Evaluación de la eficacia de los protocolos de recuperación mejorada en cirugía cardiaca. Protocolo de Ensayo Clínico Aleatorizado / Assessment of the efficacy of improved recovery protocols in cardiac surgery. Randomized Clinical Trial Protocol

Introducción: Múltiples son los artículos publicados que abordan el tema de la ciencia abierta y su importancia para la sociedad, especialmente para la comunidad de investigadores. Esta constituye, ineludiblemente, el presente y futuro de las revistas científicas como método de expandir las investigaciones con alta calidad y credibilidad. La ciencia abierta como movimiento, tiene varios componentes y dentro de ellos, la gestión de citas y referencias de datos, códigos y materiales, que fundamentan la necesidad de que los autores tengan disponibles los contenidos subyacentes a los artículos que se publican y que constituyen la base de los resultados obtenidos en cada investigación. Objetivo: Evaluación de la eficacia de los protocolos de recuperación mejorada en cirugía cardiaca. Métodos: El protocolo que se propone fue elaborado por la investigadora principal (registro público cubano de ensayos clínicos RPCEC00000304) y se describe acorde a las recomendaciones de la lista internacional de chequeo para ensayos clínicos (SPIRIT). Conclusiones: Estarían en relación a si se puede demostrar, después de terminada la investigación, si el protocolo motivo de la Intervención, es mejor, igual o peor que el protocolo de control(AU)

Introduction: There are multiple articles published that address the subject of open science and its importance for society, especially for the research community. This constitutes, inevitably, the present and future of scientific journals as a method of expanding research with high quality and credibility. Open science, as a movement, has several components including the management of citations and references of data, codes and materials, which support the need for authors to have available the underlying content of the articles published and constituting the base for the results obtained in each investigation. Objective: Assessment of the efficacy of improved recovery protocols in cardiac surgery. Methods: The proposed protocol was prepared by the main researcher (Cuban public registry of clinical trials: RPCEC00000304) and is described according to the recommendations of the international checklist for clinical trials (SPIRIT). Conclusions: They would be related to whether it can be demonstrated, after the end of the investigation, if the protocol reason for the intervention is better, equal to, or worse than the control protocol(AU)

Global perioperative surgery research: A call to Latin America / Investigación global sobre el perioperatorio quirúrgico: un llamado a América Latina

Every year, around 300 million surgical procedures are performed worldwide 1,2, with an estimated 4% early postoperative mortality rate. 3,4 However, little is known about global quality of surgery, specifically in middle-income countries. Colombia, similar to other Latin American countries, has an interesting diversity of healthcare needs. In urban settings, the healthcare offered is among the best in Latin America, with top-quality hospitals and educational programs comparable to those in the USA or Europe. In contrast, in most rural areas of Latin America, including some of the most remote locations in the world (like the Pacific Coast or the Amazon forest), a frail and fragmented healthcare system prevails, similar to the conditions in very low-income countries. At least 7.1 million people (15.1% of the population) lack hospital access within a 2-hour drive, and despite these characteristics, the early reported postoperative mortality is low - 0.74%.

Cada año se realizan alrededor de 300 millones de intervenciones quirúrgicas en todo el mundo 1,2, con una tasa estimada de mortalidad postoperatoria temprana del 4%. 3,4 Sin embargo, poco se sabe sobre la calidad global de la cirugía, específicamente en los países de ingresos medios. Colombia, al igual que otros países latinoamericanos, presenta una interesante diversidad de necesidades de atención médica. En los entornos urbanos, la oferta sanitaria se encuentra entre las mejores de América Latina, con hospitales de primera calidad y programas educativos comparables a los de Estados Unidos o Europa. En cambio, en la mayoría de las zonas rurales de América Latina, incluidas algunas de las localidades más remotas del mundo (como la costa del Pacífico o la selva amazónica), prevalece un sistema sanitario frágil y fragmentado, similar a las condiciones de los países de muy bajos ingresos. Al menos 7,1 millones de personas (el 15,1% de la población) carecen de acceso a un hospital a menos de 2 horas de viaje, y a pesar de estas características, la mortalidad postoperatoria temprana reportada es baja: 0,74%.

Immunomodulatory effects of anesthetic agents in perioperative medicine.

