Timing of Primary Surgery for Cleft Palate.

BACKGROUND: Among infants with isolated cleft palate, whether primary surgery at 6 months of age is more beneficial than surgery at 12 months of age with respect to speech outcomes, hearing outcomes, dentofacial development, and safety is unknown. METHODS: We randomly assigned infants with nonsyndromic isolated cleft palate, in a 1:1 ratio, to undergo standardized primary surgery at 6 months of age (6-month group) or at 12 months of age (12-month group) for closure of the cleft. Standardized assessments of quality-checked video and audio recordings at 1, 3, and 5 years of age were performed independently by speech and language therapists who were unaware of the trial-group assignments. The primary outcome was velopharyngeal insufficiency at 5 years of age, defined as a velopharyngeal composite summary score of at least 4 (scores range from 0 to 6, with higher scores indicating greater severity). Secondary outcomes included speech development, postoperative complications, hearing sensitivity, dentofacial development, and growth. RESULTS: We randomly assigned 558 infants at 23 centers across Europe and South America to undergo surgery at 6 months of age (281 infants) or at 12 months of age (277 infants). Speech recordings from 235 infants (83.6%) in the 6-month group and 226 (81.6%) in the 12-month group were analyzable. Insufficient velopharyngeal function at 5 years of age was observed in 21 of 235 infants (8.9%) in the 6-month group as compared with 34 of 226 (15.0%) in the 12-month group (risk ratio, 0.59; 95% confidence interval, 0.36 to 0.99; P = 0.04). Postoperative complications were infrequent and similar in the 6-month and 12-month groups. Four serious adverse events were reported (three in the 6-month group and one in the 12-month group) and had resolved at follow-up. CONCLUSIONS: Medically fit infants who underwent primary surgery for isolated cleft palate in adequately resourced settings at 6 months of age were less likely to have velopharyngeal insufficiency at the age of 5 years than those who had surgery at 12 months of age. (Funded by the National Institute of Dental and Craniofacial Research; TOPS ClinicalTrials.gov number, NCT00993551.).

Cirugía de alargamiento y engrosamiento de pene. Técnica NEF: resultados en 750 pacientes / Penis enlargement and thickening surgery. NEF technique: results in 750 patients

Introducción y objetivo: La cirugía de alargamiento y engrosamiento de pene supone un reto técnico para el cirujano, puesto que las técnicas clásicas han demostrado resultados insuficientes para los pacientes. Nuestro objetivo es presentar nuestra experiencia con una técnica reproducible que permite evitar el empleo de extensores y las complicaciones de la infiltración de grasa. Material y método: Analizamos de forma retrospectiva 750 casos de alargamiento y engrosamiento de pene primarios realizados con la técnica NEF (No Extenders No Fat) - No Extensores No Grasa), analizando la técnica quirúrgica, sus resultados y complicaciones. Esta técnica se basa en la creación de un colgajo de avance cutáneo junto con un colgajo de fascia de Scarpa y un nanofat infiltrado en las fascias profundas del pene. Resultados: La ganancia media en longitud en el grupo de pacientes estudiados fue de 4.8cm en reposo, con un espectro de 2 hasta 8.1cm. En el engrosamiento, se alcanzó un incremento medio de 1.17 cm (mínimo de 0.5 y máximo de 1.8 cm). Conclusiones: La tasa de satisfacción de pacientes, de complicaciones y retoques en nuestro grupo de estudio nos hablan de una cirugía que mejora las técnicas previas, más invasivas y con mayor tasa de complicaciones. El apoyo psicológico y la ayuda profesional preoperatoria es imperativa, y se debe ofrecer especialmente en casos de dismorfofobia. El trabajo pre y postoperatorio es esencial en estos pacientes. Conseguir pacientes con expectativas reales es la primera barrera que debemos franquear. Solo cuando el paciente haya entendido la cirugía y sus resultados, debemos avanzar hacia ella. (AU)

