Control de daños ortopédicos en pacientes politraumatizados pediátricos. Hospital Pediátrico "Eliseo Noel Caamaño" / Control of orthopedic damages in pediatric politraumatized patients. Pediatric Hospital "Eliseo Noel Caamaño"

RESUMEN Introducción: el control de daños en Ortopedia es aplazar la reparación definitiva de lesiones traumáticas, con el objetivo de la recuperación fisiológica deteriorada por lesiones y/o complicaciones que pueden poner en peligro la vida, realizando entonces procedimientos quirúrgicos sencillos, como una estabilización quirúrgica externa de las fracturas. Objetivo: determinar el comportamiento del control de daños ortopédicos en politraumatizados pediátricos. Materiales y método: se realizó un estudio observacional, descriptivo, prospectivo, de corte transversal, de enero del 2015 a diciembre del 2018. El universo estuvo constituido por 22 pacientes menores de 19 años de edad, politraumatizados en el período; la muestra por 15 pacientes, a los que se les aplicó control de daños ortopédicos, según criterios de selección. Resultados: se aplicó control de daños ortopédicos a 15 infantes. El más afectado fue el sexo masculino con el 73,3 %. Prevalecieron los traumatismos de los miembros inferiores con el 58,3 % y las fracturas cerradas con un 53,8 %. La osteomielitis crónica fue la complicación que predominó, en el 20 % de la muestra. En el 73,3 % de los casos se evaluó como satisfactoria la aplicación del control de daños ortopédicos en los politraumatizados. Conclusiones: a la totalidad de los traumatizados se le aplicó control de daños ortopédicos. Predominó el sexo masculino y el grupo de edad de 9 -14 años. Los miembros inferiores aportan la mayor cantidad con el fémur y la tibia. El control de daños ortopédicos se evaluó satisfactoriamente en la mayoría de los pacientes estudiados (AU).

ABSTRAC Introduction: the control of damages in Orthopedics is to postpone the definitive repair of traumatic lesions, with the objective of the physiologic recovery deteriorated by lesions and/or complications that can put in danger the life, carrying out simple surgical procedures, like an external surgical stabilization of the fractures at that time. . Objective: to determine the behavior of the orthopedic damage control in pediatric politraumatized patients. Material and method: a cross-sectional, prospective, descriptive, observational study was carried out from January 2015 to December 2018. The universe was formed by 22 patients younger than 19 years politraumatized in the period and the sample formed 15 patients; they underwent orthopedic damage control, according to the selection criteria. Results: the orthopedic damage control, was applied to 15 children. Male sex was the most affected one. Trauma in the lower limbs with 58.3 % and closed fractures with 53.8 prevailed. The predominating complication was chronic poliomyelitis in 20 % of the sample. The orthopedic damage control in politraumatized patients was assessed as successful in 73.3 % of the cases. Conclusions: the orthopedic damage control was applied to the total of traumatized patients. The male sex and the 9-14 years-old age group predominated. Lower limbs contributed with the biggest quantity of trauma, in femur and tibia. The orthopedic damage control was assessed as successful in most of studied patients (AU).

Cirugía videolaparoscópica pediátrica en la provincia de Matanzas / Pediatric videolaparoscopic surgery in the province of Matanzas

RESUMEN Las indicaciones de la cirugía de mínimo acceso en el niño han aumentado. Lo que ha traído consigo que aumente el espectro de las entidades resueltas por esta novedosa técnica. En marzo de 2017, se comenzaron a aplicar de manera sistemática estos procedimientos en el Hospital Docente Pediátrico "Eliseo Noel Caamaño", de Matanzas. Con este artículo se pretende describir los resultados de la cirugía mínimamente invasiva en Pediatría, durante su primer año en la mencionada provincia. Se realizó un estudio descriptivo prospectivo para presentar los resultados durante el primer año. Se operaron 77 pacientes. Predominó el sexo femenino, y el grupo etario de 15-19 años. Las intervenciones más realizadas fueron la apendicectomía, 50,6 % y la colecistectomía, 28 %. Se registró un 4 % de conversiones y un 4 % de complicaciones (AU).

