Lumbar Decompression Versus Spinal Fusion ina Private Outpatient Setting: A Retrospective Study with Three Years of Follow-up / Descompressão lombar versus fusão espinhal em ambiente ambulatorial privado: Um estudo retrospectivo com três anos de acompanhamento

Abstract Objective To compare pain, function, quality of life and adverse events of lumbar decompression and spinal fusion in patients with degenerative spinal pathologies who participated in a second opinion program for spinal surgeries with a 36-month followup. Methods The data for this retrospective cohort were withdrawn from a private healthcare system between June 2011 and January 2014. The study sample consisted of 71 patients with a lumbar spine surgical referral. The outcomes for the comparisons between lumbar decompression and spinal fusion were quality of life (evaluated through the EuroQoL 5D), pain (measured by the Numerical Rating Scale) and function (assessed through the Roland Morris Disability Questionnaire) measured at baseline, and at 12 and 36 months after the surgical procedures. The definitions of recovery were established by the minimal clinically important difference (MCID). The baseline differences between the groups were analyzed by non-paired t-test, and the differences in instrument scores between time points, by generalized mixed models. The results were presented as mean values adjusted by the models and 95% confidence intervals. Results Concerning the surgical techniques, 22 patients were submitted to spinal fusion and 49 patients, to lumbar decompression. As for the comparisons of the findings before and after the surgical interventions, the MCID was achieved in all outcomes regarding quality of life, pain and function at both time points when compared to baseline scores Moreover, concerning the complication rates, only lumbar decompression presented a surgical rate of 4% (n = 3) for recurrence of lumbar disc hernia. Conclusion Patients with degenerative spinal pathologies present improvements in long-term outcomes of pain, function and quality of life which are clinically significant, no matter the surgical intervention.

Resumo Objetivo Comparar a dor, a função, a qualidade de vida e os eventos adversos da descompressão lombar e da fusão espinhal em pacientes com patologias degenerativas da coluna vertebral que participaram de um programa de segunda opinião para cirurgias de coluna com acompanhamento de 36 meses. Métodos Os dados desta coorte retrospectiva foram obtidos de um sistema de saúde privado entre junho de 2011 e janeiro de 2014. A amostra do estudo foi composta por 71 pacientes encaminhados para cirurgia de coluna lombar. Os desfechos para comparações entre a descompressão lombar e a fusão espinhal foram qualidade de vida (avaliada pelo questionário EuroQoL 5D), dor (medida pela Escala Numérica de Classificação de Dor) e função (avaliada pelo Questionário de Incapacidade de Roland Morris) no início do estudo e aos 12 e 36 meses de acompanhamento pós-cirúrgico. As definições de recuperação foram estabelecidas pela diferença mínima clinicamente importante (DMCI). As diferenças basais entre os grupos foram analisadas por teste t não pareado, e as diferenças nas pontuações dos instrumentos entre os momentos, por modelos mistos generalizados. Os resultados foram apresentados como valores médios ajustados pelos modelos e intervalos de confiança de 95%. Resultados No total, 22 pacientes foram submetidos à artrodese, e 49 pacientes, à descompressão lombar. Quanto às comparações de achados antes e depois das intervenções cirúrgicas, a DMCI foi alcançada em todos os desfechos de qualidade de vida, dor e função nos dois pontos de acompanhamento em relação aos escores basais Em relação às complicações, apenas a descompressão lombar apresentou 4% (n = 3) de taxa cirúrgica de recidiva da hérnia de disco lombar. Conclusão Pacientes com patologias espinhais degenerativas apresentam melhoras nos desfechos de dor, função e qualidade de vida em longo prazo que são clinicamente significativas e independentes da intervenção cirúrgica.

Experiencia Quirúrgica en el Manejo del Cáncer de Recto. Hospital de SOLCA, Guayaquil ­ Ecuador / Management of Colorectal Cancer, Surgical Experience. Hospital SOLCA, Guayaquil ­ Ecuador

