Effectiveness and safety of ultra-low-dose spinal anesthesia versus perineal blocks in hemorroidectomy and anal fistula surgery: a randomized controlled trial

Abstract Background: Ultra-low-dose Spinal Anesthesia (SA) is the practice of employing minimal doses of intrathecal agents so that only the roots that supply a specific area are anesthetized. The aim of this study was to compare the effectiveness and safety of ultra-low-dose spinal anesthesia with that of Perineal Blocks (PB). Methods: A two-arm, parallel, double-blind randomized controlled trial comparing two anesthetic techniques (SA and PB) for hemorrhoidectomy and anal fistula surgery was performed. The primary outcomes were postoperative pain, complementation and/or conversion of anesthesia, and hemodynamic changes. Results: Fifty-nine patients were included in the final analysis. The mean pain values were similar in the first 48 h in both groups (p > 0.05). The individuals allocated to the SA group did not need anesthetic complementation; however, those in the PB group required it considerably (SA group, 0% vs. PB group, 25%; p = 0.005). Hemodynamic changes were more pronounced after PB: during all surgical times, the PB group showed lower MAP values and higher HR values (p < 0.05). Postoperative urinary retention rates were similar between both groups (SA group 0% vs. PB group 3.1%, p = 0.354). Conclusion: SA and PB are similarly effective in pain control during the first 48 h after hemorrhoidec-tomy and anal fistula surgery. Although surgical time was shorter among patients in the PB group, the SA technique may be preferable as it avoids the need for additional anesthesia. Furthermore, the group that received perineal blocks was under sedation with a considerable dose of propofol.

Mode establishment and preliminary clinical application of anterior cervical surgery in outpatient setting / 中国修复重建外科杂志

OBJECTIVE@#To establish the mode of anterior cervical surgery in outpatient setting, and evaluate its preliminary effectiveness.@*METHODS@#A clinical data of patients who underwent anterior cervical surgery between January 2022 and September 2022 and met the selection criteria was retrospectively analyzed. The surgeries were performed in outpatient setting ( n=35, outpatient setting group) or in inpatient setting ( n=35, inpatient setting group). There was no significant difference between the two groups ( P>0.05) in age, gender, body mass index, smoking, history of alcohol drinking, disease type, the number of surgical levels, operation mode, as well as preoperative Japanese Orthopaedic Association (JOA) score, visual analogue scale score of neck pain (VAS-neck), and visual analogue scale score of upper limb pain (VAS-arm). The operation time, intraoperative blood loss, total hospital stay, postoperative hospital stay, and hospital expenses of the two groups were recorded; JOA score, VAS-neck score, and VAS-arm score were recorded before and immediately after operation, and the differences of the above indexes between pre- and post-operation were calculated. Before discharge, the patient was asked to score satisfaction with a score of 1-10.@*RESULTS@#The total hospital stay, postoperative hospital stay, and hospital expenses were significantly lower in the outpatient setting group than in the inpatient setting group ( P<0.05). The satisfaction of patients was significantly higher in the outpatient setting group than in the inpatient setting group ( P<0.05). There was no significant difference between the two groups in operation time and intraoperative blood loss ( P>0.05). The JOA score, VAS-neck score, and VAS-arm score of the two groups significantly improved at immediate after operation when compared with those before operation ( P<0.05). There was no significant difference in the improvement of the above scores between the two groups ( P>0.05). The patients were followed up (6.67±1.04) months in the outpatient setting group and (5.95±1.90) months in the inpatient setting group, with no significant difference ( t=0.089, P=0.929). No surgical complications, such as delayed hematoma, delayed infection, delayed neurological damage, and esophageal fistula, occurred in the two groups.@*CONCLUSION@#The safety and efficiency of anterior cervical surgery performed in outpatient setting were comparable to that performed in inpatient setting. Outpatient surgery mode can significantly shorten the postoperative hospital stay, reduce hospital expenses, and improve the patients' medical experience. The key points of the outpatient mode of anterior cervical surgery are minimizing damage, complete hemostasis, no drainage placement, and fine perioperative management.

