Trasplante renal en receptor pediátrico: consideraciones y estrategias de evaluación preoperatoria / Renal transplantation in pediatric recipients: Considerations and preoperative assessment strategies

Introducción y objetivo El trasplante renal en la población pediátrica difiere del trasplante en adultos en muchos aspectos. Esta revisión se centrará en los aspectos exclusivos del receptor pediátrico. Material y métodos Se realizó una revisión narrativa de la escasa literatura existente sobre la evaluación preoperatoria del trasplante renal en receptor pediátrico con un enfoque educativo. La búsqueda bibliográfica permitió identificar publicaciones en inglés entre enero de 2000 y octubre de 2022. Los estudios publicados se identificaron mediante búsquedas en las siguientes bases de datos electrónicas: PubMed (Medline), WHO/UNAIDS, Google-Scholar, Semantic-Scholar y Research Gate. En aras de la eficacia y la fiabilidad, se utilizaron ensayos controlados aleatorizados, metaanálisis, revisiones sistemáticas de alta calidad y estudios grandes recientes bien diseñados, si estaban disponibles. Se realizaron búsquedas en internet para obtener información pertinente adicional (definiciones, políticas o directrices). Resultados El manejo de las anomalías urogenitales congénitas y la disfunción del tracto urinario inferior, junto con la evaluación urológica pediátrica preoperatoria óptima para el trasplante renal en niños, se ha abordado según la bibliografía disponible. Adicionalmente, se han mencionado consideraciones particulares relativas al trasplante preventivo y al trasplante de un riñón de tamaño adulto en un lactante o un niño pequeño. Conclusiones Los resultados del trasplante renal en niños han mejorado progresivamente en los últimos 15años. El trasplante de donante vivo emparentado ofrece los mejores resultados, y el trasplante preventivo puede ayudar a evitar la diálisis. Las consideraciones quirúrgicas y médicas, tanto en el tratamiento pretrasplante como en el postrasplante del receptor renal pediátrico, son extremadamente importantes para obtener resultados mejores a corto y a largo plazo (AU)

Introduction and objective Renal transplantation in the pediatric population differs from adults in many aspects. This review will focus on the unique issues of the pediatric recipient. Material and methods A narrative review on the scarce literature regarding preoperative evaluation before kidney transplantation of the paediatric recipient with an educational focus was conducted. The literature search allowed for identification of publications in English from January 2000 to October 2022. Published studies were identified by searching the following electronic databases: PubMed (Medline), WHO/UNAIDS, Google-Scholar, Semantic-Scholar and Research Gate. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information (definitions, policies or guidelines). Results Management of congenital urogenital anomalies and lower urinary tract dysfunction along with optimal pediatric urological preoperative assessment for renal transplantation in children is addressed in the light of the available literature. Furthermore, particular considerations including pre-emptive transplantation, transplantation of an adult-size kidney into an infant or small child is discussed. Conclusions Outcomes of renal transplantation in children have shown progressive improvement over the past 15years. Transplantation with living related donor gives the best results and pre-emptive transplantation provides with benefits of avoiding dialysis. Surgical and medical considerations in both the pre-transplant and post-transplant management of the pediatric kidney recipient are extremely crucial in order to achieve better short and long-term results (AU)

Medical Clearance for Common Dental Procedures.

Medical consultations before dental procedures present opportunities to integrate cross-disciplinary preventive care and improve patient health. This article presents recommendations related to patients with certain medical conditions who are planning to undergo common dental procedures, such as cleanings, extractions, restorations, endodontic procedures, abscess drainage, and mucosal biopsies. Specifically, prophylactic antibiotics are not recommended for preventing prosthetic joint infections or infectious endocarditis except in certain circumstances. Anticoagulation and antiplatelet therapies typically should not be suspended for common dental treatments. Elective dental care should be avoided for six weeks after myocardial infarction or bare-metal stent placement or for six months after drug-eluting stent placement. It is important that any history of antiresorptive or antiangiogenic therapies be communicated to the dentist. Ascites is not an indication for initiating prophylactic antibiotics before dental treatment, and acetaminophen is the analgesic of choice for patients with liver dysfunction or cirrhosis who abstain from alcohol. Nephrotoxic medications should be avoided in patients with chronic kidney disease, and the consultation should include the patient's glomerular filtration rate. Although patients undergoing chemotherapy may receive routine dental care, it should be postponed when possible in those currently undergoing head and neck radiation therapy. A detailed history of head and neck radiation therapy should be provided to the dentist. Multimodal, nonnarcotic analgesia is recommended for managing acute dental pain.

