Influence of laparoscopic surgery on the outcomes of radical cystectomy within a multimodal rehabilitation protocol.

INTRODUCTION AND OBJECTIVE: The implementation of Enhanced Recover After Surgery (ERAS) multimodal rehabilitation protocols in radical cystectomy has shown to improve outcomes in hospital stay and complications. The aim of this analysis is to evaluate the impact of laparoscopic surgery on radical cystectomy within a multimodal rehabilitation program. MATERIAL AND METHODS: The study was carried out in a third level center between 2011 and 2020 including patients with bladder cancer submitted to radical cystectomy according to an ERAS (Enhanced Recovery After Surgery) protocol and the Spanish Multimodal Rehabilitation Group (GERM) with 20 items to be fulfilled. RESULTS: A total of 250 radical cystectomies were performed throughout the study period, 42.8% by open surgery (OS) and 57.2% by laparoscopic surgery (LS). The groups are comparable in demographic and clinical variables (p > 0.05). Operative time was longer in the LS group (248.4 ±â€¯55.0 vs. 286.2 ±â€¯51.9 min; p < 0.001). However, bleeding was significantly lower in the LS group (417.5 ±â€¯365.7 vs. 877.9 ±â€¯529.7 cc; p < 0.001), as was the need for blood transfusion (33.6% vs. 58.9%; p < 0.001). Postoperative length of stay (11.5 ±â€¯10.5 vs. 20.1 ±â€¯17.2 days; p < 0.001), total and major complications were also significantly lower in this group (LS). The readmission rate was lower in the LS group but not significantly (36.4% vs. 29.4%; p = 0.237). The difference between 90-day mortality in both groups was not statistically significant (2.8% LS vs. 4.3% OS; p = 0.546). The differences were maintained in the multivariate models. CONCLUSIONS: Laparoscopic surgery within a multimodal rehabilitation program increases operative time but significantly decreases intraoperative bleeding, transfusion requirements, postoperative length of stay, and complications.

Neuromonitoring depth of anesthesia and its association with postoperative delirium.

Delirium after surgery or Postoperative delirium (POD) is an underdiagnosed entity, despite its severity and high incidence. Patients with delirium require a longer hospital stay and present more postoperative complications, which also increases hospital costs. Given its importance and the lack of specific treatment, multifactorial preventive strategies are evidenced based. Our hypothesis is that using general anaesthesia and avoiding the maximum time in excessively deep anaesthetic planes through BIS neuromonitoring device will reduce the incidence of postoperative delirium in patients over the age of 65 and their hospitalization stay. Patients were randomly assigned to two groups: The visible BIS group and the hidden BIS neuromonitoring group. In the visible BIS group, the depth of anaesthesia was sustained between 40 and 60, while in the other group the depth of anaesthesia was guided by hemodynamic parameters and the Minimum Alveolar Concentration value. Patients were assessed three times a day by research staff fully trained during the 72 h after the surgery to determine the presence of POD, and there was follow-up at 30 days. Patients who developed delirium (n = 69) was significantly lower in the visible BIS group (n = 27; 39.1%) than in the hidden BIS group (n = 42, 60.9%; p = 0.043). There were no differences between the subtypes of delirium in the two groups. Patients in the hidden BIS group were kept for 26.6 ± 14.0 min in BIS values < 40 versus 11.6 ± 10.9 min (p < 0.001) for the patients in the visible BIS group. The hospital stay was lower in the visible BIS group 6.56 ± 6.14 days versus the 9.30 ± 7.11 days (p < 0.001) for the hidden BIS group, as well as mortality; hidden BIS 5.80% versus visible BIS 0% (p = 0.01). A BIS-guided depth of anaesthesia is associated with a lower incidence of delirium. Patients with intraoperative neuromonitoring stayed for a shorter time in excessively deep anaesthetic planes and presented a reduction in hospital stay and mortality.

Intraoperative crystalloid utilization variability and association with postoperative outcomes: A post hoc analysis of two multicenter prospective cohort studies.

BACKGROUND: The optimal regimen for intravenous administration of intraoperative fluids remains unclear. Our goal was to analyze intraoperative crystalloid volume administration practices and their association with postoperative outcomes. METHODS: We extracted clinical data from two multicenter observational studies including adult patients undergoing colorectal surgery and total hip (THA) and knee arthroplasty (TKA). We analyzed the distribution of intraoperative fluid administration. Regression was performed using a general linear model to determine factors predictive of fluid administration. Patient outcomes and intraoperative crystalloid utilization were summarized for each surgical cohort. Regression models were developed to evaluate associations of high or low intraoperative crystalloid with the likelihood of increased postoperative complications, mainly acute kidney injury (AKI) and hospital length of stay (LOS). RESULTS: 7580 patients were included. The average adjusted intraoperative crystalloid infusion rate across all surgeries was to 7.9 (SD 4) mL/kg/h. The regression model strongly favored the type of surgery over other patient predictors. We found that high fluid volume was associated with 40% greater odds ratio (OR 1.40; 95% confidence interval 1.01-1.95, p = 0.044) of postoperative complications in patients undergoing THA, while we found no associations for the other types of surgeries, AKI and LOS CONCLUSIONS: A wide variability was observed in intraoperative crystalloid volume administration; however, this did not affect postoperative outcomes.