Effect of modified blood management strategies on blood loss and transfusion rate during outpatient total hip arthroplasty / 中华骨科杂志

Objective:To explore the impact of a modified blood management strategy on blood loss and transfusion rates during outpatient total hip arthroplasty(THA).Methods:The retrospective research was performed in a total of 125 patients (125 hips) who underwent outpatient primary THA from January 2019 to December 2021 at a medical center. According to whether a modified blood management protocol was used or not, all patients were divided into two groups. Group A was used the original perioperative blood management strategies (1 g tranexamic acid, intravenously, 10 minutes before skin incision), and group B was used the modified perioperative blood management strategy (on the basis of the original protocol, 2 g tranexamic acid was sprayed locally in the joint cavity before the incision was closed, 1 g tranexamic acid was injected intravenously 3 hours after surgery, and 1 g tranexamic acid was injected intravenously again on the first day after surgery). There were 52 cases in group A, including 32 males and 20 females, aged 58.5±9.8 years (range, 39-69 years), 13 cases were developmental hip dysplasia (Crowe I°-II°), 24 cases were avascular necrosis of the femoral head, 10 cases were hip osteoarthritis, 3 cases were ankylosing spondylitis involving hip joint, and 2 cases were femoral neck fracture. Among the 73 patients in group B, there were 43 males and 30 females, aged 55.8±10.4 years (range, 42-67 years), including 17 cases of developmental hip dysplasia (Crowe I°-II°), 32 cases of avascular necrosis of the femoral head, 16 cases of hip osteoarthritis, 7 cases of ankylosing spondylitis involving hip joint, and 1 case of femoral neck fracture. Intraoperative blood loss, transfusion, deep vein thrombosis (DVT) events (vascular ultrasound, 2w Postop.), the hemoglobin (Hb) drop, the hematocrit (Hct) drop and other complications were recorded.Results:After using the modified strategy, the intraoperative blood loss was significantly reduced (305.6±38.6 ml vs. 416.2±88.3 ml, t=9.51, P<0.001), and the drop of hemoglobin was significantly decreased (18.1±4.0 g/L vs. 22.3±5.8 g/L, t=4.97, P<0.001). The drop of Hct also decreased significantly (7.3%±0.7% vs. 9.6%±1.3%, t=10.21, P<0.001), and total blood loss decreased significantly (720.6±57.4 ml vs. 919.6±86.3 ml, t=15.49, P<0.001). The hidden blood loss was also significantly lower than that in group A (414.9±71.1 ml vs. 503.5±96.4 ml, t=5.91, P<0.001). One patient (in group A) developed intra-articular hemorrhage 2 h after surgery and was transferred back to the inpatient ward for treatment after transfusion. Three patients (2.4%, 1 in group A and 2 in group B) developed symptomatic anemia and were discharged successfully after conservative treatment. Calf muscular venous thrombosis occurred in 3 patients (2.4%), but no symptomatic deep vein thrombosis occurred in all patients. Conclusion:According to this retrospective research, the use of modified blood management strategy during outpatient THA can further reduce intraoperative blood loss, hidden blood loss and postoperative hematocrit drop, and does not increase the occurrence of perioperative thrombosis-related complications.

La chirurgie ambulatoire en orthopédie et traumatologie: expériences du Centre Hospitalier Universitaire Morafeno Toamasina / mbulatory surgery in orthopedics and traumatology: experiences of the University Hospital Morafeno Toamasin