Causas implicadas en la suspensión de pacientes tributarios para cirugía electiva / Causes for the suspension of elective surgery for eligible patients

Introducción: La suspensión de la intervención quirúrgica es una situación que ocasiona inconvenientes, va en contra de optimizar las actividades, reducir costos, evitar la pérdida de materiales y desarrollar el trabajo con la más alta calidad. Objetivo: Describir las principales causas implicadas en la suspensión de los pacientes tributarios para cirugía electiva. Métodos: Se realizó un estudio descriptivo transversal en el Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba, en el periodo comprendido de septiembre 2017-septiembre 2018. De una población de 4 511 cirugías anunciadas, se tomó una muestra de 1 289 pacientes que fueron suspendidos en la consulta de anestesia y en el preoperatorio inmediato. Resultados: La especialidad de cirugía general presenta el indicador más alto (26,9 por ciento) del total de las suspensiones en consulta, así de las 798 suspensiones en la consulta 476 (59,6 por ciento) fueron debidas a los pacientes, 341 por causas médicas (42,7 por ciento), es decir, más de la mitad de las suspensiones obedecieron a las alteraciones clínicas. Se le atribuye al hospital 386 suspensiones para 29,9 por ciento del total de las suspensiones. Conclusiones: La incidencia de las suspensiones anestésico-quirúrgicas es elevada tanto en la consulta anestésica como en el preoperatorio inmediato. Estas, junto a las causas relacionadas con el paciente, constituyen la experiencia práctica médico-asistencial más relevantes y es de tener en consideración por el anestesiólogo actuante, fundamentalmente ante la presencia de enfermos aquejados de comorbilidades cardiovasculares(AU)

Introduction: Suspension of the surgical intervention is a situation that causes inconveniences, goes against optimizing activities, reducing costs, avoiding loss of materials and developing the work with the highest quality. Objective: To describe the main causes for the suspension of elective surgery for eligible patients. Methods: A cross-sectional and descriptive study was carried out at Dr. Juan Bruno Zayas Alfonso General Teaching Hospital in Santiago de Cuba, in the period from September 2017 to September 2018. From a population of 4511 announced surgeries, a sample of 1289 patients was taken, who were interrupted for surgery during the anesthesia consultation and in the immediate preoperative period. Results: The specialty of general surgery presents the highest indicator (26.9 percent) of the total number of suspensions during consultation; thus, of the 798 suspensions during consultation, 476 (59.6 percent) were due to patients, and 341 were due to medical causes (42.7 percent), that is, more than half of the suspensions owed to clinical alterations. The hospital was attributed 386 suspensions, accounting for 29.9 percent of the total. Conclusions: The incidence of anesthetic-surgical suspensions is high both during anesthesiology consultation and in the immediate preoperative period. These, together with the causes related to the patient, constitute the most relevant medical-assistance practical experience and must be taken into consideration by the acting anesthesiologist, mainly in the presence of patients suffering from cardiovascular comorbidities(AU)

Evaluación pretrasplante en otorrinolaringología / Pretransplant evaluation in otolaryngology

Resumen Los pacientes trasplantados presentan mayor vulnerabilidad a complicaciones infecciosas, no solo debido al uso de drogas inmunosupresoras, sino que también, a las enfermedades subyacentes que presentan y a la falla de órganos primarios. A pesar de que las infecciones otorrinolaringológicas no son frecuentes en estos pacientes, es importante establecer un adecuado estudio y tratamiento de ellas. A través del siguiente artículo se aportan directrices en el estudio pretrasplante desde un enfoque otorrinolaringológico, generando recomendaciones de acuerdo a la patología del paciente y el órgano a trasplantar. Si bien, las recomendaciones se realizan según evaluación rinosinusal, otológica y faringoamigdalina, una adecuada anamnesis y examen físico son los pilares de la evaluación pretrasplante en otorrinolaringología, reservándose el estudio con imágenes para aquellos pacientes con alteraciones sospechosas.

Abstract Transplanted patients have higher frequency of infectious complications, not only due to the use of immunosuppressive drugs, but also the underlying diseases that present and the failure of primary organs. Although ear, nose and throat (ENT) infections are not frequent in these patients, it is important to establish an adequate study and treatment of them. Through the following article, guidelines are provided in the pretransplant study from an ENT approach, generating recommendations according to the pathology of the patient and the organ to be transplanted. Although, the recommendations are made according to rhinosinusal, otological and pharyngotonsiline evaluation, adequate anamnesis and physical examination are the pillars of the pretransplant evaluation in otolaryngology, reserving the study with images for patients with suspicious alterations.

