Eficacia e impacto económico del bisturí armónico Focus frente al dispositivo ACS-14C en la tiroidectomía total por bocio multinodular. Estudio prospectivo aleatorizado / Efficacy and budget impact of the Focus harmonic scalpel compared to the ACS-14C device in total thyroidectomy due to multinodular goitre. A prospective randomised study

OBJETIVO: El bisturí armónico ha mejorado la cirugía tiroidea, cuando se compara con cirugía convencional, en términos de reducción del tiempo quirúrgico, número de ligaduras, dolor postoperatorio y uso de drenajes. Analizamos las posibles ventajas en reducción de tiempo quirúrgico y ahorro de recursos del terminal Focus en comparación con el terminal ACS-14C en la cirugía tiroidea benigna. MÉTODOS: Estudio ciego, prospectivo y aleatorizado realizado desde 2009 hasta 2010.Se compararon los resultados del ACS-14C (grupo I ) con Focus (grupo II ) en pacientes con bocio multinodular operados de tiroidectomía total. Se incluyó a pacientes entre 18 y 80 años que aceptaron participar en el estudio sin cirugía cervical previa, lesión del nervio recurrente laríngeo, tratamiento analgésico crónico, coagulopatía o problemas cognitivos. La variable principal fue el tiempo quirúrgico. Otras variables secundarias fueron: tiempo de uso del dispositivo durante el procedimiento, número de ligaduras, pérdida hemática, hipocalcemia, lesión del nervio recurrente faríngeo, dolor postoperatorio y análisis de calidad de vida. RESULTADOS: Se incluyó a 54 pacientes, 26 en el grupo I y 28 en el grupo II . En el grupo de Focus hubo una reducción del tiempo quirúrgico de 16% (78,7 ± 22,01 vs. 66 ± 17,0 min; p < 0,05), del número de ligaduras (0,3 ± 0,8 vs. 2,9 ± 3,6; p < 0,05) y un ahorro adicional de 179,74 € por procedimiento. Focus se utilizó más tiempo que ACE-14S tanto en valor absoluto (26,0+-7,7 vs. 10,0+-3,5 min; p < 0.05) como en valor relativo (40,7+-11,8 vs. 13,1+-4,1%; p < 0,05). CONCLUSIONES: Focus mejora el tiempo operatorio en la tiroidectomía, causando impacto positivo sobre el presupuesto. Su mayor utilización hace que sea una herramienta más coste-eficaz que el terminal ACS-14C

OBJECTIVE: To analyse the potential advantages and outcomes of the new Harmonic Focus™ (Focus) device compared to the Harmonic Scalpel™ ACS-14C in benign thyroid surgery. METHODS: A controlled randomised study was conducted in which the Focus was compared to former ACS-14C device in patients undergoing total thyroidectomy for multinodular goitre. The primary endpoint was time of surgery. The secondary endpoints were time of use of the device, number of ligatures, blood loss, hypocalcaemia, laryngeal nerve impairment, postoperative pain and quality of life. RESULTS: Two groups of patients were included, 26 patients in group I (ACS-14C) and 28 in group II (Focus). There was a 16% reduction in surgical time (78.7 ± 22.01 vs. 66 ± 17.0 min; P < .05) between group I and II respectively. The Focus was used longer than ACE-14S, both in absolute time (26.0 ± 7.7 vs. 10.0 ± 3.5 minutes; P < .05), as well as in relative time (40.7 ± 11.8% vs. 13.1 ± 4.1%; P < .05), respectively. A significant reduction in number of ligatures in Focus patients was also observed (0,3 ± 0,8 vs. 2.9 ± 3.6; P < .05).Budget impact analysis showed an additional average savings per procedure of 179.74 €. CONCLUSIONS: Focus ergonomics significantly improved the operation time in thyroidectomy causing a positive impact on the budget.Focus also adds further benefits to those previously achieved by Harmonic technology, and it is by itself more cost-effective in total thyroidectomy than ACS-14C

[Efficacy and budget impact of the Focus harmonic scalpel compared to the ACS-14C device in total thyroidectomy due to multinodular goitre. A prospective randomised study]. / Eficacia e impacto económico del bisturí armónico Focus frente al dispositivo ACS-14C en la tiroidectomía total por bocio multinodular. Estudio prospectivo aleatorizado.

