biopsy or resection was found. Performance characteristics of computed tomography were determined by comparing with cystoscopic and pathological findings.ResultsA total of 112 patients were eligible for analysis. Seven tumors were found on cystoscopy; of these, 2 were correctly diagnosed by computed tomography and 5 were missed. An additional case was considered erroneously positive. The results are a sensitivity of 29%, specificity of 99%, positive predictive value of 67%, negative predictive value of 95%, and accuracy of 95%.ConclusionsAlthough computed tomography has a high specificity its sensitivity is limited. For this reason conventional cystoscopy should be considered the standard for bladder evaluation of patients with microscopic hematuria.     

Tratamiento de la incontinencia urinaria de esfuerzo femenina mediante cintillas suburetrales: estudio retrospectivo comparativo observacional de 2 técnicas quirúrgicas

ObjectiveThe treatment of female stress urinary incontinence has undergone a revolution in recent years due the emergence on the market of suburethral slings. The aim of this study is to compare two surgical techniques for treating stress urinary incontinence: Monarc? (transobturator suburethral sling) and MiniArc^® (single-incision suburethral mini-sling).Material and methodsComparative, retrospective, observational study from January 2005 to December 2011 on 317 women diagnosed with stress urinary incontinence. Of these, 214 were treated with the Monarc? transobturator suburethral sling, and 103 were treated with the MiniArc^® mini-sling. The results were treated with SPSS v.15 software, and the statistical significance was P ≤ .005.ResultsThe two patients groups were homogeneous in terms of age, number of births, presence of urgency urinary incontinence and prior hysterectomy. There were significant differences in hospital stay, surgical time and early complications in favour of the MiniArc^®, technique, but overall there were no significant differences in the late complications. Some 84% of the patients treated with the Monarc? transobturator sling were cured compared with the 72% of patients in whom we implanted a MiniArc^®, a difference that was statistically significant.ConclusionWe need to perform more high-quality, prospective and randomised studies with larger numbers of patients and longer follow-up times to confirm or disprove the difference that we found in the success rate for the Monarc? transobturator suburethral sling.     

Papel del antígeno prostático específico ante las nuevas evidencias científicas

ObjectiveReview the scientific evidence acquired in recent years on Prostate-Specific Antigen (PSA).Acquisition of evidenceAnalysis of the available evidence on the current role of PSA, according to a panel of experts who recorded their experience on the subject.Summary of the evidenceCurrently, PSA cannot be considered solely an indicator of the presence or absence of prostate cancer. Rather, the determination of PSA assists the urologist in indicating the most appropriate treatment for a patient with benign prostatic hypertrophic (BPH), as well as in suspecting a prostatic tumour when the PSA reading increases >0,3 ng/ml, in patients treated with 5-alpha-reductase inhibitor, over the reading achieved at six months of having initiated this treatment. Moreover, PSA is a key factor in the follow-up of patients with prostate adenocarcinoma who undergo surgery, radiation therapy or minimally invasive techniques. PSA helps to define biochemical recurrence, suggest the existence of a local or distal recurrence and propose or rule out adjuvant therapies.ConclusionsNew data on the current role of PSA in the management of patients treated for BPH and/or prostate cancer should be taken into account.     

Linfadenectomía inguinal izquierda endoscópica modificada

IntroductionEndoscopic Inguinal Lymphadenectomy is an evolution of laparoscopic surgery thanks to background in these techniques. This is a new technique and the indications in the field of penile tumors today are expanding. The technique aims at reducing the morbidity of the procedure without compromising the cancer control or reducing the template of the dissection.Material and methodsWe present the modified endoscopic inguinal lymphadenectomy in a 70 years-old male patient with penile melanoma and positive sentinel lymph node in left inguinal limb. Intraoperative data, pathology, post operatory evolution and oncological follow-up is describedResultsOperative time was 120 minutes. Nine lymph nodes were retrieved and none of then showed positivity at pathology. There were no complications. The drain was kept for five days. After 12 months of follow up, no signs of disease progression were noted.ConclusionThe endoscopic inguinal lymphadenectomy is feasible in clinical practice. New studies with a greater number of patients and long-term follow-up may confirm the oncological efficacy and possible lower morbidity of these new approach.