Neurometabolites and sport-related concussion: From acute injury to one year after medical clearance.

Sport-related concussion is associated with acute disturbances in neurometabolic function, with effects that may last weeks to months after injury. However, is presently unknown whether these disturbances resolve at medical clearance to return to play (RTP) or continue to evolve over longer time intervals. Moreover, little is known about how these neurometabolic changes correlate with other measures of brain physiology. In this study, these gaps were addressed by evaluating ninety-nine (99) university-level athletes, including 33 with sport-related concussion and 66 without recent injury, using multi-parameter magnetic resonance imaging (MRI), which included single-voxel spectroscopy (SVS), diffusion tensor imaging (DTI) and resting-state functional MRI (fMRI). The concussed athletes were scanned at the acute phase of injury (27/33 imaged), medical clearance to RTP (25/33 imaged), one month post-RTP (25/33 imaged) and one year post-RTP (13/33 imaged). We measured longitudinal changes in N-acetyl aspartate (NAA) and myo-inositol (Ins), over the course of concussion recovery. Concussed athletes showed no significant abnormalities or longitudinal change in NAA values, whereas Ins was significantly elevated at RTP and one month later. Interestingly, Ins response was attenuated by a prior history of concussion. Subsequent analyses identified significant associations between Ins values, DTI measures of white matter microstructure and fMRI measures of functional connectivity. These associations varied over the course of concussion recovery, suggesting that elevated Ins values at RTP and beyond reflect distinct changes in brain physiology, compared to acute injury. These findings provide novel information about neurometabolic recovery after a sport-related concussion, with evidence of disturbances that persist beyond medical clearance to RTP.

Apparent diffusion coefficients for predicting primary cholesteatoma risk of recurrence after surgical clearance.

PURPOSE: Beside the well-known accuracy of non-EPI DWI techniques and relative ADC maps in detecting cholesteatomatous tissue, ADC can also represent a useful tool for stratifying cholesteatoma risk of recurrence. Aim of this study is to test the role of ADC in determining risk of recurrence for primary middle ear cholesteatoma, proposing stratification based on pre-operative mean (mADC) and normalized (nADC) ADC values. METHODS: In this prospective study, 60 patients with primary unilateral middle ear cholesteatoma underwent a three-years-long follow-up to assess the presence of recurrent disease after macroscopically complete excisional surgery. Baseline MRI examination mADC and nADC values in the group with early evidence of recurrent cholesteatoma were compared to the group with no evidence of recurrence by using T statistics. RESULTS: ADC values on pre-operative MRI examination were lower in cholesteatomas with early evidence of recurrence, and statistical significance was slightly higher for nADC compared to mADC measurements. We also determined a cut-off between the two groups, proposing stratification in high-risk of recurrence cholesteatomas (mADC≤ 1000 or nADC< 1.3) and low-risk cholesteatomas (mADC>1000 or nADC≥1.3). CONCLUSIONS: ADC values resulted discriminating in identifying cholesteatomas with higher risk of early recurrence, both for mean and normalized ADC, with optimized tissue characterization and outcome prediction.

Valoración de la densidad de masa ósea en la indicación quirúrgica. Nueva herramienta / Assessment of bone mass density in the surgical indication. New tool

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Branching pattern of the portal vein in Indian population

Thorough knowledge of the variation of intrahepatic course of the portal vein is essential for pre-operative assessment of various hepatic surgeries like hepatectomy and live donor liver transplant. This study aims to determine the variation in the branching pattern of the portal vein in South Indian population. The branching pattern of the portal vein was studied by 3D reconstruction of 100 contrast-enhanced computed tomography images and in 15 formalin fixed livers using modified luminal casting technique. Radiologically, the normal portal vein anatomy was seen in 89%. The most common variation was trifurcation of portal vein (5%). A rare anomaly was noted in one case where the left portal vein gave a branch to segment VII. Using the modified luminal casting technique all the 15 specimens displayed Type I portal vein anatomy. The most common variation in the intrahepatic branching pattern ob-served was the right posterior segmental division supplying segment VIII. A rare left portal vein variation, in which it gave branches to segments V and VIII was noted. In this study, variations in the segmental supply of the portal vein were observed, which have not been studied in detail previously in the Indian population. Variations on the left portal vein are infrequent. A prior knowledge of such variations will help the interventional radiologists to reduce misinterpretations and subsequent misdiagnosis and guide the hepatobiliary