Introduction : Plus qu'un défi ou un enjeu, la chirurgie ambulatoire, constitue pour les pays en voies de développement une opportunité d'accroître l'accès aux soins. Elle est un concept d'organisation centrée sur le malade, basée sur la sélection des patients et des actes chirurgicaux afin d'assurer une qualité et une sécurité maximale de soins. Objectifs : Partager les résultats de notre expérience sur la chirurgie ambulatoire en orthopédie traumatologie et de déterminer les difficultés rencontrées lors de sa mise en place. Matériels et Méthodes: Il s'agit d'une étude prospective, descriptive et observationnelle allant de janvier 2018 au janvier 2019 (12 mois) réalisée au CHU Morafeno Toamasina. Résultats: Au total, 108 patients ont été retenus. Les interventions réglées étaient réalisées chez 82,40% des patients contre 17,59% d'urgences traumatologiques. L'âge moyen des patients était de 32 ans ± 8,6 ans avec une prédominance masculine (sex ratio:3,9) . Le type d'intervention réalisé était dominé par les ablations de matériels d'ostéosynthèses avec un taux de 25,92%, suivies des tentatives de réduction orthopédique de fractures dans 22,22 % des cas. Le type d'anesthésie la plus pratiquée était l'anesthésie locorégionale (52,77%). Les évènements en postopératoire étaient dominés par l'insomnie (4,62%), la céphalée (2,77 %), les nausées et vomissements (5,55%) et les hématomes (3,70%). Soixante-douze virgule deux pour cent des patients déclaraient satisfaits de leur prise en charge. Conclusion: Le développement extensif de la chirurgie ambulatoire est basé sur la sélection des patients à qui l'on propose ce type de prise en charge. Elle présente un enjeu majeur en matière de restructuration et d'amélioration de l'offre de soins en chirurgie orthopédique et traumatologie

Tratamiento quirúrgico ambulatorio en la solución de las afecciones de la glándula tiroides / Outpatient surgical treatment in the solution of the thyroid gland conditions

RESUMEN Introducción: La cirugía tiroidea es uno de los procedimientos más comúnmente realizados en la cirugía de cabeza y cuello. Era tradicional que los pacientes tuvieran estancias hospitalarias que, en ocasiones, superaban los 3 días. Objetivo: Describir los resultados de la cirugía mayor ambulatoria, en la solución de las afecciones quirúrgicas de la glándula tiroides. Métodos: Se realizó un estudio descriptivo en 307 pacientes con afecciones de la glándula tiroides que recibieron tratamiento quirúrgico ambulatorio. Se confeccionó modelo de recogida de datos para las variables: edad, sexo, afección tiroidea, tipo de intervención quirúrgica, método anestésico y complicaciones. Se calcularon frecuencias absolutas y relativas. Resultados: El grupo de edades más frecuente fue entre los 30-39 años (32,57 %), predominó el sexo femenino (91,53 %). Las afecciones tiroideas más frecuentes fueron el bocio adenomatoso (23,13 %) y el carcinoma (20,85 %), la intervención quirúrgica más frecuente fue la tiroidectomía total (39,08 %); se aplicó analgesia quirúrgica acupuntural en 39 pacientes (12,71 %), 8 pacientes presentaron complicaciones posoperatorias (2,6 %). La estancia hospitalaria fue inferior a 24 horas en el 99,02 % de los pacientes. Conclusiones: La cirugía mayor ambulatoria se emplea en la solución de las afecciones quirúrgicas de la glándula tiroides, más frecuente en las afecciones benignas, en pacientes mayores de 19 años de edad, con predominio del sexo femenino, la intervención quirúrgica realizada con mayor frecuencia es la tiroidectomía total. Con mayor frecuencia se aplica anestesia general orotraqueal; se reserva la analgesia quirúrgica acupuntural para casos seleccionados.

ABSTRACT Introduction: Thyroid surgery is one of the most commonly performed procedures in otorhinolaryngology, and head and neck surgery. Traditionally, it presented hospital stays that were sometimes longer than 3 days. Objective: To describe the results of major outpatient surgery in the solution of surgical conditions of the thyroid gland. Methods: A descriptive study was carried out in 307 patients with thyroid gland disorders who received outpatient surgical treatment. A data collection model was created for the variables: age, sex, thyroid disease, type of surgical intervention, anesthetic method and complications, absolute and relative frequencies were calculated. Results: The most frequent age group was between 30-39 years (32.57 %), females predominated (91.53 %). The most frequent thyroid conditions were adenomatous goiter (23.13 %) and carcinoma (20.85 %), the most frequent surgical intervention was total thyroidectomy (39.08 %), surgical acupuncture analgesia was applied in 39 patients (12.71 %), 8 patients presented postoperative complications (2.6 %). The hospital stay was less than 24 hours in 99.02 % of the patients. Conclusions: Major outpatient surgery is used in the solution of surgical conditions of the thyroid gland, more frequent in benign conditions, in patients over 19 years of age, with a predominance of females, the surgical intervention performed with greater frequency is total thyroidectomy. The most frequent was general orotracheal anesthesia, reserving acupuncture surgical analgesia for selected cases.

