Ensayo clínico multicéntrico para la resección de pólipos rectales mediante un nuevo dispositivo de acceso transanal híbrido laparoendoscópico / Multicenter clinical trial for the resection of rectal polyps using a new laparoendoscopic hybrid transanal access device

Introducción: Los pólipos complejos requieren el uso de técnicas endoscópicas avanzadas o la cirugía mínimamente invasiva para su abordaje. En los pólipos rectales es de especial relevancia llegar a un consenso de cuál es el mejor abordaje de estos para evitar infratratamientos o sobretratamientos que incrementen una morbimortalidad innecesaria. Métodos: Se describe un ensayo clínico piloto con un producto sanitario de primer uso en humanos multicéntrico y prospectivo. Se plantea la hipótesis que UNI-VEC® facilita la cirugía laparoendoscópica transanal para la extirpación de tumores rectales precoces. El objetivo principal es evaluar que es seguro y cumple los requisitos funcionales establecidos. Los secundarios son evaluar resultados, complicaciones y nivel de satisfacción.Resultados: Se reclutaron 16 pacientes en 12 meses con un seguimiento mínimo de dos meses. El tamaño medio ha sido de 3,4 cm, siendo el pólipo mayor de 6 cm. Respecto a la localización, la media se encontraba a 6,6 cm del margen anal. Se realizó resección endoscópica mucosa (REM) (6,3%), disección submucosa endoscópica (DSE) (43,8%), resección espesor completo (REC) (6,3%) y transanal minimally invasive surgery (TAMIS) (43,8%). El tiempo medio fueron 73,25 min; 56,3% utiliza una cámara de 30̊ y 43,8% el endoscopio flexible como instrumento de visión. El 56,3% son lesiones benignas y 43,8% malignas. En 87,5% se consigue resección completa. En cuanto a las complicaciones, se presenta sangrado leve (Clavien I) en 25, 6,3 y 21,4% a las 24 h, 48 h y siete días, respectivamente. La continencia se valora según la Escala de Wexner. A los siete días, 60% presentan continencia perfecta, 26,7% IF leve y 13,3% IF moderada. A los 30 días, 66,7% continencia perfecta, 20% IF leve y 13,3% IF moderada. A los dos meses se revisan cuatro de los pacientes que a los 30 días presentaban un Wexner superior al preoperatorio y se demuestra continencia perfecta en 25% de los pacientes, 50% leve y 25% moderada. (AU)

Introduction: Complex polyps require the use of advanced endoscopic techniques or minimally invasive surgery for their approach. In rectal polyps it is of special relevance to reach a consensus on the best approach to avoid under- or overtreatment that increases unnecessary morbidity and mortality. Methods: We describe a prospective, multicenter, pilot clinical trial with a first-in-human medical device. It is hypothesized that UNI-VEC® facilitates transanal laparoendoscopic surgery for the removal of early rectal tumors. The primary objective is to evaluate that it is safe and meets the established functional requirements. Secondary objectives are to evaluate results, complications and level of satisfaction. Results: Sixteen patients were recruited in 12 months with a minimum follow-up of 2 months. The mean size was 3.4 cm with the largest polyp being 6 cm. Regarding location, the mean was 6.6 cm from the anal margin. Endoscopic mucosal resection (EMR) (6.3%), endoscopic submucosal dissection (ESD) (43.8%), REC (6.3%) and TAMIS (43.8%) were performed. The mean time was 73.25 min. The 56.3% used a 30° camera and 43.8% used the flexible endoscope as a viewing instrument. The 56.3% were benign lesions and 43.8% malignant. Complete resection is achieved in 87.5%. Regarding complications, mild bleeding (Clavien I) occurred in 25%, 6.3% and 21.4% at 24 h, 48 h and 7 days, respectively. Continence was assessed according to the Wexner scale. At 7 days, 60% showed perfect continence, 26.7% mild FI and 13.3% moderate FI. At 30 days, 66.7% had perfect continence, 20% mild FI and 13.3% moderate FI. At 2 months, 4 patients were reviewed who at 30 days had a Wexner's degree higher than preoperative and perfect continence was demonstrated in 25% of the patients, 50% mild and 25% moderate. (AU)

Multicenter clinical trial for the resection of rectal polyps using a new laparoendoscopic hybrid transanal access device.