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Limitaciones diagnósticas de las determinaciones inmunohistoquímicas preoperatorias en el linfoma anaplásico de células grandes asociado a implante mamario (LACG-AIM) / Diagnostic limitations of preoperative immunohistochemical determinations in breast implant associated anaplastic large cell lymphoma (BIA-ALCL)

Presentamos un caso de linfoma anaplásico de células grandes asociado a implante mamario (LACG-AIM) que debutó como seroma periprotésico unilateral izquierdo de características acelulares en su estudio inicial. Esto limitó la determinación inmunohistoquímica de marcadores CD30 y cinasa del linfoma anaplásico (ALK) y su diagnóstico preoperatorio. La paciente fue intervenida quirúrgicamente realizándose retirada del implante y capsulectomía completa bilateral. El estudio anatomopatológico de la cápsula periprotésica izquierda mostró un linfoma anaplásico de células grandes. Dado que algunos casos de LACG-AIM pueden presentarse sin celularidad en el seroma periprotésico, limitando la efectividad de las determinaciones inmunohistoquímicas preoperatorias, en casos de alta sospecha clínica cabría plantearse un tratamiento quirúrgico de forma precoz que iniciase el tratamiento oncológico sin demora y aportase un diagnóstico definitivo

We present a case of breast implant associated anaplastic large cell lymphoma (BIA-ALCL) that debuted as a left unilateral periprosthetic seroma of acellular features in its initial study. This aspect limited the immunohistochemical determination of CD30 markers and anaplastic lymphoma kinase (ALK) and its preoperative diagnosis. Patient was operated performing implant removal and bilateral complete capsulectomy. The pathological study of the left periprosthetic capsule showed an anaplastic large cell lymphoma. Since some cases of BIA-ALCL can occur without cellularity in the periprosthetic seroma, limiting the effectiveness of preoperative immunohistochemical determinations, in cases of high clinical suspicion an early surgical treatment could be considered in order to begin the oncological treatment without delay and providing a definitive diagnosis

Estimulación preoperatoria del asa eferente de la ileostomía con ácidos grasos de cadena corta / Stimulation the efferent limb before loop ileostomy closure with short chain fatty acids

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Intervencionismo mamario guiado por imagen: ¿dónde estamos? / Imaging-guided interventional breast techniques: where are we now?

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Supermini nefrolitotomía percutánea para cálculos renales menores de 25 mm en pacientes pediátricos: ¿podría ser una alternativa a la litotricia por ondas de choque? / Super-mini percutaneous nephrolithotomy for renal stone less than 25 mm in pediatric patients: Could it be an alternative to shockwave lithotripsy?

Objetivo: Evaluar la eficacia de 2 técnicas diferentes, la litotricia por ondas de choque (LOC) frente a la supermini nefrolitotomía percutánea (SMP), en términos de éxito y tasas de complicaciones en cálculos renales pediátricos de tamaño < 25 mm. Pacientes y métodos: Se incluyeron un total de 219 niños (edades comprendidas entre uno y 17 años) sometidos a 2 modalidades de tratamiento diferentes (LOC vs. SMP) para cálculos renales < 25 mm. Dependiendo del tipo de procedimiento aplicado, los niños se dividieron en 2 grupos diferentes: grupo 1 (n = 108), formado por niños tratados con LOC, y grupo 2 (n = 111), integrado por niños tratados con SMP. Todos los parámetros relacionados con el tratamiento (tasas libres de cálculos, número de sesiones, duración del tratamiento, hospitalización, presencia de fragmentos residuales, complicaciones así como la necesidad de intervenciones adicionales) se observaron y evaluaron entre 2 grupos de forma comparativa. Resultados: La evaluación de nuestros datos ha demostrado claramente que el porcentaje de fragmentos residuales fue significativamente mayor en los casos sometidos a procedimiento de LOC en comparación con SMP. Aunque LOC requirió varias sesiones bajo anestesia general en un cierto porcentaje de los casos (54,6%), SMP tuvo éxito en una sesión en todos los casos. Por último, pero no por ello menos importante, además de las tasas de complicaciones menores similares observadas en ambos grupos de casos, no se observó ninguna complicación grave y ningún caso requirió transfusión de sangre después de estos 2 procedimientos, sin tasas significativas de descenso en los niveles de hemoglobina. Conclusiones: Aunque la LOC sigue siendo la modalidad de tratamiento preferida para la mayoría de los cálculos renales en niños por su naturaleza segura y no invasiva, la modalidad de SMP puede aplicarse como una alternativa valiosa en esta población específica de pacientes por sus excelentes tasas de ausencia de cálculos obtenidas en una sesión única y tasas de complicaciones aceptables en el manejo invasivo mínimo de cálculos < 25 mm