Anesthetics comprise a heterogeneous group of drugs with multiple functions and mechanisms of action, which are not yet fully elucidated. In the clinical setting, it is difficult to isolate the effects of anesthetic agents from those of surgical stress itself or of other individual covariates. For this reason, several methods involving human immune cells and animal models have been used to study the effects of anesthetic agents on the immune system. The immunomodulation caused by anesthetic agents may lead to distinct consequences: suppression of the immune response, preventing or minimizing further distal organ injury; or suppression of the host immune reaction, which can lead to unacceptably increased risk of opportunistic infections. This review discusses the perioperative inflammatory response and the immunomodulatory properties of the most commonly used anesthetic agents in the perioperative period, addressing both their effects and proposed mechanisms of action on the innate immune system, including: biochemical and cellular defenses; barriers such as the endothelium and epithelium; biological macromolecules; domain proteins; specific cell types; and molecules such as cytokines and chemokines, which coordinate the host defense process. The immunomodulatory consequences of general anesthesia are complex. Immunosuppression can lead to beneficial effects, reducing systemic and local inflammation, or negative effects, which result in increased risk of infection. Anesthesiologists should choose the most appropriate agents based on the immune status of each patient.

Cirugía robótica colorectal: nuestra experiencia inicial / ROBOTIC COLORECTAL SURGERY: AUTHOR'S EXPERIENCE

Introduccion: La cirugía robótica colorectal se llevó a cabo por primera vez en el Hospital Clínic de Barcelona en Enero de 2016. El objetivo de este estudio es presentar nuestra experiencia inicial en cirugía robótica de pacientes afectos de patología colorectal. Metodos: Esta es una revisión retrospectiva de los datos recogidos de forma prospectiva de los pacientes intervenidos de patología colorectal mediante cirugía robótica entre Enero y Diciembre 2016. Se obtuvieron para análisis las características de los pacientes y los datos tanto peri como postoperatorios. Resultados: Un total de 40 pacientes con una edad media de 69.3 años (42- 93) y un índice de masa corporal medio de 26.8 kg/m2 (15-37) fueron intervenidos mediante cirugía robótica de su patología colorectal. La indicación quirúrgica fue por patología maligna en el 90 % de los casos y patología benigna en el 10 %. La intervención más frecuente fue la sigmoidectomía (57.5 %), seguida de la hemicolectomía derecha (20 %), la resección anterior baja (12.5 %), la hemicolectomía izquierda (7.5 %) y la resección segmentaria de ángulo esplénico (2.5 %). El tiempo operatorio medio fue de 159.9 min (90-260). El número medio de ganglios resecados fue 18.1 (5-42). La estancia mediana fue de 4.6 días (2-13). No hubo ningún caso de conversión a cirugía abierta, únicamente hubo un caso convertido a cirugía laparoscópica (2.5 %) y el índice de fallos de sutura fue de 2.6%. Conclusiones: Aunque se trata de nuestra experiencia inicial, podemos considerar que la cirugía robótica es una técnica factible y segura en pacientes afectos de patología colorectal

ntroduction Robotic colorectal surgery was first performed at our institution in January 2016. The objective of this study is to present our initial experience with robotic colorectal surgery. Methods: This is a retrospective review of the prospectively collected data of all patients who underwent robotic colorectal surgery from January 2016 to December 2016. Baseline, perioperative, and postoperative data were obtained for analysis. Results: A total of 40 patients with a mean age of 69.3 years (42-93) and a body mass index of 26.8 kg/m2 (15-37) underwent robotic colorectal surgery between January and December 2016. The indication for surgery was malignancy in 90% and benign diseases in 10% of the patients. The most common operation was sigmoidectomy (57.5%) followed by right colectomy (20%), low anterior resection (12.5%), left colectomy (7.5%) and splenic flexure segmentary resection (2.5%). The mean operative time was 159.9 (90-260) minutes. The median number of lymph nodes harvested was 18.1 (5-42). The median duration of hospital stay was 4.6 days (2- 13). Conversion to laparoscopic surgery occurred in one case (2.5%) and anastomotic leakage rate was 2.6% Conclusions: Despite being our initial experience, we can consider robotic surgery as a safe and feasible technique for patients with colorectal diseases

Medicina perioperatoria ¿El futuro de la anestesiología? / Perioperative Medicine, the Future of Anesthesiology?