Cancelación de procedimientos quirúrgicos electivos: Una agenda para la investigación en Colombia / Cancellation of elective surgical procedures: A research agenda in Colombia

Resumen La cancelación de cirugías programadas es un problema latente en Colombia que tiene repercusiones negativas para el paciente (física y psicológicamente), el personal de la salud (bienestar laboral, satisfacción, desempeño) y la institución (costo-eficiencia). La tasa de cancelación varía entre 2,7 - 7,6 %. La mayoría de las cancelaciones son prevenibles y ocurren por errores administrativos o de programación. En este documento se realiza una revisión sobre el estado y vacíos de conocimiento sobre este problema en Colombia, y se plantean algunos puntos para la agenda de investigación.

Summary Cancellation of scheduled surgeries is a latent problem in colombia, which encompasses negative consequences for the patient (physically and psychologically), the health care personnel (well-being, satisfaction, performance) and the institution (cost-effectiveness). The rate of cancellation varies between 2,7 - 7,6 %. Most cancellations are preventable and occur due to administrative or programming issues. In this document, we performed a review on the gaps of knowledge on this problem in colombia, and we highlighted some points for the research agenda.

Hiperparatiroidismo primario: experiencia en cirugía por mini abordaje unilateral / Primary hyperparathyroidism: experience in surgery by unilateral mini-approach

INTRODUCCIÓN: En el hiperparatiroidismo primario el origen del trastorno, como su nombre lo indica, está en la propia glándula paratiroides, la cual genera una secreción autónoma y excesiva. La cirugía de las glándulas paratiroides evolucionó en forma considerable en los últimos 30 a 40 años, pasamos de exploraciones cervicales exhaustivas, hasta una época en que gracias al desarrollo tecnológico y sobre todo medicina nuclear, podemos localizar en forma preoperatoria el tejido patológico; siendo esta a su vez la base fundamental en la realización de procedimientos más selectivos. OBJETIVO: mostrar la casuística de cirugía por mini abordaje de la glándula paratiroides en el hiperparatiroidismo primario en un centro mutual de Montevideo. MATERIAL Y MÉTODOS: Realizamos un estudio observacional descriptivo y retrospectivo. Se estudió una muestra de 18 pacientes con diagnóstico de hiperparatiroidismo primario y con sospecha de lesión única los cuales fueron intervenidos en un centro mutual de la ciudad de Montevideo entro julio de 2017 y enero de 2020. CONCLUSIÓN: La cirugía por mini abordaje de la glándula paratiroides puede ser aplicada en el hiperparatiroidismo primario en pacientes seleccionados con las ventajas de; tener un menor tiempo quirúrgico, ser ambulatoria (reintegro al hogar en pocas horas), indemnidad de la logia tiroidea contralateral, mejor resultado estético con similar tasa de éxito que la cirugía convencional.

BACKGROUND: In primary hyperparathyroidism, the origin of the disorder, as its name indicates, is in the parathyroid gland itself, which generates excessive and autonomous secretion. Parathyroid gland surgery has evolved dramatically in the last 30 to 40 years, from exhaustive cervical examinations, to nowadays when, thanks to technological development and especially nuclear medicine, we can locate pathological tissue preoperatively; this, in fact, is the fundamental basis for the performance of more selective procedures. OBJECTIVE: to show the casuistry of mini-approach surgery of the parathyroid gland in primary hyperparathyroidism in a mutual center in Montevideo. METHODS: We carried out a descriptive and retrospective observational study. We studied a sample of 18 patients diagnosed with primary hyperparathyroidism and a single suspicious lesion, who underwent surgery in a private center in the city of Montevideo from July 2017 to January 2020. CONCLUSION: Mini-approach surgery of the parathyroid gland can be applied in primary hyperparathyroidism in selected patients, with the advantages of a shorter surgical time, ambulatory (return home in a few hours), keeping the indemnity of the contralateral thyroid loggia, a better cosmetic result with a similar success rate than conventional surgery.