Aim: To evaluate the efficacy of 2 different techniques: shock wave lithotripsy (SWL) vs. super-mini percutaneous nephrolithotomy (SMP), in terms of success as well as complication rates in pediatric renal stones sizing < 25 mm. Patients and methods: A total of 219 children (aging between 1-17 years) undergoing 2 different treatment modalities (SWL vs. SMP) for kidney stones < 25 mm were included. Depending on the type of the procedure applied, children were divided into 2 different groups: group 1 (n = 108), children treated with SWL, and group 2 (n = 111), children treated with SMP. All treatment related parameters (stone free rates, number of sessions, treatment duration, hospitalization, presence of the residual fragments, complications as well as the need for additional interventions) were noted and evaluated between 2 groups in a comparative manner. Results: Evaluation of our data have clearly demonstrated that the percentage of residual fragments after SWL was significantly higher when compared with SMP. Although SWL required several sessions under general anesthesia in a certain per cent of the cases (54.6%), SMP was successful in one session in all of the cases. Last but not least, in addition to the similar minor complication rates observed in both group of cases, no major complication observed in any case and no case in both groups again required blood transfusion after these 2 procedures with no significant drop rates in hemoglobin levels. Conclusions:Although SWL is still the preferred treatment modality for the majority of kidney stones in children due to its safe and non-invasive nature, SMP modality may be applied as a valuable alternative in this specific patient population for its excellent stone free rates obtained in a single session and acceptable complication rates in the minimal invasive management of stones < 25 mm

Indicaciones y resultados de las recesiones parciales de los rectos verticales / Indications and outcome of vertical rectus partial recessions

OBJETIVO: Valorar indicaciones y resultados conseguidos con las recesiones parciales de los rectos verticales en pacientes con diplopía y estrabismo vertical de pequeño ángulo (≤10 dp). MATERIAL Y MÉTODO: Estudio retrospectivo de 9 pacientes tratados con recesión parcial temporal o nasal de recto superior (RS) o inferior (RI), en 2017. Se consideró buen resultado la eliminación de la diplopía al final del seguimiento en posición primaria de la mirada e infraversión. RESULTADOS: Se incluyeron 9 casos. Edad media: 66,3 años (55,5% mujeres), diagnosticados de paresia del IV nervio (3), paresia incompleta del III (2), sagging eye (2), estrabismo asociado a la edad (1) y estrabismo restrictivo poscirugía de retina (1). La desviación vertical media preoperatoria en posición primaria de la mirada fue 8,2 dp y la postoperatoria 0,8 dp (diferencia significativa entre medias, p = 0,007). En 4 se operó el RS (3 el extremo temporal y uno el nasal). En 5 se operó el RI (4 el extremo temporal y uno el nasal). La dosis media de recesión parcial fue de 3,77mm. En un 55,5% se eliminó la diplopía y un 33,3% quedó con diplopía intermitente bien tolerada. Se obtuvo un buen resultado en el 88,8% con un periodo de seguimiento de 7,1 meses, sin hipercorrecciones. CONCLUSIONES: La recesión parcial de RS o RI consiguió buenos resultados en la mayoría de los casos en los estrabismos verticales de pequeño ángulo con diplopía. Aunque no provocó torsión postoperatoria, ni modificación de la preoperatoria, se debería realizar un estudio previo

OBJECTIVE: To assess the indications and results obtained with partial vertical recti recessions in patients with diplopia and small-angle vertical strabismus ( ≤ 10 dp). MATERIAL AND METHODS: A retrospective study was conducted on 9 patients that were operated on with partial temporal or nasal recession of the superior (SR) or inferior rectus (IR), during 2017. A good outcome was considered when diplopia was resolved in primary position and infraversion, at the end of follow-up. RESULTS: A total of 9 cases were included, with a mean age 66.3 years (55.5 % women), diagnosed with sixth nerve palsy (3), incomplete third nerve palsy (2), sagging eye (2), age related strabismus (1), and restrictive strabismus post-retinal surgery (1). Mean preoperative vertical deviation was 8.2 dp in primary position and the post-operative vertical deviation was 0.8 dp (mean difference was statistically significant, P = .007). In 4 cases, the SR was operated on (temporal pole in 3 and nasal in 1). The IR was operated on in 5 patients (temporal pole in 4 and nasal in 1). Mean recession was 3.77 mm. In 55.5% of case diplopia was eliminated, and in a 33.3% a well-tolerated, intermittent diplopia persisted. A good outcome was obtained in 88.8% of the cases at the end of follow-up (mean: 7. 1 months), with no over-corrections. CONCLUSIONS: Partial SR or IR recessions obtained good results in most of the cases with small angle vertical strabismus and diplopia. Although post-operative torsion or modification of the pre-operative torsion was not observed, a prior study should be made of torsion

Cardiorespiratory Fitness (Peak Oxygen Uptake): Safe and Effective Measure for Cardiovascular Screening Before Kidney Transplant.