Recommendations on the use of deep neuromuscular blockade by anaesthesiologists and surgeons. AQUILES (Anestesia QUIrúrgica para Lograr Eficiencia y Seguridad) Consensus. / Recomendaciones sobre el uso de bloqueo neuromuscular profundo por parte de anestesiólogos y cirujanos. Consenso AQUILES (Anestesia QUIrúrgica para Lograr Eficiencia y Seguridad).

INTRODUCTION: Neuromuscular blockade enables airway management, ventilation and surgical procedures. However there is no national consensus on its routine clinical use. The objective was to establish the degree of agreement among anaesthesiologists and general surgeons on the clinical use of neuromuscular blockade in order to make recommendations to improve its use during surgical procedures. METHODS: Multidisciplinary consensus study in Spain. Anaesthesiologists experts in neuromuscular blockade management (n=65) and general surgeons (n=36) were included. Delphi methodology was selected. A survey with 17 final questions developed by a dedicated scientific committee was designed. The experts answered the successive questions in two waves. The survey included questions on: type of surgery, type of patient, benefits/harm during and after surgery, impact of objective neuromuscular monitoring and use of reversal drugs, viability of a multidisciplinary and efficient approach to the whole surgical procedure, focussing on the level of neuromuscular blockade. RESULTS: Five recommendations were agreed: 1) deep neuromuscular blockade is very appropriate for abdominal surgery (degree of agreement 94.1%), 2) and in obese patients (76.2%); 3) deep neuromuscular blockade maintenance until end of surgery might be beneficial in terms of clinical aspects, such as as immobility or better surgical access (86.1 to 72.3%); 4) quantitative monitoring and reversal drugs availability is recommended (89.1%); finally 5) anaesthesiologists/surgeons joint protocols are recommended. CONCLUSIONS: Collaboration among anaesthesiologists and surgeons has enabled some general recommendations to be established on deep neuromuscular blockade use during abdominal surgery.

Spanish survey on enhanced recovery after surgery. / Encuesta nacional sobre cirugía con recuperación intensificada.

INTRODUCTION: The aim of this study was to determine the interest in ERAS protocols, and the extent to which clinicians are familiar with and apply these protocols during perioperative care. MATERIALS AND METHODS: Free access survey hosted on the Spanish Society of Anesthesiology and Critical Care; Spanish Association of Surgeons and Spanish Society of Enteral and Parenteral nutrition and ERAS Spain (GERM) websites conducted between September and December 2014. RESULTS: The survey was answered by 272 professionals (44.5% anaesthetists, 45.2% general surgeons) from 110 hospitals, 73% of whom had experience in ERAS protocols. Most (86.1%) had specific knowledge of ERAS protocols, whereas only 50.9% were familiar with ERAS recommendations and 42.4% with GERM recommendations. Most (73.1%) respondents reported that ERAS protocols are performed in their hospitals, mainly in colorectal surgery (93%), and 52.2% reported that GERM/ERAS recommendations are followed. Nearly all (95.5%) would be interested in the development of multidisciplinary national guidelines. Less than half (46.6%) perform preoperative nutritional assessment, albeit without a universal malnutrition screening method (56.8%). Preoperative loading with carbohydrate drinks is carried out in only 51.4% of cases; nasogastric tube and drainage are avoided (79.3%), prophylaxis for postoperative nausea and vomiting (73.4%), goal directed fluid therapy (73.3%), and active normothermia maintenance (87.4%) are performed. In most cases, mobilization (90.1%) and early feeding (87.9%) are performed. The leading causes of protocol failure are postoperative nausea and vomiting (46.5%) and ileus (58.9%). CONCLUSION: Clinicians in Spain are familiar with fast track protocols, although there is no overall consensus, and hospitals do not adhere to existing guidelines. Overall compliance with the items of the protocol is adequate, although perioperative nutritional management is poor.

Predictive ultrasound factors of lymphatic invasion in rectal cancer: "extra-corporeal" study.