INTRODUCTION: Complex polyps require the use of advanced endoscopic techniques or minimally invasive surgery for their approach. In rectal polyps it is of special relevance to reach a consensus on the best approach to avoid under- or overtreatment that increases unnecessary morbidity and mortality. METHODS: We describe a prospective, multicenter, pilot clinical trial with a first-in-human medical device. It is hypothesized that UNI-VEC® facilitates transanal laparoendoscopic surgery for the removal of early rectal tumors. The primary objective is to evaluate that it is safe and meets the established functional requirements. Secondary objectives are to evaluate results, complications and level of satisfaction. RESULTS: 16 patients were recruited in 12 months with a minimum follow-up of 2 months. The mean size was 3.4 cm with the largest polyp being 6 cm. Regarding location, the mean was 6.6 cm from the anal margin. Endoscopic Mucosal Resection (EMR) (6.3%), Endoscopic Submucosal Dissection ESD (43.8%), REC (6.3%) and TAMIS (43.8%) were performed. The mean time was 73.25 min. The 56.3% used a 30° camera and 43.8% used the flexible endoscope as a viewing instrument. The 56.3% were benign lesions and 43.8% malignant. Complete resection is achieved in 87.5%. Regarding complications, mild bleeding (Clavien I) occurred in 25%, 6.3% and 21.4% at 24 h, 48 h and 7 days respectively. Continence was assessed according to the Wexner scale. At 7 days, 60% showed perfect continence, 26.7% mild FI and 13.3% moderate FI. At 30 days, 66.7% had perfect continence, 20% mild FI and 13.3% moderate FI. At 2 months, 4 patients were reviewed who at 30 days had a Wexner's degree higher than preoperative and perfect continence was demonstrated in 25% of the patients, 50% mild and 25% moderate. In no case did rectal perforation or major complications requiring urgent reintervention occur. As for the level of reproducibility, safety, level of satisfaction with the device and evaluation of the blister, the evaluation on a scale of 0-10 (9.43, 9.71, 9.29 and 9.50 respectively). All the investigators have previous experience with transanal devices. CONCLUSIONS: The study demonstrates the efficacy and safety of UNI-VEC® for the treatment of rectal lesions. It will facilitate the implementation of hybrid procedures that seek to solve the limitations of pure endoscopic techniques by allowing the concomitant use of conventional laparoscopic and robotic instrumentation with the flexible endoscope.

Rejuvenecimiento facial híbrido en envejecimiento intermedio: 18 años de ritidopexia circular cerrada y procedimientos auxiliares / Hybrid facial rejuvenation in intermediate aging: 18 years of closed circular rhytidopexy and ancillary procedures

Introducción y objetivo: Presentamos un conjunto de técnicas que denominamos rejuvenecimiento facial hibrido (RFH), como alternativa menos invasiva y traumática indicada preferentemente para individuos entre los 30 a 55 años, franja etárea del envejecimiento intermedio, que solicitan procedimientos ambulatorios efectivos con rápida recuperación y precoz integración laboral y social. Material y método: En el grupo de técnicas simultaneas practicadas destacamos: ritidopexia circular cerrada y profunda periauricular (round block Stochero), sin retirada cutánea (Fórmula 1) o con escisión sin despegamiento (Fórmula 2); cervicoplastia cerrada o abierta, blefaroplastia, peeling químico, lipotransferencia malar y de surcos nasogenianos, dependiendo del plan quirúrgico individual. Resultados: Entre 2002 a 2019 tratamos 482 pacientes, 95% entre los 30 a 55 años (media de 52 años), 85% mujeres y 15% varones. El 84% de las cirugías fueron casos primarios y el 16% secundarios. El índice de satisfacción al año, en 452 casos, fue bueno para el 89% de los pacientes. Las intercurrencias fueron mínimas y por debajo del 1.6%. Conclusiones: Este conjunto de técnicas que denominamos RFH en pacientes entre los 30 a 55 años de edad, permite buenos resultados con procedimientos ambulatorios, bajo anestesia local y con mínimo trauma, convalecencia corta y un rápido retorno a las actividades diarias. (AU)