Background and objective: Penis lengthening and thickening surgery is a technical challenge for the surgeon, since classical techniques have shown insufficient results for patients. Our objective is to present our experience in the develop of a a reproducible technique that avoids the use of extensors and the complications of fat infiltration. Methods: Retrospectiv análisis of 750 cases of primary penis enlargement and thickening performed with the NEF (No Extenders No Fat) technique, analyzing the surgical technique, its results and complications. This technique is based on the creation of a skin advancement flap, together with a Scarpa fascia flap and a nanofat infiltrated at the deep fascia of the penis. Results: Mean gain in length in the group of patients studied was 4.8 cm at rest with a spectrum from 2 to 8.1 cm. In thickening, the measurement reached an average increase of 1.17 cm (minimum of 0.5 and a maximum of 1.8 cm). Conclusions: Rates of patient satisfaction, complications and retouching in our group tell us about a surgery that improves previous more invasive techniques with a higher rate of complications. Psychological support and professional pre-surgery help is imperative and should be offered especially in those cases of dysmorphophobia. Pre and postoperative work is essential in these patients. Getting patients with real expectations is the first barrier we must overcome. Only when the patient has understood the surgery and its results, should we move towards it. (AU)

Tratamiento quirúrgico del síndrome subacromial mediante la técnica de Neer. Estudio casuístico / Surgical treatment of the subacromial syndrome using Neer's technique. Case study

RESUMEN Introducción: el síndrome subacromial es una afección caracterizada por el pinzamiento tendinoso intraarticular por osteofitos o estrechamiento del espacio. Objetivos: evaluar la técnica de Neer en el tratamiento de pacientes con síndrome subacromial y los factores y actividades que favorecen esta afección. Materiales y métodos: se realizó un estudio observacional, descriptivo, prospectivo a pacientes con síndrome subacromial tratados con acromioplastia por la técnica de Neer. El universo lo conformaron 66 pacientes mayores de 20 años, que presentaron síndrome subacromial con síntomas por más de seis meses, y que fueron tratados con la técnica de Neer. Resultados: el sexo más afectado fue el femenino, con 65,2 %. Predominó el grupo etario de 41 a 50 años. El dolor en etapa prequirúrgica fue de moderado a severo en un 77,2 %, y nulo o leve después de la operación. La función en etapa prequirúrgica estuvo afectada de moderada a severa en un 68,1 %, y nula o leve después del tratamiento quirúrgico. La flexión anterior activa estuvo por debajo de 90º en un 83,1 % antes de ser operados, y por encima de 90º en un 80,3 % en el posquirúrgico. La fuerza muscular era mala o regular en etapa prequirúrgica en un 77,2 %, resultando ser excelente o buena después de la operación. Conclusiones: una vez aplicada la técnica de Neer, el dolor fue leve o nulo en la mayoría del universo, la función del hombro fue buena, la flexión anterior adecuada, y buena la fuerza muscular. Se recomienda emplear esta técnica quirúrgica en esta afección (AU).

ABSTRACT Introduction: subacromial syndrome is a condition characterized by intra-articular tendinous impingement by osteophytes or narrowing of space. Objective: to evaluate Neer's technique in the treatment of patients with subacromial syndrome and the factors and activities favoring this condition. Materials end methods: an observational, descriptive, prospective study was performed in patients with subacromial syndrome treated with acromioplasty using Neer's technique. The universe was formed by 66 patients aged over 20 years, who presented subacromial syndrome with symptoms for more than 6 months, and were treated with Neer's technique. Results: the most affected sex was the female one, with 65.2 %. The age group aged 41 to 50 years predominated. In pre-surgical stage, pain ranged from moderate to severe in 77.2 %, and from null to mild after surgery. Preoperative function was moderate to severe in 68.1 % and null or mild after surgical treatment. The previous active flexion was below 90° in 83.1 % before being operated, and above 90° in 80.3 % after surgery. Muscle strength was poor or regular in pre-surgical stage in 77.2 %, being excellent or good after surgery. Conclusions: once Neer's technique was applied, the pain was mild or null in most of the universe, the shoulder function was good, the anterior flexion adequate, and the muscle strength good (AU).