OBJECTIVE: the accuracy of preoperative endorectal ultrasound in the status evaluation of lymph nodes is around 50-70%, with a lack of eco-morphological patterns of clinical use. Since, accurate local staging is of great value in prognosis and decision-making we decided to analyze the referenced eco-morphological parameters in a try to find a proper predictive tool of clinical help that could improve the accuracy of rectal ultrasound. MATERIAL AND METHOD: the resected specimens of 24 patients that were operated on by radical surgery because rectal cancer, without preoperative radiotherapy were suspended in warm water and ultrasound scanned (360º circular probe with a transducer of 10 Mhz). All suspicious nodes were recorded and marked for the definitive histological report. RESULTS: from the 24 specimens, 318 nodes were imaged(210 benign and 100 involved). All ultrasound parameters analysed were significant but only lobulation, echogenicity and hilar reflection were independent values. An score system was design with the addition of all parameters that showed a sensitivity of 98%and specificity of 99,1%. CONCLUSIONS: our study shows that a careful study of ultra-sound lymph node images can get a high level of accuracy and better help in tailoring the treatment of any particular case.

A prospective study about functional and anatomic consequences of transanal endoscopic microsurgery.

INTRODUCTION: transanal endoscopic microsurgery (TEM) was developed in 1983 by Büess as a minimally invasive technique to manage rectal villous adenomas and early rectal adenocarcinomas. Many studies have been published worldwide about its excellent results in morbidity and recidive rate, but there are few studies addressing functional results. The objective of this study is to analyze the effect of this technique in the anal anatomy and compare with the manometric results. MATERIAL AND METHODS: we devised a prospective study of 40 patients. 39% female, 61% male. All of them filled an incontinence questionnaire (Pescatori scale) and endoanal ultrasonography and manometry was carried out preoperatively, third month postoperative and at sixth month only if incontinence appeared. RESULTS: 32 patients (80%) had villous adenomas and 8 patients (20%) had adenocarcinomas (uT1). Three patients complained of flatus incontinence at 3rd postoperative month that disappeared with normal continence at 6th month. Anorectal manometric values: mean anal resting pressure (ARP) decreased at 3rd month (from 87.2 mmHg to 70.1 mmHg), as it was for maximal squeeze pressure (MSP) from 152.5 mmHg preoperatively to 142.2 mmHg at 3rd month. Ultrasonography demonstrated internal anal sphincter (IAS) rupture in 3 patients, with a full integrity of the external anal sphincter in all patients. CONCLUSIONS: during TEM, a significant anal dilatation occurs, because of rectoscopy (40 mm wide), what can produce a rupture of IAS, with the consequent decreasing in ARP, and a dilatation without rupture of external sphincter what produces a decreasing of MSP. The fall of anal pressures had minima clinical repercussion when sphincter is intact, but when IAS is broken a temporal incontinence develops.

Sequential treatment for proctalgia fugax. Mid-term follow-up.

INTRODUCTION: Proctalgia fugax (PF) is a benign, self-limiting disease characterized by episodes of intense anorectal pain at frequent intervals in the absence of organic proctological disease. Even though PF was described more than a century ago, its etiology remains unclear. Currently there is no information available. Few papers quoting many ways of management have been published. The aim of this study was to investigate patients complaining of this condition and to treat them with sequential therapy. PATIENTS AND METHODS: We devised a descriptive, prospective study of patients complaining of acute perianal pain--duration less than 30 minutes--without organic disease or previous perianal surgery since 1996 to 2002 in our Department. We treated these patients using a three-step treatment (1: information, hip bath, benzodiazepines; 2: sublingual nifedipine 10 mg, or topic 0.1% nitroglycerin on demand; 3: internal anal sphincterotomy if hypertrophy of the internal anal sphincter was demonstrated by anal ultrasonography and no improvement was confirmed with the previous steps of treatment). We defined remarkable improvement as a decrease in the number of episodes by half or in pain intensity by 50%. RESULTS: Fifteen patients with an average follow-up of 4 years. Anal endosonography confirmed a grossly thickened internal anal sphincter (IAS) in 5 cases. After the first step of treatment 7 patients improved and 1 patient was cured; after the second step of treatment 3 patients improved and 1 was cured; the third step was applied to 3 patients with a thickened IAS; 1 patient improved and 1 patient was cured. CONCLUSION: A total resolution of PF is not always possible, but we may improve symptoms and their frequency. Almost 50% of patients in our series improved with the first step of treatment; 30% of our patients had IAS hypertrophy. Anal endosonography can help in the diagnosis of organic diseases or IAS hypertrophy, for which we can perform an internal anal sphincter myectomy.

Anal endosonography for the study of anal canal anatomy: normal images and sonographic variants.