Background and objective: We present a group of techniques called hybrid facial rejuvenation (HFR) as a less invasive or traumatic alternative indicated in patients between 30 and 55 years old, age group of the senile intermediate stage, who request effective outpatient procedures, with rapid recovery and early labor and social integration. Methods: In this group of simultaneous techniques practiced stands out: closed circular peri-auricular deep ritidopexy (round block Stochero), without skin removal (Formula 1) or with excision without undermining (Formula 2); closed or open cervicoplasty, blepharoplasty, chemical peeling, malar and nasolabial fold lipotransfer, depending on the individual surgical plan. Results: Between 2002 to 2019 were treated 482 patients, 95% between 30 and 55 years old (average age of 52 years), 85% female and 15% male; 84% of the surgeries were primary cases and 16% secondary. The satisfaction index pear 1 year, of 452 cases, were good for 89% patients. Complications were minimal and under 1.6%. Conclusions: Our set of techniques, called together as HFR, preferably indicated for individuals between 30 and 55 years, showed excellent results with ambulatory procedures under local anesthesia, minimal morbidity and allow a short convalescence with quick return to different daily activities. (AU)

Arteria subclavia aberrante izquierda, hallazgo infrecuente / Aberrant left subclavian artery, an uncommon variation

Objetivo: La arteria subclavia aberrante (ASA) o arteria lusoria, es una de las malformaciones más comunes del arco aórtico; en especial su variante derecha. Por otro lado, la arteria subclavia aberrante izquierda es más rara. Presentamos un caso infrecuente de un paciente con síndrome deleción 22q11.2 y ASA izquierda con síntomas en extremidad superior izquierda. La ASA izquierda es una condición muy poco frecuente y hay escasa información sobre su tratamiento quirúrgico. La mayoría de las veces, el ASA es asintomática; especialmente en adultos. Si presenta clínica, sus síntomas son disfagia, tos, disnea, claudicación de la extremidad superior. La presencia de sintomatología es una indicación quirúrgica. El tratamiento quirúrgico de una ASA es discutido. Éste va a depender de la anatomía, comorbilidades y experiencia del cirujano.

Objective: The Aberrant Right Subclavian Artery (ARSA) or Lusoria Artery is one of the most common aortic arch malformations. Aberrant Left Subclavian Artery (ALSA) on the other hand, is a much rarer condition. We present an uncommon case of ALSA in a patient with 22q11.2 deletion syndrome with upper limb symptoms and review the treatment options. ALSA is an exceedingly rare condition and information on its surgical treatment is scarce. In most cases the presence of an ALSA is asymptomatic, especially in adults. Some of the most typical symptoms are dysphagia (dysphagia lusoria), cough, dyspnea, claudication of the upper limb extremity. When symptomatic, the patient has indication of surgery. The treatment of an ALSA is still debatable and it depends on the anatomy, comorbidities and surgeon´s experience.

Infección de injerto carótido-carotídeo para debranching aórtico: tratamiento con injerto autológo de vena / Infection of a carotid-carotid graft for aortic debranching: treatment with an autologous venous graft

Resumen El uso de prótesis vasculares y dispositivos endovasculares ha permitido tratar muchas patologías que antes no se intervenían dado el gran riesgo quirúrgico, como es el caso de los aneurismas de aorta torácica. Los materiales usados para estas reconstrucciones son muy resistentes y de larga duración, pero son muy sensibles a ser colonizados y presentar infección, lo que genera morbimortalidad considerable. Se presenta el caso de un paciente de 64 años con antecedente de aneurisma del arco aórtico y aorta descendente, tratado en forma extra institucional con prótesis de aorta torácica endovascular y debranchig de las ramas del arco aórtico, con injerto carótido-carotídeo y carótido-subclavio izquierdo en dacrón, por vía pretraqueal, con antecedente de intento de cubrimiento del injerto expuesto con un flap miocutáneo el cual fue fallido por necrosis; ingresó al Hospital Universitario Clínica de San Rafael, con exposición del injerto carótido-carotídeo a nivel cervical, signos locales de infección y sepsis secundaria.

