Protocolo de recuperación mejorada después de cirugía (ERAS) atenúa el estrés y acelera la recuperación en pacientes después de resección radical por cáncer colorrectal: Experiencia en la Clínica Universitaria Colombia / Enhanced Recovery After Surgery (ERAS) protocol attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: Experience at Clínica Universitaria Colombia

Introducción. El conjunto de estrategias de recuperación mejorada después de la cirugía (ERAS, por sus siglas en inglés) constituye un enfoque de atención multimodal y multidisciplinario, cuyo propósito es reducir el estrés perioperatorio de la cirugía, disminuir la morbilidad y acortar la estancia hospitalaria. Este estudio tuvo como objetivo describir los resultados clínicos de pacientes sometidos a cirugía por cáncer colorrectal, identificando las complicaciones principales y los factores perioperatorios relacionados con el alta temprana. Métodos. Se analizaron los pacientes consecutivos sometidos a cirugía colorrectal entre los años 2020 y 2023, todos los cuales siguieron el protocolo ERAS institucional. Se evaluaron las características clínicas, los factores perioperatorios, los desenlaces postoperatorios y la tasa global de adherencia al protocolo. Resultados. Un total de 456 pacientes fueron sometidos a cirugía colorrectal, 51% de sexo masculino, con edad media de 60 años. La mayoría de las intervenciones se realizaron por laparoscopia (78 %), con una tasa de conversión del 14,5 %. Las complicaciones postoperatorias incluyeron fuga anastomótica (4,6 %), sangrado, infección intraabdominal y obstrucción intestinal. La estancia hospitalaria promedio fue de 4 días y la mortalidad del 2,8 %. La tasa global de adherencia al protocolo ERAS fue del 84,7 %. Conclusiones. El enfoque combinado de cirugía laparoscópica y protocolo ERAS es factible, seguro y se asocia con una estancia hospitalaria más corta. La implementación y adherencia al protocolo ERAS no solo mejora los resultados postoperatorios, sino que también resalta la importancia de acceder a datos sólidos, permitiendo mejorar la atención perioperatoria local.

Introduction. The Enhanced Recovery After Surgery (ERAS) protocol is a multimodal, multidisciplinary approach to care, the purpose of which is to reduce the perioperative stress of surgery, decrease morbidity, and shorten hospital stay. This study aimed to describe the clinical outcomes of patients undergoing surgery for colorectal cancer, identifying the main complications and perioperative factors related to early discharge. Methods. Consecutive patients undergoing colorectal surgery between 2020 and 2023 were analyzed, who followed the institutional ERAS protocol. Clinical characteristics, perioperative factors, postoperative outcomes, and overall protocol adherence rate were evaluated. Results. A total of 456 patients underwent colorectal surgery, 51% male, with a mean age of 60 years. Most interventions were performed laparoscopically (78%), with a conversion rate of 14.5%. Postoperative complications included anastomotic leak (4.6%), followed by bleeding, intra-abdominal infection, and intestinal obstruction. The average hospital stay was 4 days and mortality was 2.8%. The overall adherence rate to the ERAS protocol was 84.7%. Conclusions. The combined approach of laparoscopic surgery and ERAS protocol is feasible, safe, and associated with a shorter hospital stay. Implementation and adherence to the ERAS protocol not only improves postoperative outcomes, but also highlights the importance of accessing solid data, allowing for improved local perioperative care.

Hypertonic saline infusion does not improve the chance of primary fascial closure after damage control laparotomy: a randomized controlled trial.

BACKGROUND: Previous observational studies showed higher rates of abdominal wall closure with the use of hypertonic saline in trauma patients with abdominal injuries. However, no randomized controlled trials have been performed on this matter. This double-blind randomized clinical trial assessed the effect of 3% hypertonic saline (HS) solution on primary fascial closure and the timing of abdominal wall closure among patients who underwent damage control laparotomy for bleeding control. METHODS: Double-blind randomized clinical trial. Patients with abdominal injuries requiring damage control laparotomy (DCL) were randomly allocated to receive a 72-h infusion (rate: 50 mL/h) of 3% HS or 0.9 N isotonic saline (NS) after the index DCL. The primary endpoint was the proportion of patients with abdominal wall closure in the first seven days after the index DCL. RESULTS: The study was suspended in the first interim analysis because of futility. A total of 52 patients were included. Of these, 27 and 25 were randomly allocated to NS and HS, respectively. There were no significant differences in the rates of abdominal wall closure between groups (HS: 19 [79.2%] vs. NS: 17 [70.8%]; p = 0.71). In contrast, significantly higher hypernatremia rates were observed in the HS group (HS: 11 [44%] vs. NS: 1 [3.7%]; p < 0.001). CONCLUSION: This double-blind randomized clinical trial showed no benefit of HS solution in primary fascial closure rates. Patients randomized to HS had higher sodium concentrations after the first day and were more likely to present hypernatremia. We do not recommend using HS in patients undergoing damage control laparotomy. Trial registration The trial protocol was registered in clinicaltrials.gov (identifier: NCT02542241).

Risk factors for posttraumatic empyema in diaphragmatic injuries.