Serie de casos: colgajo sóleo-gastrocnemio en pacientes con defectos de partes blandas en miembros inferiores / Case series: soleo-gastrocnemius muscle flap in patients with defects of soft tissue-lower limbs

Antecedentes: La exposición ósea puede ser consecuencia de fracturas traumáticas abiertas o cerradas con complicaciones, así como secundarias a procesos infecciosos. La cobertura del miembro inferior con defecto cutáneo se basa en la preservación de la perfusión sanguínea y nerviosa para favorecer la consolidación ósea y así el salvamento del miembro. Descripción de los casos: Se describe la reconstrucción con colgajo muscular rotacional pediculado de sóleo y/o gastrocnemio en 16 pacientes con complicaciones asociadas a fracturas expuestas en miembros inferiores con defectos de partes blandas y pérdida de cobertura cutánea, realizados en el Servicio de Ortopedia y Traumatología del Hospital Escuela (HE) durante el período 2012-2015. Se realizó colocación de colgajo con sóleo en 50.0% (8/16) y gastrocnemio en 50.0% (8/16). El éxito terapéutico calificado quirúrgica y funcionalmente fue del 87.5% (14/16). Conclusión: Con la técnica de reconstrucción realizada a estos pacientes se logró disminuir la frecuencia de complicaciones y por consiguiente evitar la amputación de la extremidad afectada...(AU)

Routine group and save screening prior to emergency laparoscopic surgery.

INTRODUCTION: Two group and save (G&S) samples are routinely collected from patients undergoing diagnostic laparoscopy and/or emergency appendicectomy. We aimed to identify the necessity of this practice by looking at the perioperative transfusion rates. METHODS: Data were obtained from our electronic theatre system for all patients who underwent emergency laparoscopic surgery (specifically diagnostic laparoscopy and/or laparoscopic appendicectomy) between January 2017 and December 2018. Records were reviewed for the number of G&S samples sent and perioperative transfusion rates. RESULTS: A total of 451 patients were included in the study. The numbers of procedures performed in 2017 and 2018 were 202 (44.8%) and 249 (55.2%), respectively. The total number of samples sent was 930. Only 786 (84.5%) samples were processed and the rest were rejected for various reasons. Of the 451 patients included in the study, 308 (68.3%) had two G&S samples sent, whereas 41 patients (9.1%) had only one G&S sample sent. Fifty-six (12.4%) and 20 (4.4%) patients had three and four G&S samples sent, respectively. Only two patients required transfusion perioperatively (0.4%), and the indication in both was irrelevant to the primary operation. CONCLUSIONS: These results demonstrate a near-zero transfusion rate in this patient cohort. Omitting G&S is safe and potentially saves time and resources.

Staging laparoscopy in gastric cancer surgery. A population-based cohort study in patients undergoing gastrectomy with curative intent.

BACKGROUND: Studies on the value of a staging laparoscopy in detecting metastases in gastric cancer patients show great variation. This study investigates the avoidable surgery rate in patients with and without a staging laparoscopy scheduled for surgery with curative intent. METHODS: This population-based cohort study included all patients with an intentional resection for a potentially curable gastric adenocarcinoma, between 2011 and 2016, registered in the Dutch Upper GI Cancer audit. Patients with and without a staging laparoscopy were compared. The primary outcome was the avoidable surgery rate (detection of metastases and/or locoregional non-resectable tumor during intentional gastrectomy). Secondary outcomes were the negative predictive value, postoperative morbidity and pathology parameters. RESULTS: 2849 patients who underwent an intentional gastrectomy were included. 414 of 2849 (14.5%) patients underwent a staging laparoscopy before initiation of treatment. The avoidable surgery rate was 16.2% in the staging laparoscopy group, compared to 8.5% in the non-staging group (P < 0.001), resulting in a negative predictive value of 83.8%. The avoidable surgery rate remained significantly different after correction for possible confounders. The main reason for not executing the gastrectomy was the presence of distant metastasis in both groups. cT and cN stage were significantly higher in patients who underwent a staging laparoscopy. CONCLUSIONS: The staging laparoscopy group had a higher cTN and pTN stage, implicating selection of patients with more advanced disease for a staging laparoscopy. Despite the staging laparoscopy, a higher rate of avoidable surgery was found, suggesting a low sensitivity for detecting metastases or locoregional non-resectability in this patient group.