INTRODUCCIÓN: El cáncer colorrectal ocupa el tercer lugar a nivel mundial entre las neoplasias malignas. El tratamiento utilizado depende entre otros factores de la localización, y va desde la escisión local hasta una resección abdominoperineal y se puede acompañar de tratamiento neoadyuvante y adyuvante, dependiendo del estadiaje. Los objetivos de este estudio fueron, determinar el tipo histológico más común del cáncer de recto, establecer el estadio más frecuente del cáncer de recto y conocer el tratamiento quirúrgico más empleado en el cáncer de recto y sus complicaciones. MATERIALES Y MÉTODOS: Se realizó un estudio descriptivo transversal, con un total de 160 pacientes del Servicio de Cirugía digestiva del Hospital SOLCA, Guayaquil ­ Ecuador, durante el período comprendido entre Enero 2011 y Diciembre 2016, diagnosticados de cáncer de recto histológicamente e intervenidos quirúrgicamente. RESULTADOS: El sexo femenino fue el más afectado con 65.7 %, el 63.1% de los pacientes se diagnosticaron en estadio III, el diagnóstico histológico de adenocarcinoma fue el más común (73.7%), se localizó a nivel bajo en el 67.5 % de los pacientes. Se realizó cirugía programada en el 83.7 %, colostomía derivativa en el 48.8 % y las principales complicaciones registradas fueron las relacionadas con la ostomía en el 9.4% de la población. La mortalidad inmediata corresponde al 1.2 % y la tardía corresponde al 8.1 %. CONCLUSIÓN: El presente estudio, permitió evidenciar que el cáncer de recto afectó principalmente a mujeres, a pacientes mayores de 60 años. La mayoría de pacientes se diagnosticaron en estadios avanzados (III), con histología de adenocarcinoma. La colostomía derivativa fue la técnica quirúrgica más utilizada y la mayoría de pacientes con necesidad de terapia neoadyuvante. Las complicaciones más frecuentes fueron las relacionadas con las ostomías.(au)

BACKGROUND: Colorectal cancer is the third most common among malignant neoplasms worldwide. Treatment choice depends on the location of the tumor, among other factors, and varies from local excision to abdominoperineal resection, adjuvant or neoadjuvant therapy can be needed, depending on clinical stage. The purpose of this study was to determine the most common histological type of rectal cancer, establish the most frequent clinical stage at diagnosis, the most common surgical technique and complications. METHODOLOGY: A cross-sectional study was carried out, with 160 patients treated in the digestive surgery service of Hospital SOLCA, Guayaquil ­ Ecuador, between January 2011 and December 2016, with colorectal cancer histologically diagnosed and treated surgically. RESULTS: Female sex was the most affected, with 65.7%, 63.1% of the patients were diagnosed at stage III, adenocarcinoma was the most common histological type (73.7%), the tumor was more frequently located at a low level, in 67.5% of the patients. Surgery was scheduled for 83.7% of the patients, derivative colostomy was the most common surgical procedure for treatment (48.8%), and the most common complications were those related to the ostomy, in 9.4% of the patients. Immediate mortality was 1.2% and late mortality was 8.1%. CONCLUSION: This study evidenced that colorectal cancer affected with more frequency to women, mainly to people over 60 years old. Most of the patients were diagnosed with advanced clinical stage (III) carcinoma, most frequently adenocarcinoma. Derivative colostomy was the procedure of choice for most of the patients, most of them needed neoadjuvant therapy too. The most common postsurgical complications were those related to ostomies.(au)

Veress needle versus direct trocar entry for laparoscopy: a retrospective study

Background: The aim of this paper is to compare the outcomes of veress needle entry versus direct trocar for laparoscopy in terms of the duration of the procedure, ease of performance and the complications encountered during each technique.Methods: The present study was conducted on a retrospective basis from April ‘2008 to September 2017, in the dept of Obstetrics and Gynecology, in a 100 bedded hospital, ABGH hospital. All the cases who underwent laparoscopic ligation procedure during this time were taken into account. From 2008 to 2012 traditional technique of veress needle entry was used for access(group -1) but it had been switched over to direct trocar since 2013(group -2) These two groups were compared in terms of the demographic profile, duration of procedure, previous h/o surgical interventions ,ease of performance and various complications encountered during the procedure.Results: The total number of patients who underwent ligation during this period were 1912, which were divided into two groups ,till 2012(veress needle entry group,group-1) 754 patients(39.44%),and after 2012 (direct trocar,group -2) 1158 patients(60.56%).Duration of procedure was 4.5±1.2 min in group 1 which was significantly higher than group 2,2.2±0.8 min(p-value <0.001).Amount of gas required was greater in group 1, 4.9±1.3 lts as compared to group 2,2.4±0.5lts.Conclusions: Direct trocar entry is a reliable alternative to traditional technique for pneumoperitoneum establishment and should be regarded as a part of the surgical armamentarium of a trained laparoscopic surgeon.