BACKGROUND: Significant heterogeneity exists in practice patterns and algorithms used for cardiac screening before kidney transplant. Cardiorespiratory fitness, as measured by peak oxygen uptake (VO2peak), is an established validated predictor of future cardiovascular morbidity and mortality in both healthy and diseased populations. The literature supports its use among asymptomatic patients in abrogating the need for further cardiac testing. METHODS AND RESULTS: We outlined a pre-renal transplant screening algorithm to incorporate VO2peak testing among a population of asymptomatic high-risk patients (with diabetes mellitus and/or >50 years of age). Only those with VO2peak <17 mL/kg per minute (equivalent to <5 metabolic equivalents) underwent further noninvasive cardiac screening tests. We conducted a retrospective study of the a priori dichotomization of the VO2peak <17 versus ≥17 mL/kg per minute to determine negative and positive predictive value of future cardiac events and all-cause mortality. We report a high (>90%) negative predictive value, indicating that VO2peak ≥17 mL/kg per minute is effective to rule out future cardiac events and all-cause mortality. However, lower VO2peak had low positive predictive value and should not be used as a reliable metric to predict future cardiac events and/or mortality. In addition, a simple mathematical calculation documented a cost savings of ≈$272 600 in the cardiac screening among our study cohort of 637 patients undergoing evaluation for kidney and/or pancreas transplant. CONCLUSIONS: We conclude that incorporating an objective measure of cardiorespiratory fitness with VO2peak is safe and allows for a cost savings in the cardiovascular screening protocol among higher-risk phenotype (with diabetes mellitus and >50 years of age) being evaluated for kidney transplant.

Protocolo fast track ("rápida implementación") disminuye el tiempo de estadía hospitalaria, y el tiempo de inicio de la alimentación por vía bucal, en el paciente sometido a cirugía colorectal electiva / Fast track decreases the hospital stay, the time of begining of oral feeding in the patient undergoing, elective colorectal surgery

Introducción: el protocolo "fast track" (rápida implementación) ha revolucionado a la cirugía colorectal. Algunos cirujanos aún efectúan la preparación preoperatoria para los pacientes que serán sometidos a cirugía colorectal. El propósito de este escrito es el de comparar los resultados entre el protocolo "fast track "y la cirugía convencional en la preparación de los pacientes sometidos a cirugía colorectal por afecciones benignas. Métodos: desde enero 2012 hasta agosto 2015, los pacientes operados por cirugía colorectal debido a afecciones benignas se incluyeron en el estudio. El grupo de comparación consistió en pacientes con cirugía colónica mayor con cuidado convencional y el "fast track". Resultados: hubo 86 pacientes en total, 43 para cada grupo. Ambos grupos eran similares. Los pacientes con cuidado convencional tuvieron una estadía hospitalaria mayor y de inicio de la alimentación por boca comparada con los pacientes del protocolo "fast track", p = 0.000 para ambas diferencias. Las complicaciones postoperatorias y las reoperaciones fueron similares en ambos grupos, sin ninguna diferencia significativa, p>0.05. No hubo fallecimientos en los dos grupos. Conclusión: el protocolo "fast track" es efectivo en la cirugía colorectal electiva porque disminuye el tiempo del comienzo de la alimentación por boca y el de la estadía hospitalaria en los pacientes, sin comprometer la seguridad.

Introduction: The Fast-track protocol has revolutionized colorectal surgery. Some surgeons still perform preoperative preparation for patients undergoing colorectal surgery. The aim of this paper is to compare the results between the Fast-track protocol and conventional surgery in preparing patients undergoing colorectal surgery for benign disease. Methods: From January 2012 to August 2015, the patients operated for colorectal surgery for benign diseases were included. The comparison group consisted of patients with major colon surgery with conventional care and Fast-track. Results: There were 86 patients in total, 43 in each group. Both groups were similar. Patients with conventional care had higher hospital stay and start of oral feeding compared to patients in Fasttrack protocol,p = 0.000 for both differences. Postoperative complications and reoperations were similar in both groups, with no significant difference, p> 0.05. There were no deaths in both groups. Conclusion: Fast-track protocol is effective in elective colorectal surgery because it decreases the start time of the oral feeding and the hospital stay of patients without compromising safety.