BACKGROUND: Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury, contamination severity, and surgical management to the risk of posttraumatic empyema in patients who underwent surgical repair of diaphragmatic injuries at a level 1 trauma center. METHODS: This is a retrospective review of the patients who survived more than 48 h. Univariate OR calculations were performed to identify potential risk factors. Multiple logistic regression was used to calculate adjusted ORs and identify independent risk factors. RESULTS: We included 192 patients treated from 2011 to 2020. There were 169 (88.0) males. The mean interquartile range, (IQR) of age, was 27 (22-35) years. Gunshot injuries occurred in 155 subjects (80.7%). Mean (IQR) NISS and ATI were 29 (18-44) and 17 (10-27), respectively. Thoracic AIS was > 3 in 38 patients (19.8%). Hollow viscus was injured in 105 cases (54.7%): stomach in 65 (33.9%), colon in 52 (27.1%), small bowel in 42 (21.9%), and duodenum in 10 (5.2%). Visible contamination was found in 76 patients (39.6%). Potential thoracic contamination was managed with a chest tube in 128 cases (66.7%), with transdiaphragmatic pleural lavage in 42 (21.9%), and with video-assisted thoracoscopy surgery or thoracotomy in 22 (11.5%). Empyema occurred in 11 patients (5.7%). Multiple logistic regression identified thoracic AIS > 3 (OR 6.4, 95% CI 1.77-23. 43), and visible contamination (OR 5.13, 95% IC 1.26-20.90) as independent risk factors. The individual organ injured, or the method used to manage the thoracic contamination did not affect the risk of posttraumatic empyema. CONCLUSION: The severity of the thoracic injury and the presence of visible abdominal contamination were identified as independent risk factors for empyema after penetrating diaphragmatic trauma.

Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension?

Current literature shows the association of post-intubation hypotension and increased odds of mortality in critically ill non-trauma and trauma populations. However, there is a lack of research on potential interventions that can prevent or ameliorate the consequences of endotracheal intubation and thus improve the prognosis of trauma patients with post-intubation hypotension. This review paper hypothesizes that the deployment of REBOA among trauma patients with PIH, by its physiologic effects, will reduce the odds of mortality in this population. The objective of this paper is to review the current literature on REBOA and post-intubation hypotension, and, furthermore, to provide a rational hypothesis on the potential role of REBOA in severely injured patients with post-intubation hypotension.

Casualties of peace: an analysis of casualties admitted to the intensive care unit during the negotiation of the comprehensive Colombian process of peace.

Background: After 52 years of war in 2012, the Colombian government began the negotiation of a process of peace, and by November 2012, a truce was agreed. We sought to analyze casualties who were admitted to the intensive care unit (ICU) before and during the period of the negotiation of the comprehensive Colombian process of peace. Methods: Retrospective study of hostile casualties admitted to the ICU at a Level I trauma center from January 2011 to December 2016. Patients were subsequently divided into two groups: those seen before the declaration of the process of peace truce (November 2012) and those after (November 2012-December 2016). Patients were compared with respect to time periods. Results: Four hundred forty-eight male patients were admitted to the emergency room. Of these, 94 required ICU care. Sixty-five casualties presented before the truce and 29 during the negotiation period. Median injury severity score was significantly higher before the truce. Furthermore, the odds of presenting with severe trauma (ISS > 15) were significantly higher before the truce (OR, 5.4; (95% CI, 2.0-14.2); p < 0.01). There was a gradual decrease in the admissions to the ICU, and the performance of medical and operative procedures during the period observed. Conclusion: We describe a series of war casualties that required ICU care in a period of peace negotiation. Despite our limitations, our study presents a decline in the occurrence, severity, and consequences of war injuries probably as a result in part of the negotiation of the process of peace. The hysteresis of these results should only be interpreted for their implications in the understanding of the peace-health relationship and must not be overinterpreted and used for any political end.

Analysis of combat casualties admitted to the emergency department during the negotiation of the comprehensive Colombian process of peace / Análisis de los soldados heridos en combate admitidos al departamento de emergencias durante la negociación del proceso de paz en Colombia

Abstract Aim: Our objective was to describe the variations in casualties admitted to the emergency department during the period of the negotiation of the comprehensive peace agreement in Colombia between 2011 and 2016. Methods: A retrospective study of all hostile military casualties managed at a regional Level I trauma center from January 2011 to December 2016. Patients were subsequently divided into two groups: those seen before the declaration of the process of peace truce (November 2012) and those after (negotiation period). Variables were compared with respect to periods Results: A total of 448 hostile casualties were registered. There was a gradual decline in the number of admissions to the emergency department during the negotiation period. The number of soldiers suffering blast and rifle injuries also decreased over this period. In 2012 there were nearly 150 hostile casualties' admissions to the ER. This number decreased to 84, 63, 32 and 6 in 2013, 2014, 2015 and 2016 respectively. Both, the proportion of patients with an ISS ≥9 and admitted to the intensive care unit were significantly higher in the period before peace negotiation. From August to December/2016 no admissions of war casualties were registered. Conclusion: We describe a series of soldiers wounded in combat that were admitted to the emergency department before and during the negotiation of the Colombian process of peace. Overall, we found a trend toward a decrease in the number of casualties admitted to the emergency department possibly in part, as a result of the period of peace negotiation.