OBJECTIVE: To analyse the potential advantages and outcomes of the new Harmonic Focus™ (Focus) device compared to the Harmonic Scalpel™ ACS-14C in benign thyroid surgery. METHODS: A controlled randomised study was conducted in which the Focus was compared to former ACS-14C device in patients undergoing total thyroidectomy for multinodular goitre. The primary endpoint was time of surgery. The secondary endpoints were time of use of the device, number of ligatures, blood loss, hypocalcaemia, laryngeal nerve impairment, postoperative pain and quality of life. RESULTS: Two groups of patients were included, 26 patients in group i (ACS-14C) and 28 in group ii (Focus). There was a 16% reduction in surgical time (78.7 ± 22.01 vs. 66 ± 17.0 min; P<.05) between group i and ii respectively. The Focus was used longer than ACE-14S, both in absolute time (26.0 ± 7.7 vs. 10.0 ± 3.5 minutes; P<.05), as well as in relative time (40.7 ± 11.8% vs. 13.1 ± 4.1%; P<.05), respectively. A significant reduction in number of ligatures in Focus patients was also observed (0,3 ± 0,8 vs. 2.9 ± 3.6; P<.05). Budget impact analysis showed an additional average savings per procedure of 179.74 €. CONCLUSIONS: Focus ergonomics significantly improved the operation time in thyroidectomy causing a positive impact on the budget. Focus also adds further benefits to those previously achieved by Harmonic technology, and it is by itself more cost-effective in total thyroidectomy than ACS-14C.

Postresection parathyroid hormone and parathyroid hormone decline accurately predict hypocalcemia after thyroidectomy.

Hypocalcemia is the most frequent complication after total thyroidectomy. Parathyroid hormone (PTH) measurement has been proposed as an early predictor of this condition. Total thyroidectomy was performed in 39 patients. Hypocalcemia was present in 15 cases (38%). Patients undergoing hemithyroidectomy (n = 13) were considered control subjects not developing hypocalcemia. PTH was measured before surgery and 10 minutes after resection of the gland using a rapid (15 minutes) chemiluminescent immunometric assay. Patients developing hypocalcemia had lower calcium and postresection PTH levels and higher PTH decline than patients not developing hypocalcemia (P < .0001). PTH decline (cutoff value, 62.5%) had the better sensitivity (93.3%) for predicting hypocalcemia, allowing for a fairly safe early discharge. However, the best overall results corresponded to the combination of postresection PTH level (< or = 18 pg/mL [< or = 1.9 pmol/L]) and PTH decline (>62.5%), with a sensitivity of 90% and a specificity of 97.9%. Perioperative PTH measures can accurately predict hypocalcemia after thyroidectomy, granting the laboratory a key role in the immediate decision about calcium supplementation for patients at risk.

Resultados de la cirugía tiroidea limitada a un lóbulo en régimen ambulatorio. Estudio preliminar / Results of ambulatory unilateral thyroid surgery. A preliminary study

Introducción. La cirugía del tiroides en régimen ambulatorio ha demostrado ser eficaz, pero su implementación no ha sido la esperada. La probabilidad de hemorragia en las primeras 24 h del postoperatorio y el desarrollo posterior de hematoma sofocante planean sobre los cirujanos endocrinos y promueven la desconfianza en esta indicación. El advenimiento de nuevas tecnologías aplicadas a la cirugía tiroidea y la especialización del cirujano endocrino pueden revertir esta situación de transición que vive la cirugía tiroidea en régimen ambulatorio. Presentamos nuestros resultados preliminares en cirugía tiroidea limitada a un lóbulo en régimen ambulatorio. Métodos. Los pacientes han sido intervenidos en el período febrero de 2005-julio de 2006 por un único cirujano dedicado a la cirugía endocrina desde el año 2000, que aplicó a la mayoría los criterios de cirugía mínimamente invasiva (incisión < 3 cm). Resultados. El 79,1% (53/67) de los pacientes sometidos a intervenciones de cirugía tiroidea limitada han sido considerados candidatos a cirugía mayor ambulatoria (CMA). El índice de sustitución (IS) y el índice de ingresos no deseados (IND) han sido del 90,5 (48/53) y el 9,4% (5/53), respectivamente; 2 pacientes han presentado complicaciones menores (3,8%) y ninguno presentó hemorragia ni reingresó en el postoperatorio inmediato. Conclusiones. Estos resultados, aunque preliminares, deberían por lo menos replantear la posibilidad de realizar la tiroidectomía en régimen ambulatorio e incluir este proceso en la rutina de la CMA de algunos hospitales. Todo ello, eso sí, realizado por cirujanos con un mínimo de experiencia acumulada en cirugía tiroidea y con un número de casos de cirugía tiroidea asegurados a lo largo del año (AU)