Correlación de hallazgos preoperatorios en la tomografía axial computarizada con la presencia de vía aérea difícil en pacientes intervenidos mediante cirugía otorrinolaringológica de cabeza y cuello / Correlation of preoperative findings in computed axial tomography with the presence of difficult airway in patients undergoing head and neck otorhinolaryngological surgery

Objetivos: Establecer una correlación entre 4 mediciones realizadas en la tomografía axial computarizada preoperatoria y la presencia de vía aérea difícil, y con la predicción clínica de la misma, en pacientes intervenidos mediante cirugía otorrinolaringológica. Material y métodos: Se realizó un estudio observacional, retrospectivo, usando como fuente de información las historias clínicas de 104 pacientes intervenidos bajo anestesia general e intubación endotraqueal por enfermedad oncológica durante un periodo de 36 meses. Sobre la base de los hallazgos obtenidos en las pruebas de imagen preoperatorias se realiza un análisis de regresión logística multivariante, donde las variables dependientes son grados extremos de visualización de la glotis (Cormack III-IV) o la presencia de predictores de intubación dificultosa (Mallampati III-IV). Se introdujeron en dicho modelo un total de 4 factores tomográficos y clínicos de vía aérea difícil. Resultados: En el grupo Cormack III-IV, en el modelo multivariante los resultados no fueron estadísticamente significativos cuando se comparaban con los predictores tomográficos (p>0,05; IC 95% distancia de la epiglotis a la pared faríngea posterior 0,030-2,31; distancia de la base de la lengua a la pared faríngea posterior 0,018-1,37). En el grupo Mallampati III-IV, en el modelo multivariante únicamente la distancia de las cuerdas vocales a la pared faríngea posterior muestra resultados clínicamente significativos (p<0,05; IC 95% 0,104-8,53). Conclusiones: En el abordaje de la vía aérea actualmente nos podemos apoyar en los predictores correspondientes al examen físico para adelantarnos a situaciones que pongan en riesgo la oxigenación y la ventilación de nuestros pacientes. Aunque aún los datos son insuficientes para recomendar las pruebas de imagen en este ámbito, parece que en un futuro pueden sumarse al examen físico para aumentar el rendimiento diagnóstico

Objectives: To establish a correlation between 4 measurements made on preoperative computed axial tomography and the presence of difficult airway, as well as its clinical prediction in patients undergoing otorhinolaryngological surgery. Material and methods: A retrospective, observational study was carried out using the information gathered from the clinical notes of 104 patients undergoing general anaesthesia and endotracheal intubation for oncological otorhinolaryngological surgery over a period of 36 months. Based on the findings in the preoperative imaging tests, a multivariate logistic regression analysis was performed, where the dependent variable was the presence of extreme grades of visualization of the glottis visualisation (Cormack III-IV) or the presence of predictors of difficult intubation (Mallampati III-IV). This resulted in a total of 4 tomographic and clinical factors of difficult airway being introduced in this model. Results: In the Cormack III-IV group, the results were not statistically significant in the multivariate model when compared to the tomography predictors, distance from epiglottis to posterior pharyngeal wall (95% CI; 0.030 - 2.31, P<.05), and the distance from the base of the tongue to the posterior pharyngeal wall (95% CI; 0.018-1.37, P<.05). In the Mallampati III-IV group, in the multivariate model only the distance from the vocal cords to the posterior pharyngeal wall showed clinically significant results (95% CI; 0.104 - 8.53, P<.05). Conclusions: In the approach to the airway, reliance on predictors is based on physical examination to anticipate situations that put oxygenation and ventilation of the patients at risk. There are still insufficient data to recommend imaging tests in this area, however it seems that in the future they may be added to the diagnostic performance of physical examination as predictors of difficult airway

Factores prequirúrgicos asociados con dificultades técnicas de la colecistectomía laparoscópica en la colecistitis aguda / Preoperative factors associated with technical difficulties of laparoscopic cholecystectomy in acute cholecystitis