Perfil dos eventos adversos de cirurgia ambulatorial em uma policlínica do Rio de Janeiro / Profile of adverse events of outpatient surgery in a polyclinic in Rio de Janeiro

O foco deste estudo foi o perfil dos eventos adversos oriundos de procedimentos cirúrgicos, visto que essa ocorrência não é desejável e causa malefícios aos pacientes. Eventos adversos representam problemas de qualidade do cuidado relacionado à dimensão da segurança do paciente. O estudo teve como objetivo geral caracterizar o perfil dos eventos adversos cirúrgicos em uma unidade de cirurgia ambulatorial. Trata-se de um estudo quantitativo, no qual foi elaborado instrumento próprio para coleta de dados por meio de contato telefônico, em que foram feitas perguntas aos pacientes participantes buscando constatar a ocorrência de eventos adversos decorridos do procedimento cirúrgicos. A pesquisa foi realizada em unidade de cirurgia ambulatorial e identificou-se 43,2% de ocorrências de eventos adversos pós-cirúrgicos, entre os quais os de maior prevalência foram dor (35,1%) e hematomas (19,3%). Foram registrados mais de uma ocorrência de eventos adversos pós-cirúrgicos em 40,6% dos pacientes. Todos os eventos adversos identificados foram considerados preveníveis, de impacto leve ou moderado. O estudo mostrou ser necessária a revisão de processos administrativos e assistenciais visando a melhoria dos processos e diminuição de erros, além de sugerir a adoção de práticas de avaliação de controle de qualidade.

The focus of this study was the profile of adverse events arising from surgical procedures, since this occurrence is undesirable and causes harm to patients. Adverse events represent quality of care problems related to the dimension of patient safety. The general objective of the study was to characterize the profile of surgical adverse events in an outpatient surgery unit. This is a quantitative study, in which a specific instrument was developed for data collection through telephone contact, in which participating patients were asked questions in order to verify the occurrence of adverse events resulting from the surgical procedure. The survey was carried out in an outpatient surgery unit and 43.2% of occurrences of post-surgical adverse events were identified, among which the most prevalent were pain (35.1%) and hematomas (19.3%). More than one occurrence of post-surgical adverse events was recorded in 40.6% of patients. All adverse events identified were considered preventable, of mild or moderate impact. The study showed that it is necessary to review administrative and care processes in order to improve processes and reduce errors, in addition to suggesting the adoption of quality control assessment practices.

Modelo para el perfeccionamiento del proceso de atención en cirugía mayor ambulatoria y de corta estadía / A Model for Improving the Care Process in Major Outpatient and Short-Stay Surgeries

Introducción: Existen limitaciones en la coordinación entre los niveles primario y secundario de salud en el proceso quirúrgico ambulatorio y de corta estadía, lo que repercute en la calidad del servicio. Objetivo: Diseñar una propuesta de modelo asistencial para el perfeccionamiento del proceso de atención al paciente en cirugía mayor ambulatoria y cirugía de corta estadía. Métodos: Se desarrolló una investigación prospectiva descriptiva del 3 de septiembre de 2012 al 20 de marzo de 2018. En su diseño fueron empleados la modelación y el sistémico-estructural fundamentalmente. Se aplicaron encuestas a expertos con experiencia en los niveles primario y secundario de salud para evaluar la calidad y pertinencia del modelo propuesto. También fueron encuestados los jefes de los grupos provinciales de Cirugía General y Medicina Familiar. Se realizaron entrevistas grupales a clientes del proyecto de investigación (del que se deriva) y a decisores institucionales y del nivel provincial. Fue empleada la técnica de triangulación metodológica y de fuentes. Resultados: La estructuración del modelo partió de la coordinación del trabajo asistencial y metodológico entre los niveles primario y secundario de salud. Se sustentó en cuatro pilares: preparación teórica del personal de salud, observancia de normas de relación en el contexto laboral, cumplimiento de procedimientos en el contexto asistencial y evaluación continua de la calidad asistencial. Los expertos, clientes y decisores avalaron su calidad, pertinencia y posibilidades de implementación. Conclusiones: El modelo presenta calidad, es pertinente y su aplicación es factible(AU)