Abstract The use of vascular replacements and endovascular devices has led to the treatment of many conditions that could not be operated on due to a high surgical risk, such as aortic aneurysms. The materials used for these reconstructions are very resistant and durable, but are very susceptible to being colonised and infected, which leads to a considerable morbidity and mortality. The case is presented of a 64 year-old patient with a history of an aortic arch and descending aortic aneurysm. This had been treated in another hospital with a thoracic aortic endovascular repair and debranching of the aortic arch, with carotid-carotid and left carotid-subclavian Dacron graft. The pretracheal route was used, after attempting to cover the exposed graft with a myocutaneous flap that failed due to necrosis. The patient was admitted to the Hospital Universitario Clínica de San Rafael, presenting with a carotid-carotid graft at cervical level, with local signs of infection and secondary sepsis.

Mapeo y ablación por radiofrecuencia a cielo abierto: un caso de taquicardia ventricular refractaria en anomalía de Ebstein / Open-heart mapping and radiofrequency ablation: a case of refractory ventricular tachycardia in Ebstein's anomaly

Resumen La anomalía de Ebstein es una enfermedad congénita, caracterizada por el desplazamiento y la adherencia de la válvula tricúspide. Las valvas septal y posterior se implantan en posiciones más inferiores, causando insuficiencia tricuspídea, esta condición de forma progresiva genera dilatación y deterioro de la función sistólica ventricular derecha. Comúnmente se asocia a otras entidades, principalmente, a la comunicación interauricular y las arritmias mediadas por vías accesorias. La muerte súbita ocurre en estadios avanzados, usualmente relacionados con episodios de taquicardia ventricular. Este reporte describe un caso de anomalía de Ebstein y tormenta arrítmica, que se sometió a ablación del sustrato arrítmico endo y epicárdico en la porción atrializada del ventrículo derecho, que presentó como complicación intraprocedimiento la perforación del ventrículo, el taponamiento cardiaco y la necesidad urgente de la reparación quirúrgica, realizándose en el intraoperatorio una segunda ablación por radiofrecuencia a cielo abierto con el objetivo de eliminar los potenciales tardíos y los fragmentados remanentes en el área de bajo voltaje de la escara. Veintidós semanas después de la ablación se implantó un cardiodesfibrilador subcutáneo para prevención secundaria de la muerte súbita; en el seguimiento a 14 meses no hubo terapias apropiadas del dispositivo.

Abstract Ebstein's anomaly is a congenital disease characterised by the displacement and adherence of the tricuspid valve. Septal and posterior valves are implanted in lower positions, thus causing tricuspid insufficiency. This condition gradually generates dilation and deterioration of the right ventricular systolic function. It is commonly associated to other conditions, mainly atrial septal defect and accessory pathway arrhythmias. Sudden death occurs in the advanced stages, usually related to episodes of ventricular tachycardia. This report describes a case of Ebstein's anomaly and arrhythmic storm who underwent ablation of the arrhythmic endo- and epicardial substract in the atrialized portion of the right ventricle, that developed as an intrasurgical complication the perforation of the ventricle, cardiac tamponade and urgent need of surgical repair. During the surgery a second open-heart radiofrequency ablation was conducted with the goal of eliminating potentially late and fragmented remnants in the low voltage area of the scars. Twenty two weeks after the ablation a subcutaneous cardioverterdefibrillator was implanted for secondary prevention of sudden death; in the follow-up after 14 months there were no appropriate therapies of the device.