We are in the middle of great changes in health care worldwide. There is great pressure to contain costs, population ages rapidly and at the same time significant technological advances are continuously incorporated into medical practice. In the near future, it is likely that reimbursement and incentive mechanisms will also change, and progress will be made towards what has been called value-based medical care, where compensation will be directly related to clinical outcomes. Anesthesiology as a specialty, needs also to adapt to these new scenarios, given that the perioperative period as a whole have been observed as not very efficient and susceptible to improvement. This is why, in many places, anesthesiologists, given their wide range of clinical skills, are beginning to expand their field of action towards clinical activities outside the operating room, taking care of the patient through all their surgical process, which has been called Perioperative Medicine. The anesthesiologist is evolving towards this new type of specialist and this is how they effectively add value to medical care as a whole.

Estamos en medio de una etapa de grandes cambios en atención de salud en todo el mundo. Existe gran presión por contener los costos, envejece la población y al mismo tiempo se incorporan rápidamente adelantos tecnológicos a nuestra práctica médica. Muy probablemente, en el futuro cercano cambien también los mecanismos de pago e incentivos y se avance a lo que se ha denominado atención médica basada en el valor, donde las compensaciones estarán directamente relacionadas con los desenlaces o resultados. La anestesiología como especialidad, también deberá adaptarse a estos nuevos escenarios, dado que el período perioperatorio en su conjunto ha sido observado como poco eficiente y susceptible de mejorar. Es aquí donde en muchos lugares los anestesiólogos, dado su amplia gama de competencias clínicas, están empezando a aumentar su campo de acción hacia actividades clínicas fuera del pabellón, haciéndose cargo del paciente a través de todo su proceso quirúrgico lo que se ha denominado Medicina Perioperatoria. El anestesiólogo está evolucionando hacia este nuevo tipo de especialista y es de esta manera como efectivamente logra agregar valor al cuidado médico en su conjunto.

Análise crítica do tratamento perioperatório para transplante hepático em crianças com atresia de vias biliares e com peso menor que dez quilogramas / Critical analysis of the perioperative treatment of livingrelated hepatic transplantation in children with biliary atresia and weight under 10 kilograms

O transplante de fígado é o tratamento estabelecido para crianças com insuficiência hepática aguda e crônica. Alguns trabalhos sugerem que crianças com peso abaixo de 10 quilogramas e com cirurgia de Kasai prévia seja um grupo associado com resultados menos satisfatórios. Esta dissertação descreve a nossa experiência na evolução perioperatória de transplante hepático com doador vivo em 54 crianças com atresia de vias biliares e peso menor que 10 quilogramas. Foram revisados os prontuários de 54 crianças com idade média de 345 dias de vida (desvio padrão (d. p.) de 130 dias) e peso médio de 7,7 quilogramas (d.p. de 1,2 quilogramas), sendo 39 destes com cirurgia de Kasai prévia. Os dados analisados incluíram a indicação de técnica anestésica, necessidade de vasopressores, diuréticos, drogas complementares, reposição de glicose e de cloreto de cálcio, reposição volêmica e sangüínea, tempo para desintubação, complicações perioperatórias, tempo de internação na unidade de terapia intensiva e no hospital e a sobrevida de seis meses destes pacientes. Não houve mortalidade perioperatória nesta casuística. A transfusão sangüínea média foi de 38,69 ml*kg-1 (d.p. de 24,7 ml*kg-1), sendo que um paciente necessitou da reposição de plasma fresco congelado e em nenhum houve necessidade de reposição de concentrado de plaquetas. A sobrevida em seis meses foi de 89,9%. Os pacientes com atresia de vias biliares e com peso menor que 10 quilogramas não são um grupo de exceção para o transplante hepático intervivos.

The liver transplantation is the established treatment for children with acute and chronic liver failure. Some reports suggest that children with weight below 10 kilograms and with previous Kasai are a group associated with less satisfactory results. This dissertation describes our experience in the perioperative period of living-related hepatic transplantation in 54 children with biliary atresia and weight under 10 kilograms. We reviewed the records of 54 infants with mean age 345 ± 130 days; mean weight 7.7 ± 1.2 kilograms, 39 of these with previous Kasai. We analyzed the indication of anesthetic technique, the need of vasopressors, diuretics, complemental drugs, glucose and calcium chloride replacement, volemic replacement and blood transfusion, time for extubation, perioperative complications, time of Pediatric Intensive Care Unit and hospital stay and mean overall survival rate of these patients. There was no perioperative mortality in this series. Mean peroperative blood transfusions were 38.69 ± 24.7 ml*kg-1, one patient needed the replacement of fresh plasma and there was not need of platelet replacement. Overall 6 month survival rate was 89.9%. The patients with biliary atresia and with weight smaller than 10 kilograms are not an exception group for the living-related liver transplantation.