Appraisal of Laparoscopic Common Bile Duct Explorations Using Balloon-Assisted Stone Extraction Method: Seventeen Years Experiences.

Background: Balloon-assisted stone extraction (BASE) can be applied to remove the common bile duct (CBD) stones during laparoscopic CBD exploration (LCBDE). This study aimed to analyze the efficacy of BASE. Methods: A retrospective analysis of patients with CBD stone who underwent LCBDE using BASE from 2001 to 2017 was conducted. The outcomes of BASE and potential factor for failure of technique were also evaluated. Results: A total of 163 patients underwent LCBDE using BASE were enrolled. Success rate of BASE was 88.3% (144/163) and 19 (11.7%) patients with failed BASE underwent basket for lithotripsy additionally. The reason for aborting BASE were stone impaction (n = 6), small stone (n = 4), migration into intrahepatic duct (IHD) (n = 3), and others (n = 6). The overall success rate of stone clearance was 98.2% (160/163). The mean CBD diameter was 15.8 mm (range 7-34 mm), and the largest stone size was 13.8 mm (range 3-36 mm). The overall rate of complication related with procedure was 4.9% (8/163), including bile leakage in 2 patients (1.2%), bleeding in 2 patients (1.2%), and pancreatitis in 4 patients (2.4%). There was no procedure-related mortality. Conclusions: BASE for CBD stone is safe and effective technique for the treatment of CBD stones.

Lung biopsy in children: when is it useful?

AIM: To provide a further insight into the usefulness of lung biopsy in children. METHODS: Lung biopsies in children from January 2007 to December 2017 were reviewed (n=39). The histology results were categorised as: definitive diagnosis, normal lung parenchyma, inconclusive. RESULTS: Lung biopsy provided a definitive diagnosis in 25 (64%) cases. A suspected diagnosis was confirmed in 16 (41%) and a new diagnosis was found in 9 (23%) children. Histology was inconclusive in 11 (28%) cases and normal in 3 (8%). Fifteen (38%) children had treatment altered due to the biopsy result. CONCLUSION: Lung biopsy mostly confirmed the suspected diagnosis and was associated with a low procedure related morbidity (n=1) and mortality (n=0). Importantly, the biopsy result identified a pathology which altered treatment in over one third of patients. However, in a number of cases the histology was inconclusive, therefore careful patient selection is recommended to maximise diagnostic yield.

Surgical findings in cryptorchidism in children with Zika-related microcephaly: a case series.