Resumen Objetivo: Describir las variaciones en los soldados heridos en combate admitidos al departamento de emergencias durante el periodo de negociación del proceso de paz colombiano entre el 2011 y el 2016. Métodos: Estudio retrospectivo de todos los soldados heridos en combate que fueron manejados en un centro de trauma desde Enero del 2011 a Diciembre del 2016. Los pacientes se dividieron en dos grupos: aquellos que ingresaron al departamento de emergencias antes de la tregua del proceso de paz (Noviembre 2012) y aquellos que ingresaron durante la negociación. Los grupos se compararon con respecto a los periodos de tiempo. Resultados: Un total de 448 soldados heridos en combate fueron incluidos. Hubo una disminución gradual en el número de admisiones durante el periodo de negociación. Además, el número de soldados que sufrieron heridas por explosiones y fusiles disminuyó durante este periodo. En el 2012 se registraron 150 soldados heridos en combate. Este número disminuyó a 84, 63, 32 y 6 en los años 2013, 2014, 2015 y 2016 respectivamente. La proporción de pacientes con un ISS ≥9 y la proporción de admitidos a la unidad de cuidado intensivo fueron significativamente mayores en el periodo antes de la negociación. Desde Agosto a Diciembre/2016 no se registraron admisiones. Conclusión: Este estudio describe una disminución gradual en el número de soldados heridos en combate admitidos al departamento de emergencia en un periodo de 6 años. Este fenómeno pudo deberse al periodo de negociación del proceso de paz.

Uso actual del balón de resucitación aórtico endovascular (REBOA) en trauma / Current use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma

ABSTRACT Introduction: Non-compressible torso haemorrhage is the leading cause of death in trauma cases. This has led to the development of new devices to control bleeding, including Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Objective: To perform a non-systematic review of the literature on the use of Resuscitative Endovascular Balloon Occlusion of the Aorta in trauma. Materials and methods: A systematic literature search through Medline was conducted. Articles relevant to our objective were selected. A qualitative and narrative synthesis of results is presented. Results: Our qualitative and narrative results show that Resuscitative Endovascular Balloon Occlusion of the Aorta could be a safe and effective intervention for the control of haemorrhage in abdomino-pelvic trauma. Its use is controversial in thoracic trauma. Finally, the performance of this intervention may cause complications. Conclusion: Resuscitative Endovascular Balloon Occlusion of the Aorta is an alternative that can be used in damage control surgery. It could be effective for early control of bleeding in patients with non-compressible torso haemorrhage. As a complex intervention, REBOA is in its development phase, and the evidence available preclude us from providing strong recommendations.

Resumen Introducción: La hemorragia no compresible del torso es la principal causa de muerte asociada al trauma. Esto ha llevado al desarrollo de nuevos dispositivos para el control hemorrágico, y uno de estos es el balón de resucitación aórtico endovascular (REBOA). Objetivo: Realizar una revisión no sistemática de la literatura con respecto al uso del REBOA en trauma. Materiales y métodos: Se realizó una búsqueda sistemática de la literatura en Medline, se seleccionaron los artículos relevantes para el logro de nuestro objetivo ycon estos se realizó una síntesis cualitativa y narrativa de la literatura disponible. Resultados: Nuestra síntesis cualitativa y narrativa muestra que el REBOA podría ser una intervención segura yefectiva para el control de la hemorragia en trauma abdominopélvico. Su uso es controvertido en trauma torácico. Finalmente, el uso del balón de resucitación aórtico endovascular puede causar complicaciones relacionadas con su aplicación. Conclusión: El REBOA es una alternativa en la cirugía de control de daños que podría ser efectiva en el control de la hemorragia no compresible del torso de origen abdominopélvico. Al ser una intervención compleja, el REBOA se encuentra todavía en fase de desarrollo yla evidencia disponible no es suficiente para proveer recomendaciones fuertes.

A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients.

BACKGROUND: The objective of this systematic review and meta-analysis was to determine the effect of REBOA, compared to resuscitative thoracotomy, on mortality and among non-compressible torso hemorrhage trauma patients. METHODS: Relevant articles were identified by a literature search in MEDLINE and EMBASE. We included studies involving trauma patients suffering non-compressible torso hemorrhage. Studies were eligible if they evaluated REBOA and compared it to resuscitative thoracotomy. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. We conducted meta-analysis using random effect models. RESULTS: We included three studies in our systematic review. These studies included a total of 1276 patients. An initial analysis found that although lower in REBOA-treated patients, the odds of mortality did not differ between the compared groups (OR 0.42; 95% CI 0.17-1.03). Sensitivity analysis showed that the risk of mortality was significantly lower among patients who underwent REBOA, compared to those who underwent resuscitative thoracotomy (RT) (RR 0.81; 95% CI 0.68-0.97). CONCLUSION: Our meta-analysis, mainly from observational data, suggests a positive effect of REBOA on mortality among non-compressible torso hemorrhage patients. However, these results deserve further investigation.