Objetivo. Identificar en pacientes con colecistitis aguda (CoA) los factores preoperatorios asociados con el tiempo quirúrgico y con la conversión de colecistectomía laparoscópica (CL) a cirugía abierta. Método. Se realizó un estudio transversal que incluyó 99 pacientes mayores de 17 años con diagnóstico definitivo de CoA tratados con CL. Se registraron variables prequirúrgicas, como datos clínicos, valores de laboratorio y hallazgos ecográficos como el grosor de la pared de la vesícula, el volumen vesicular y la presencia de: líquido perivesicular, colelitiasis múltiple o barro biliar. Se consideraron medidas indirectas de dificultad técnica de la CL, el tiempo quirúrgico empleado y la necesidad de conversión a cirugía abierta. Se utilizaron las pruebas de ji-cuadrado o U de Mann-Whitney para establecer la relación entre las variables prequirúrgicas y aquellas indicativas de dificultad técnica. Se construyeron curvas ROC (Receiver Operating Characteristic) de las variables con asociación estadística significativa (p ≤0,05 e intervalo de confianza del 95% [IC95%]) para determinar los puntos de corte de mejor rendimiento para predecir la conversión de CL a cirugía abierta. Resultados. Un grosor de la pared vesicular ≥6mm detectado por ultrasonido tiene una odds ratio de 11,71 (IC95%: 1,38-99; p = 0,008), con una sensibilidad del 87,5% y una especificidad del 62,6% para predecir la conversión a cirugía abierta. No hubo relación entre el tiempo quirúrgico y las variables prequirúrgicas evaluadas. Conclusión. El grosor de la pared de la vesícula biliar detectado por ultrasonido se asocia con la necesidad de conversión de la CL a cirugía abierta en pacientes con CoA (AU)

Objective. To identify preoperative factors associated with surgical time and conversion of the laparoscopic cholecystectomy (LC) to open surgery in subjects with acute cholecystitis (AC). Method. We developed a cross-sectional study that included 99 subjects older than 17 years with definitive diagnosis of AC who had undergone to LC. Preoperative variables such as clinical data, laboratory markers and ultrasound findings as wall thickness, the size of the major calculus and the presence of: perivesicular fluid, multiple cholelithiasis, biliary mud or microlithiasis were registered. We consider indirect measures of technical difficulties of LC the total surgical time and the need for conversion to open surgery. We used the square chi and Mann-Whitney U test to stablish the correlation between preoperative variables and the technical difficulties of LC. We build ROC curves of the variables with significant statistical association (p ≤0.05 and 95% confidence interval [95%CI]) to determine the cut-off points of better sensitivity and specificity to predict conversion of LC to open surgery. Results. A gallbladder wall thickness ≥6mm detected by ultrasound has a sensitivity of 87.5% and a specificity of 62.6% with OR 11.71 (95%CI: 1.38-99; p = 0.008) for predict conversion to open surgery. There was no relationship between surgical time and the preoperative evaluated variables. Conclusion. The gallbladder wall thickness detected by the ultrasound is associated with the need of conversion of LC to open surgery in subjects with AC, furthermore this finding could warn the surgeon on the complexity with a particular patient (AU)

Protocolized Laboratory Screening for the Medical Clearance of Psychiatric Patients in the Emergency Department: A Systematic Review.

OBJECTIVE: Emergency department (ED) patients with psychiatric chief complaints undergo medical screening to rule out underlying or comorbid medical illnesses prior to transfer to a psychiatric facility. This systematic review attempts to determine the clinical utility of protocolized laboratory screening for the streamlined medical clearance of ED psychiatric patients by determining the clinical significance of individual laboratory results. METHODS: We searched PubMed, Embase, and Scopus using the search terms "emergency department, psychiatry, diagnostic tests, laboratories, studies, testing, screening, and clearance" up to June 2017 for studies on adult psychiatric patients. This systematic review follows the recommendations of Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. The quality of each study was rated according to the Newcastle-Ottawa quality assessment scale. RESULTS: Four independent reviewers identified 2,847 publications. We extracted data from three studies (n = 629 patients). Included studies defined an abnormal test result as any laboratory result that falls out of the normal range. A laboratory test result was deemed as "clinically significant" only when patient disposition or treatment plan was changed because of that test result. Across the three studies the prevalence of clinically significant results were low (0.0%-0.4%). CONCLUSIONS: The prevalence of clinically significant laboratory test results were low, suggesting that according to the available literature, routine laboratory testing does not significantly change patient disposition. Due to the paucity of available research on this subject, we could not determine the clinical utility of protocolized laboratory screening tests for medical clearance of psychiatric patients in the ED. Future research on the utility of routine laboratory testing is important in a move toward shared decision making and patient-centered health care.