Introduction. Ambulatory thyroid surgery has been demonstrated to be effective but this technique has been less widely implemented than expected. Because of the probability of hemorrhage in the first 24 hours after the intervention and the subsequent development of a suffocating hematoma, endocrine surgeons are reluctant to perform this procedure. The advent of new technologies applied to thyroid surgery and specialization of thyroid surgeons could reverse this impasse in ambulatory thyroid surgery. We present our preliminary results of ambulatory unilateral thyroid surgery. Methods. The patients underwent surgery between February 2005 and June 2006 carried out by the same surgeon performing endocrine surgery exclusively since 2000. In most patients, the criteria of minimally invasive surgery (incision < 3 cm) were applied. Results. A total of 79.1% (53/67) of the patients undergoing unilateral thyroid surgery were considered candidates for ambulatory surgery. The substitution index and the unplanned admission rate was 90.5% (48/53) and 9.4% (5/53), respectively. Two patients had minor complications (3.8%). None of the patients developed hemorrhage or required readmission in the immediate postoperative period. Conclusions. Although preliminary, these results should at least lead to reconsideration of the possibility of performing thyroidectomy in the ambulatory setting and of including this process in the routine activity of ambulatory units in certain hospitals. However, this type of surgery should be performed by surgeons experienced in thyroid surgery and there should be a sufficient number of patients requiring thyroid surgery throughout the year (AU)

[Factors associated with morbidity and mortality after gastric bypass. Alternatives for risk reduction: sleeve gastrectomy]. / Factores asociados a morbimortalidad tras el bypass gástrico. Alternativas para disminuir riesgos: gastroplastia tubular.

INTRODUCTION: The aim of this study was to analyze factors related to morbidity and mortality after gastric bypass and to evaluate lower-risk alternatives in selected patients. PATIENTS AND METHODS: A prospective cohort of 761 patients who underwent gastric bypass was included. Prognostic factors were studied using a logistic regression model with SPSS 11.0. Independent variables were age, sex, body mass index (BMI), comorbidities, and the laparoscopic approach. Dependent variables consisted of medical complications, surgical complications, and mortality. We performed a preliminary descriptive study of morbidity and weight loss at 3 months after sleeve gastrectomy. RESULTS: In the postoperative period, 2.8% of patients presented medical complications and 5.4% presented surgical complications. Mortality was 0.52%. Surgical complications were significantly associated with age > 45 years (P = .04; OR = 2.00 [1.03-3.8]) and male sex (P = .041; OR = 2.40 [1.12-5.14]). Medical complications were significantly associated with a BMI of > 50 kg/m2 (P = .012; OR = 3.32 [1.23-8.98]), and mortality was significantly associated with a BMI of > 50 kg/m2 (P = .006) and male sex (P = .006). Sleeve gastrectomy was performed in eight patients with a BMI of > 60 kg/m2, in three patients with a BMI of > 50 kg/m2, cardiopulmonary disease and android fat distribution, and in four patients with a BMI of between 35 and 40 kg/m2 and major comorbidity. Morbidity consisted of self-limited febrile syndrome in one patient. There was no mortality. Weight loss at 3 months was 39.8 +/- 5.36% of excess BMI in superobese patients (n = 4) and was 50.2 +/- 11.05% of excess BMI in morbidly obese patients (n = 4). CONCLUSIONS: Postoperative morbidity and mortality was significantly higher in male patients, in patients aged more than 45 years, and in those with a BMI of > 50 kg/m2. Sleeve gastrectomy in selected patients could be a lower-risk alternative.

Factores asociados a morbimortalidad tras el bypass gástrico. Alternativas para disminuir riesgos: gastroplastia tubular / Factors associated with morbidity and mortality after gastric bypass. Alternatives for risk reduction: sleeve gastrectomy