BACKGROUND: Complications in the urinary tract related to congenital Zika syndrome have recently been reported. One complication, cryptorchidism, has been reported by the Microcephaly Epidemic Research Group/MERG, in Pernambuco/Brazil. The present article describes for the first time the surgical findings in a case series of boys with Zika-related microcephaly and cryptorchidism, who underwent surgical testicular exploration as a contribution to better understand the possible mechanisms involved in gonads formation and descent. METHODS: A total of 7 children (11 testicular units), aged 3 to 4 years, were submitted to inguinal or scrotal orchidopexy for the treatment of palpable cryptorchidism between August 2019 and January 2020. Characteristics of the gonads and its annexes related to appendixes, testis-epididymis dissociation, gubernacular insertion, and associated hydroceles and/or hernias were described. Measures in centimetres were taken for volume calculate. RESULTS: We found a low prevalence of testicular and epididymal appendix (66.7%), a high prevalence of testis-epididymis dissociation (55.6%), low mean testicular volume for their ages (lower for older boys) and ectopic gubernacular insertion in all cases. There was no evidence of associated hydroceles and/or hernias in any case. No surgical complication was registered or reported, and all explored gonads were properly placed in the scrotal sac. CONCLUSIONS: We herein describe the surgical findings of these children's orchidopexies and discuss the possible mechanisms of viral action in embryogenesis and postnatal growth and development of the testes and annexes. These children need to be followed over time due to the higher risk of testicular atrophy and malignancy. Surgical timing seems to be relevant to avoid loss of testicular volume.

Resumption of oncological therapy in patients with advanced cancer undergoing explorative laparotomy for bowel obstruction.

INTRODUCTION: Obstruction of the gastrointestinal tract is a frequent surgical emergency experienced by patients with advanced cancers. We aimed to evaluate factors associated with resumption of post-operative chemotherapy in patients with advanced cancer undergoing explorative laparotomy for bowel obstruction. METHODS: This retrospective cohort study was conducted between 2009 and 2013 at Herlev Hospital, Denmark. All patients with advanced cancer were identified from a local electronic database containing all emergency laparotomies. Adult patients with mechanical bowel obstruction were included if they had any kind of cancer and had been under active oncological treatment within the last eight weeks prior to surgery. Demographic, clinical, pre-, and post-operative data were collected and reviewed manually. Multivariate logistic regression analysis was performed to identify predictors for resuming oncological treatment. RESULTS: A total of 76 patients admitted with bowel obstruction and undergoing oncological treatment within eight weeks before surgery were included. Post-operatively, cancer treatment was resumed in 58% of patients. An American Society of Anesthesiologists (ASA) score less-than III (odds ratio = 12.6 (95% confidence interval (CI): 2.9-54.6); p = 0.001) and a performance status less-than 3 (odds ratio = 9.7 (95% CI: 1.4-67.2); p = 0.021) were associated with resuming post-operative cancer treatment. CONCLUSIONS: We found that ASA score and performance status are associated with resumption of cancer treatment post-operatively and should be taken into consideration when considering the treatment strategy for patients with advanced cancer and malignant bowel obstruction. FUNDING: The authors received no financial support for the research, authorship, and/or publication of this article. TRIAL REGISTRATION: not relevant.

Adding diagnostic laparoscopy to computed tomography for the evaluation of peritoneal metastases in patients with colorectal cancer: A retrospective cohort study.

BACKGROUND: Despite its widespread use, computed tomography (CT) is not perfect for evaluating peritoneal metastases of colorectal origin before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). We therefore evaluated the value of adding diagnostic laparoscopy to CT when assessing patient eligibility for CRS + HIPEC. METHODS: This was a retrospective study of a consecutive series of 112 patients evaluated systematically by diagnostic laparoscopy and CT between January 2012 and January 2018. Patient eligibility for CRS + HIPEC was assessed by the peritoneal cancer index (PCI) both at the time of initial diagnostic laparoscopy and during the retrospective review of CT images. Two experienced radiologists who were blinded to the PCI result at laparoscopy then independently estimated the PCI based on CT imaging. The primary outcome was the number of patients eligible for CRS + HIPEC by each method. RESULTS: We identified 112 patients, of whom 95 (85%) were eligible for CRS + HIPEC based on diagnostic laparoscopy and 84 underwent CRS + HIPEC. Overall, 14 patients (17%) experienced an "open-and-close" procedure. In contrast to diagnostic laparoscopy, 100 patients (89%) were identified as being eligible for CRS + HIPEC by CT (p = 0.13), which would have resulted in an additional five open-and-close procedures. CONCLUSIONS: Adding diagnostic laparoscopy to CT produced a clinically relevant, but statistically non-significant, reduction in the number of patients eligible for CRS + HIPEC. We conclude that diagnostic laparoscopy may be of use in preoperative assessments when systematic analysis by CT scores the PCI as greater than ten. Future research should focus on the cost-effectiveness of this approach.