Introduction: There are limitations in the coordination between the primary and secondary health levels in the outpatient and short-stay surgical processes, which affects the quality of the service. Objective: Designing a proposal for a healthcare model for the improvement of the patient care process in major outpatient surgery and short-stay surgery. Methods: A descriptive and prospective research was carried out from September 3, 2012 to March 20, 2018. Its design involved essentially modeling and the systemic-structural method. Surveys were applied to experts with experience in primary and secondary health levels, in order to assess the quality and relevance of the proposed model. The heads of the provincial groups of General Surgery and Family Medicine were also surveyed. Group interviews were conducted with clients of the research project (from which it is derived) and with institutional and provincial decision-makers. The methodological and source triangulation technique was used. Results: The structuring of the model started from the coordination of the care and methodological work between the primary and secondary health levels. It was based on four pillars: theoretical training of health personnel, observance of relationship rules in the work context, compliance with procedures in the care context, and continuous assessment of the quality of care. The experts, clients and decision-makers recognized its quality, relevance and possibilities of implementation. Conclusions: The model presents quality, is pertinent and its application is feasible(AU)

Efectividad del tratamiento acupuntural en las urgencias hipertensivas durante el preoperatorio de cirugías menores / Effectiveness of Acupuncture against Hypertensive Emergencies during the Preoperative of Minor Surgeries

Introducción: Las urgencias hipertensivas constituyen una de las complicaciones agudas más frecuentes de la hipertensión arterial y es causa de muerte prematura entre adultos. Muchas publicaciones abogan por el uso de la Medicina Tradicional y Natural como método terapéutico eficaz e inocuo en su manejo. Objetivo: Evaluar la efectividad del tratamiento acupuntural en las urgencias hipertensivas durante el preoperatorio en los pacientes que serán sometidos a intervenciones quirúrgicas ambulatorias menores en el Hospital Clínico Quirúrgico Dr. Juan Bruno Zayas Alfonso, de enero a octubre de 2019. Métodos: Se efectuó un estudio de intervención terapéutica. El universo estuvo constituido por 150 pacientes hipertensos que fueron asignados aleatoriamente a un grupo estudio que recibió tratamiento con acupuntura y un grupo control que recibió tratamiento medicamentoso. A todos se les realizó diagnóstico occidental y oriental. Ambos grupos estuvieron conformados por 75 pacientes. Resultados: Predominó el grupo de edades de 45 a 54 años en ambos grupos, un mayor número de mujeres enfermas. El síntoma que más afectó al total de los pacientes fue la cefalea y hubo superioridad del diagnóstico síndrome hiperactividad de fuego de hígado. El 74 por ciento de los pacientes a los que se les aplicó acupuntura mejoraron y un 66 por ciento lo lograron en el grupo control. Conclusiones: El tratamiento acupuntural resultó ser efectivo en los pacientes con urgencias hipertensivas durante el preoperatorio para las intervenciones quirúrgicas ambulatorios menores(AU)

Introduction: Hypertensive emergencies are one of the most frequent acute complications of arterial hypertension and the cause of premature death among adults. Many publications advocate the use of traditional and natural medicine as an effective and safe therapeutic method for its management. Objective: To assess the effectiveness of acupuncture against hypertensive emergencies during the preoperative period in patients who will undergo minor outpatient surgical interventions at Dr. Juan Bruno Zayas Alfonso Clinical-Surgical Hospital, from January to October 2019. Methods: A therapeutic intervention study was carried out. The population consisted of 150 hypertensive patients who were randomly assigned to either a study group that received acupuncture or a control group that received drug treatment, all of whom underwent Western and Eastern diagnoses. Both groups consisted of 75 patients. Results: The age set 45-54 years predominated in both groups, together with a greater number of sick women. The symptom that most affected all the patients was headache and there was superiority of the diagnosis of Liver-fire hyperactivity syndrome. 74 percent of the patients who received acupuncture improved, while 66 percent achieved it as part of the control group. Conclusions: Acupuncture turned out to be effective in patients with hypertensive emergencies during the preoperative period for minor outpatient surgeries(AU)