Introducción. El objetivo fue estudio ha sido evaluar factores relacionados con la morbimortalidad tras el bypass gástrico y considerar alternativas de menor riesgo en pacientes seleccionados. Pacientes y métodos. Se incluye una cohorte prospectiva de 761 pacientes a los que se realizó bypass gástrico. Se realiza un estudio de factores pronósticos mediante el modelo de regresión logística con SPSS 11.0. Las variables independientes fueron edad, sexo, índice de masa corporal (IMC), comorbilidades, abordaje laparoscópico; las variables dependientes fueron complicaciones médicas, complicaciones quirúrgicas y mortalidad. Es un estudio preliminar descriptivo de morbilidad y resultados ponderales a 3 meses con gastroplastia tubular. Resultados. En el postoperatorio el 2,8% de los pacientes presentó complicaciones médicas y el 5,4%, complicaciones quirúrgicas. La mortalidad fue del 0,52%. Las variables que han presentado relación estadísticamente significativa con las complicaciones quirúrgicas fueron la edad > 45 años (p = 0,04; odds ratio [OR] = 2,00; intervalo de confianza [IC] del 95%, 1,03-3,8) y el sexo masculino (p = 0,041; OR = 2,40; IC del 95%, 1,12-5,14). Las variables presentaron relación estadísticamente significativa con las con las complicaciones médicas fueron: IMC > 50 kg/m2 (p = 0,012; OR = 3,32; IC del 95%, 1,23-8,98); con la mortalidad: IMC > 50 kg/m2 (p = 0,006), el sexo masculino (p = 0,006). Se ha realizado gastroplastia tubular en pacientes con IMC > 60 kg/m2 (8 casos); IMC > 50 kg/m2 con afección cardiopulmonar y morfología androide (3 casos); IMC entre 35 y 40 kg/m2 y comorbilidad mayor (4 casos); con la morbilidad: síndrome febril autolimitado. No hubo mortalidad. En superobesos el descenso del 39,8 ± 5,36% del exceso de IMC en 3 meses (n = 4); en obesos mórbidos un descenso del 50,2 ± 11,05% del exceso del IMC en 3 meses (n = 4). Conclusiones. La morbimortalidad postoperatoria fue significativamente mayor en los varones, mayores de 45 años y con IMC > 50 kg/m2.La gastroplastia tubular en pacientes seleccionados podría ser una alternativa de menor riesgo (AU)

Introduction. The aim of this study was to analyze factors related to morbidity and mortality after gastric bypass and to evaluate lower-risk alternatives in selected patients. Patients and methods. A prospective cohort of 761 patients who underwent gastric bypass was included. Prognostic factors were studied using a logistic regression model with SPSS 11.0. Independent variables were age, sex, body mass index (BMI), comorbidities, and the laparoscopic approach. Dependent variables consisted of medical complications, surgical complications, and mortality. We performed a preliminary descriptive study of morbidity and weight loss at 3 months after sleeve gastrectomy. Results. In the postoperative period, 2.8% of patients presented medical complications and 5.4% presented surgical complications. Mortality was 0.52%. Surgical complications were significantly associated with age > 45 years (P=.04; OR = 2.00 [1.03-3.8]) and male sex (P=.041; OR = 2.40 [1.12-5.14]). Medical complications were significantly associated with a BMI of > 50 kg/m2 (P=.012; OR = 3.32 [1.23-8.98]), and mortality was significantly associated with a BMI of > 50 kg/m2 (P=.006) and male sex (P=.006). Sleeve gastrectomy was performed in eight patients with a BMI of > 60 kg/m2, in three patients with a BMI of > 50 kg/m2, cardiopulmonary disease and android fat distribution, and in four patients with a BMI of between 35 and 40 kg/m2 and major comorbidity. Morbidity consisted of self-limited febrile syndrome in one patient. There was no mortality. Weight loss at 3 months was 39.8 ± 5.36% of excess BMI in superobese patients (n = 4) and was 50.2 ± 11.05% of excess BMI in morbidly obese patients (n = 4). Conclusions. Postoperative morbidity and mortality was significantly higher in male patients, in patients aged more than 45 years, and in those with a BMI of > 50 kg/m2. Sleeve gastrectomy in selected patients could be a lower-risk alternative (AU)

Abordaje perineal en el tratamiento quirúrgico del hamartoma quístico retrorrectal / The perineal approach in the surgical treatment of retrorectal cystic hamartoma

El hamartoma quístico es una lesión congénita derivada de los restos del desarrollo embrionario del tubo digestivo en su parte caudal. Su localización suele ser retrorrectal, aunque pueden extenderse hacia el espacio perirrenal o paravesical, zonas donde hayan residido vestigios del tubo digestivo durante el desarrollo embrionario. El diagnóstico diferencial de esta lesión incluye fundamentalmente todos los tumores benignos y malignos del espacio retrorrectal. Ante el hallazgo clínico casual (o con sintomatología asociada) de este tipo de tumores, se deben resecar quirúrgicamente y así evitar el riesgo de posibles complicaciones, incluida su degeneración maligna. Para el estudio y la decisión de la táctica quirúrgica es imprescindible la práctica de pruebas de imagen, de las que la tomografía axial computarizada y la resonancia magnética nuclear son las más indicadas porque permiten evaluar su relación con los órganos vecinos, aspecto que puede determinar la elección de la vía de abordaje. Presentamos un caso de hamartoma quístico retrorrectal en un varón de 49 años que había sido intervenido previamente en diversas ocasiones por reiteradas recidivas, y que fue abordado por una única vía perineal (AU)