Efecto del sistema de recuperación de sangre autóloga y transfusiones homólogas en pacientes quirúrgicos de alta complejidad / Effect of homologous transfusions and the autologous blood recovery system in highly complex surgical patients

Introducción: la transfusión autóloga presenta tres modalidades: transfusión autóloga con predepósito, hemodilución preoperatoria (normovolémica o hipervolémica) y el sistema de recuperación de sangre autóloga (cell saver) intraoperatoria o posoperatoria. Objetivo: demostrar la efectividad del uso del sistema de recuperación de sangre autóloga en pacientes quirúrgicos de alta complejidad en el Hospital Alcívar. Método: estudio retrospectivo, no experimental, de observación indirecta, con análisis correlacional. La muestra fue de 112 pacientes intervenidos por afecciones cardiovasculares, ortopédicas y traumatológicas, incluidos según criterios de inclusión y exclusión. Se utilizó cell saver en 56 pacientes, y 56 pacientes utilizaron transfusiones de sangre homóloga. Resultados. el cell saver fue beneficioso en 93 por ciento de los pacientes; la morbilidad y la mortalidad disminuyeron, principalmente en los pacientes intervenidos de cualquier afección cardiovascular y aumentó el índice costo/beneficio, debido a que se priorizaron los recursos económicos. En traumatología y ortopedia no fue muy beneficioso, pues la cantidad de sangre recuperada fluctuó entre 300 y 500 mL en intervenciones convencionales, lo que motivó el uso de hemoderivados y aumentó el costo. En resecciones tumorales e instrumentaciones en diferentes segmentos de la columna vertebral se recuperó hasta 800 mL de sangre, lo que resultó significativo. La tasa de complicaciones fue menor en pacientes que utilizaron cell saver (7 por ciento) frente a los pacientes que utilizaron hemoderivados homólogos (32 por ciento). Se constató una menor estancia hospitalaria en el grupo cell saver (1-20 días) en comparación con los que usaron hemoderivados homólogos (> 10 días, en 5 casos fue mayor 21 días). Conclusiones: el uso de sistema de recuperación de sangre autóloga constituye un procedimiento efectivo para infundir hemoderivados con mayor seguridad(AU)

Introduction: Autologous transfusion has three modalities: autologous transfusion with predeposit, preoperative hemodilution (normovolemic or hypervolemic), and the system for autologous blood recovery (cell saver), whether intraoperative or postoperative. Objective: To show the effectiveness of the use of the autologous blood recovery system in highly complex surgical patients at Alcívar Hospital. Method: Nonexperimental, retrospective study, of indirect observation and with correlational analysis. The sample consisted of 112 patients who underwent surgery for cardiovascular, orthopedic and traumatological conditions, chosen based on inclusion and exclusion criteria. The cell saver system was used in 56 patients and 56 patients used homologous blood transfusions. Results: The cell saver system was beneficial in 93 percent of patients; morbidity and mortality decreased, mainly in patients operated for any cardiovascular condition, while the cost-benefit ratio increased, due to the fact prioritization of economic resources. In traumatology and orthopedics, it was not so beneficial, since the amount of blood recovered fluctuated between 300 and 500 mL in conventional interventions, which motivated the use of blood products and increased the cost. In tumor resections and instrumentation of different spine segments, up to 800 mL of blood were recovered, which was significant. The complication rate was lower in patients who used the cell saver system (7 percent), compared to patients who used homologous blood products (32 percent). A shorter hospital stay was observed in the cell saver group (1-20 days), compared to those who used homologous blood products (over 10 days, while in 5 cases it was over 21 days). Conclusions: The use of the autologous blood recovery system is an effective procedure to infuse blood products with greater safety(AU)

A Cadaveric Study of Normal and Variant Levels of Division of Sciatic Nerve and Coupled Anomalies with Clinical Application in Surgical Interventions.

Background: Sciatic nerve, the thickest and the largest nerve of the body, is formed in the pelvis. After passing through the greater sciatic foramen, it enters the gluteal region, and subsequently the nerve passes on the back of thigh to reach the superior angle of popliteal fossa where it bifurcates into tibial and common fibular nerves. It usually divides into its terminal branches outside the pelvis; however it may rarely divide within the pelvis. In such cases, the tibial nerve and the common fibular nerve may leave the pelvis through different routes. The knowledge of different routes of exits of the sciatic nerve is of utmost importance for the surgeons and the interventionists dealing with this region as this is the site of innumerable surgical manipulations as well as nerve injuries during deep intramuscular injections in gluteal region, failed sciatic nerve block in anaesthesia and injury during posterior hip surgeries. These variations may result in non-discogenic sciatica because of the nerve compressions under other adjacent anatomic structures. Purpose of the study: This study is an attempt to analyse the course, distribution and levels of the division of sciatic nerve into tibial nerve and common fibular nerve and their clinical implications. Results: Out of the total 120 lower limbs studied, deviation from the usual described pattern was observed in four limbs. One cadaver showed bilateral variation while other two described unilateral disparity from the standard prototype. Conclusion: This knowledge of variant anatomy of division and course of sciatic nerve and its terminal branches will not only assist surgeons to take care during interventions, but also facilitate to plan accordingly during various surgical procedures and management.