Lung cryobiopsy and interstitial lung disease: What is its role in the era of multidisciplinary meetings and antifibrotics?

Diagnosing ILD can be complex, and despite detailed evaluation and HRCT imaging, many patients require lung biopsy to help classify their disease. SLB has served as the reference standard for histopathology in ILD, since initial classification schemes were created more than 50 years ago. Frequently, patients are too unwell to undertake SLB and remain unclassifiable, despite the input of expert MDD. This can limit access to therapy and establishment of prognosis. TBLC is an emerging procedure for sampling lung tissue with promising results in research and clinical settings. Although diagnostic yield is not as high as SLB, the risk profile looks to be more acceptable and the accuracy appears to be good. There is increasing evidence for the utility of cryobiopsy in ILD diagnosis, particularly within the MDD. Cryobiopsy serves as an important adjunct for the diagnosis of ILD, enhancing the diagnostic confidence of treating clinicians.

Preliminary study on the application of en bloc resection combined with near-infrared molecular imaging technique in the diagnosis and treatment of bladder cancer.

BACKGROUND: To evaluate the surgical safety of en bloc resection of bladder tumor (ERBT) and the effectiveness of ERBT combined with near-infrared (NIR) imaging technique in the diagnosis and treatment of non-muscle invasive bladder cancer (NMIBC). METHODS: From October 2017 to June 2018, 26 patients newly diagnosed with single NMIBC were included in this retrospectively trial. All patients received ERBT with monopolar current. After surgery, the fresh specimen was incubated with anti-CD47-Alexa Fluor 790, and then imaged under NIR imaging technique. Operative details, intraoperative and postoperative complications of ERBT regarded as safety outcomes, the mean fluorescence intensity (MFI) of tumor tissue and adjacent normal background tissue, and 12 months follow-up data were analyzed. RESULTS: Of 26 collected patients, obturator nerve reflex was occurred in six patients during tumor resection, and only one patient was observed with bladder perforation. In NIR gray image, the gray scale of MFI of tumor tissue were 132.31 ± 6.67 and the adjacent normal background tissue were 52.27 ± 12.09. The result showed a significantly higher MFI signals in tumor tissue compared to adjacent normal background tissue (P < 0.001). The recurrence-free survival rate at 12 month was 96.15%. CONCLUSIONS: ERBT with monopolar current is a safe and feasible technique to treat patients with NMIBC. A integrated bladder tumor tissue-bound anti-CD47-Alexa Fluor 790 was detected under NIR light, and the NIR image indicates that higher MFI signals in surgical margin is a predictive factor for residual tumor in patients with NMIBC after ERBT.

Surgery versus Imaging in Non-Localizing Primary Hyperparathyroidism: A Cost-Effectiveness Model.