OBJECTIVE: To present normal images and sonographic variants of the anal canal to be used as reference for the study of sphincter and anal canal abnormalities. MATERIAL AND METHODS: Sixty subjects without known anal canal disease were studied by means of anal endosonography. Subject were divided according to age in two groups (up to 50 years and more than 50 years). All of them underwent an outpatient study with B&K medical ultrasound 2,003 scanner and 1,850 multifrequency transducer. RESULTS: Four layers can be sonographically identified in the anal canal: an inner hyperechoic layer which is the submucosa, a second hypoechoic layer which is the internal sphincter, a third one which is a longitudinal muscle and the outer hyperechoic layer which is the external sphincter and the only to be found in the low anal canal. In people older than 50 years, both sphincters were significantly thicker (0.3-0.5 mm). At the high anal canal 40% of women presented an anterior gap in the external anal sphincter. CONCLUSIONS: Anal endosonography allows an easy division in high-, mid-, and low anal canal. In some women there is a gap at the mid-high anal canal that must be taken into account in order to avoid diagnostic errors. An internal sphincter thickness greater than 3.5 mm should be considered abnormal at any sex or age.

Transanal endoscopic surgery for rectal tumors.

OBJECTIVE: To report our results with local excision by transanal endoscopic microsurgery (TEM) to treat 42 cases of rectal lesions (29 adenomas and 13 carcinomas). METHODS: Prospective, descriptive study. Sex distribution: 55% men, 45% women, mean age 65 years (range: 17-84 years). SYMPTOMS: rectal bleeding 67%, diarrhea 23%. SURGICAL TECHNIQUE: mucosectomy 6 cases, full-thickness excision 36 cases. Average follow-up: 11 months (range: 1-36 months). RESULTS: We analyzed operating time (average 85 min; range: 25-180 min), bleeding (average 100 ml, range 10-350 ml), distance of the tumor from the anal verge (lower tumor margin: mean, 8.8 cm; range, 1-20 cm; distal tumor margin: mean, 12.9 cm; range, 5-22 cm), tumor size (mean, 3.9 cm; range, 2-10 cm), postoperative hospital stay (average, 4 days; range, 2-15 days), morbidity (hemorrhage 1 case; perforation, 1 case), mortality (0) and follow-up (temporary incontinence to flatus in 6 cases, 1 recurrence of carcinoma treated with abdominoperineal resection, 2 recurrences of adenoma and 2 new adenomas). CONCLUSIONS: TEM is a safe technique for the treatment of rectal lesions. Low morbidity and recurrence rates and short hospital stays make TEM a procedure of choice when local rectal surgery is indicated.

[Anal endoluminal endosonography in the study of fecal incontinence]. / La endoecografía anal en el estudio de la incontinencia fecal.

OBJECTIVE: Classically, clinical assessment of faecal incontinence is supported by anal manometry and electromyography. Recently, anal endosonography has appeared to be the ideal method evaluating anatomically both the internal and external anal sphincter. In this paper, our experience in evaluating faecal incontinence by anal endosonography is presented. PATIENTS: 34 patients (26 female, 4 male; mean age, 40) complaining of faecal incontinence were analysed by traditional anorectal physiologic tests as well as by anal endosonography. Previously, patients were clinically grouped in: group 1, post-delivery, 18 cases; group 2, post-surgery, 6 cases; group 3, "idiopathic", 10 cases. RESULTS: Results of anal physiologic test showed significant differences between group 1 and the rest of patients. All patients complaining of post-surgery incontinence were found to have sphincter disruptions. 2 out of 10 patients from group 3 presented unsuspected lesions. Nearly 40% of women with post-delivery incontinence had normal anal muscles. CONCLUSIONS: Anal endosonography is a imaging technique that permits fully vision of the sphincters. It showed to be a great help in cases of faecal incontinence particularly in the decision-making of surgical approach.

[Solitary neurofibroma of the esophagus]. / Neurofibroma solitario de esófago.

A case of solitary neurofibroma located in the mid-portion of the esophagus in a 61-year-old woman is reported. She was operated with the diagnosis of benign tumor of the esophagus (leiomyoma). The microscopic examination of the tumor tissue found nervous cells. The immunohistochemistry analysis confirmed neurofibroma.

[Antibodies against human immunodeficiency virus in generalized lupus erythematosus]. / Anticuerpos contra el virus de la immunodeficiencia humana en lupus eritematoso generalizado.

After studying a bisexual male with a clinical picture suggestive of AIDS a positive ELISA test for antibodies against the Human Immunodeficiency Virus (HIV), but negative results on indirect immunofluorescence testing, as well, as absence of core and envelope HIV antibodies by ELISA, and who later turned out to have Systemic Lupus Erythematosus (SLE) which become asymptomatic on corticosteroid therapy, we decided to test 70 patients with SLE for HIV antibodies. Four of them (5.6%) were positive by ELISA, but on a repeated test only 2 (2.8%) remained positive, and their sera was tested by indirect immunofluorescence. They were negative, as was the ELISA test for core and envelope HIV antibodies. We conclude that the possibility of more such cases, of SLE mimicking AIDS, should be kept in mind, including the occurrence of false positive ELISA tests in such patients.