OBJECTIVE: To determine whether advanced imaging is cost-effective compared to primary bilateral neck exploration in the management of non-localizing primary hyperparathyroidism. STUDY DESIGN: Cost-effectiveness analysis. METHODS: Cost-effectiveness analysis based on decision tree model and available Medicare financial data using data from 347 consecutive patients having parathyroidectomy for primary hyperparathyroidism with either 1) positive, concordant ultrasound and sestamibi or 2) negative sestamibi and negative ultrasound. RESULTS: Bilateral neck exploration (BNE) costs $9578 and has a success rate of 97.3%. Single photon emission computed tomography (SPECT) + minimally invasive parathyroidectomy (MIP) was modeled to have a total cost of $8197 with a success rate of 98.6%. SPECT/computed tomography (CT) + MIP was modeled to have a total cost of $8271 and a 98.9% success rate. Four-dimensional (4D)-CT + MIP was modeled to cost $8146 with a success rate of 99%. Incremental cost-effectiveness ratios (IECR) (as compared to BNE) were -536.1, -605.5, and -701.6 ($/percent cure rate) for SPECT, SPECT/CT, and 4D-CT respectively. One-way sensitivity analyses demonstrate the change in IECR and cut-off points (IECR = 0) for four major variables. CONCLUSIONS: In patients with non-localizing primary hyperparathyroidism, advanced imaging is associated with cost-savings compared to routine bilateral neck exploration. Increased cost-savings were predicted with increased imaging accuracy and decreased imaging costs. Increasing time for BNE or decreasing time for MIP were associated with increased cost savings. LEVEL OF EVIDENCE: III Laryngoscope, 2020.

Prognostic impact of the Bismuth-Corlette classification: Higher rates of local unresectability in stage IIIb hilar cholangiocarcinoma.

BACKGROUND: The Bismuth-Corlette (BC) classification is used to categorize hilar cholangiocarcinoma by proximal extension along the biliary tree. As the right hepatic artery crosses just behind the left bile duct, we hypothesized that BC IIIb tumors would have a higher likelihood of local unresectability due to involvement of the contralateral artery. METHODS: A retrospective review of a prospectively maintained database identified patients with hilar cholangiocarcinoma taken to the operating room for intended curative resection between April 2008 and September 2016. Cases were assigned BC stages based on preoperative imaging. RESULTS: Sixty-eight patients were included in the study. All underwent staging laparoscopy after which 16 cases were aborted for metastatic disease. Of the remaining 52 cases, 14 cases were explored and aborted for locally advanced disease. Thirty-eight underwent attempt at curative resection. After excluding cases aborted for metastatic disease, the chance of proceeding with resection was 55.6% for BC IIIb staged lesions compared to 80.0% of BC IIIa lesions and to 82.4% for BC I-IIIa staged lesions (P < 0.05). About 44.4% of BC IIIb lesions were aborted for locally advanced disease versus 17.6% of remaining BC stages. CONCLUSIONS: When hilar cholangiocarcinoma is preoperatively staged as BC IIIb, surgeons should anticipate higher rates of locally unresectable disease, likely involving the right hepatic artery.

Estudio comparativo entre vías de acceso de implantación de Port-A-Cath* / Comparative study of access routes for Port-A-Cath(R) implantation

Introducción: Ha habido un aumento en la implantación de reservorios subcutáneos en los últimos años. El objetivo de este estudio es comparar las técnicas de punción venosa (PV) frente a la disección venosa (DV). Métodos: Estudio de cohortes retrospectivo. Incluyó a pacientes que requirieron un Port-A-Cath*. Se dividió a los pacientes en 2grupos: PV y DV. Los pacientes eran mayores de 18 años, requerían tratamiento intravenoso continuado, sin restricciones de patología. Se excluyó a quienes habían sido portadores de un reservorio previo y pacientes pediátricos. La elección de la técnica se basó en preferencias del cirujano. Se analizaron los parámetros clínicos de edad, sexo, ASA, IMC, motivo de colocación y lateralidad, y los datos referidos a las complicaciones y la tasa de retirada en cada uno de los grupos. El seguimiento medio fue de 2 años. Resultados: Fueron incluidos 386 pacientes durante 5 años: 228 en el grupo DV y 155 en el grupo PV. En 3 casos la técnica no quedó registrada. No hubo diferencias entre ambos grupos en edad, sexo, ASA, IMC y motivo de implantación (p > 0,05). La DV presentó menor cifra de complicaciones y se observó un mayor recambio y retirada de catéter en PV. A pesar de ello, no hubo diferencias estadísticamente significativas (p = 0,113). Conclusiones: Tanto la DV como la PV son técnicas seguras y eficaces. En nuestra experiencia, la DV presentó mejores resultados intraoperatorios y a largo plazo. Se recomienda realizar más estudios para discernir la técnica a utilizar con mayor seguridad

Introduction: There has been an increase in the implantation of subcutaneous reservoirs in recent years. The objective of this study was to compare puncture techniques against venous dissection. Methods: This retrospective cohort study included patients who required a Port-a-Cath and were divided into two groups: venous puncture (PV) and venous dissection (DV). Patients were over 18 years of age, requiring continued intravenous treatment, with no restriction of pathology. Patients with a previous reservoir and < 18 years old were excluded. The choice of the technique was based on the surgeon's preferences. We analyzed the clinical parameters of age, sex, ASA, BMI, reason for placement and laterality, and data related to the complications and withdrawal rate in each of the groups. Results: 386 patients were included for 5 years: 228 DV group and 155 PV group. In three cases, the technique was not documented. There were no differences between the two groups with respect to age, sex, ASA, BMI and reason for implantation (p > 0.05). The average follow-up was two years. The DV group was found to have a lower number of complications, while the PV group had an increased incidence of catheter replacement and removal. However, these differences were not statistically significant (p = 0.113). Conclusions: Both DV and PV are safe and effective techniques. In our experience, DV presented better intraoperative and long-term results. Further studies are recommended to discern which technique to use more safely

The Role of Ultrasound for Detecting Occult Penetrating Cardiac Wounds in Hemodynamically Stable Patients.

BACKGROUND: There is evidence in favor of using the ultrasound as the primary screening tool in looking for an occult cardiac injury. We report on a prospective single-center study to determine the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac wounds in a low-resource hospital from a middle-income country. METHODS: Data were collected prospectively. We included all consecutive patients 14 years and older who presented to the Emergency Trauma Unit with (1) penetrating injuries to the precordial area and (2) a systolic blood pressure ≥ 90 mmHg (hemodynamically stable). The main outcome measures were sensitivity, specificity, and positive and negative predictive values of ultrasound compared with those of the pericardial window, which was the standard test. RESULTS: A total of 141 patients met the inclusion criteria. Our results showed that for diagnosing an occult cardiac injury, the sensitivity of the chest ultrasonography was 79.31%, and the specificity was 92.86%. Of the 110 patients with a normal or negative ultrasound, six had a positive pericardial window. All of these patients had left hemothoraces. None of them required further cardiac surgical interventions. CONCLUSION: We found that ultrasound was 79% sensitive and 92% specific for the diagnosis of occult penetrating cardiac wounds. However, it should be used with caution in patients with injuries to the cardiac zone and simultaneous left hemothorax.

Evaluation of the PROMIS Physical Function Computer Adaptive Test in Patients Undergoing Knee Surgery.

A cross-sectional analysis of data derived from patients undergoing knee surgery at a single institution was conducted. The objectives of the study were to (1) compare how the Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) computer adaptive test performs against the International Knee Documentation Committee (IKDC) Subjective Knee Form in evaluating functional status, and (2) to determine demographic, clinical, and psychosocial correlates of each outcome measure in an urban population undergoing a variety of knee surgeries. We hypothesized that there would be a strong correlation between PROMIS PF and IKDC, with minimal floor and ceiling effects, and similar clinical correlates. The sample consisted of 412 patients undergoing knee surgery. Bivariate and multivariable statistical analyses were performed to identify significant independent predictors. The PROMIS PF and IKDC scores were strongly correlated (r s = 0.71, p < 0.001), and neither exhibited floor nor ceiling effects. Lower body mass index, no preoperative opioid use, lower Charlson comorbidity index score, employment, and lower income were found to be significant independent predictors for better scores on both PROMIS PF and IKDC. Patients undergoing total knee arthroplasty had significantly lower PROMIS PF and IKDC scores (p < 0.05). Potential explanations for these findings are presented, and clinical implications are discussed.