ABSTRACT The indications of minimal access surgery in children have increased and the spectrum of the entities resolved with this new technique has enhanced. In March 2017, these procedures began to be used systematically at the Teaching Pediatric Hospital "Eliseo Noel Caamaño", of Matanzas. In this article, the authors pretend to describe the results of the minimally invasive surgery in Pediatrics during the first year in the before-mentioned province. A descriptive prospective study was conducted to present the achieved results. 77 patients underwent surgery. Female sex predominated and the age group of 15-19 years. The most common surgeries were appendectomy (50.6 %) and cholecistectomy (28 %). A 4 % of conversions and 4 % complications were recorded (AU).

Minor surgery in general practice in Ireland- a report of workload and safety.

BACKGROUND: The provision of minor surgical services is an established part of the task profile of general practitioners (GPs) in many countries in Europe and elsewhere. This study aimed to collect data on the clinical process and outcomes for specified minor surgical procedures undertaken in Irish general practice by GPs experienced in minor surgery in order to document the scope and safety of minor surgery being undertaken. METHODS: Over a six-month period, 24 GPs in 20 practices recorded data on a pre-determined list of procedures undertaken in adults (aged 18 and older); procedures for ingrown toenails were also recorded for those aged 12-18 years. Clinical data were rendered fully anonymous by the participating GPs, entered onto the Excel database template and returned to the project team monthly. RESULTS: On average, each practice undertook 212 procedures in a six-month period. The four most frequent procedures include two relatively non-invasive procedures (cryosurgical ablation of skin lesions and aspiration and/or injection of joints) and two more invasive procedures (full thickness excision of skin lesion and shave, punch or incisional biopsy). Overall, 83.8% of relevant specimens were submitted for histology. Combining benign and malignant cases, there was an overall 87% clinical and histological concordance; 85% of malignancies were suspected clinically. A complication was recorded in 0.9% after 1 month. CONCLUSIONS: Irish GPs with experience in minor surgery can provide a range of surgical services in the community safely.

Turoctocog alfa pegol provides effective management for major and minor surgical procedures in patients across all age groups with severe haemophilia A: Full data set from the pathfinder 3 and 5 phase III trials.

INTRODUCTION: Turoctocog alfa pegol is a glycoPEGylated recombinant factor VIII (FVIII) with an extended half-life developed for prophylaxis, treatment of bleeds and perioperative management in patients with haemophilia A. AIM: Evaluate the efficacy and safety of turoctocog alfa pegol treatment for major and minor surgeries in the pathfinder 3 and 5 phase III trials. METHODS: Adults/adolescents aged ≥12 years with severe haemophilia A (FVIII <1%) received perioperative turoctocog alfa pegol treatment planned to achieve FVIII activity levels >80% during major surgery (pathfinder 3). The primary end point was haemostatic efficacy during surgery; secondary end points were blood loss, haemostatic effect postsurgery, consumption, transfusions, safety and health economics. Children (0-11 years) undergoing minor surgeries received 20-75 IU/kg turoctocog alfa pegol at Investigator's discretion (pathfinder 5). RESULTS: pathfinder 3 included 35 patients undergoing 49 major surgeries. Haemostasis was successful in 47/49 (95.9%) surgeries; two had moderate haemostatic responses. Median (mean) blood loss during major surgery was 75 (322.6) mL. Four bleeds were reported postsurgery; three were successfully treated with turoctocog alfa pegol (one was not evaluated). On the day of surgery, overall mean (median) dose was 75.5 (74.5) IU/kg and mean (median) number of doses was 1.7 (2.0). Five procedures required 11 transfusions on the day of surgery or days 1-6. No safety concerns or inhibitors were identified. Forty-five minor surgeries in 23 children were performed without complications. CONCLUSION: Turoctocog alfa pegol was effective for perioperative haemostatic management of major and minor surgeries in patients across age groups with severe haemophilia A.

Onicectomía parcial con matricectomía por abrasión mecánica vs. fenolización en el tratamiento de la uña incarnata / Partial onicectomy with matricectomy by mechanical abrasion versus phenolization in the treatment of the incarnate nail

INTRODUCCIÓN: La onicocriptosis o uña incarnata es una patología altamente prevalente en la población pediátrica. El abordaje quirúrgico es el tratamiento definitivo en estadios avanzados, siendo la onicectomía con matricectomía química y la mecánica las técnicas más utilizadas. El objetivo de este estudio es comparar la tasa de recidivas locales de ambas técnicas quirúrgicas. Población y métodos: Se realiza un estudio ambispectivo entre 2010 y 2017 en pacientes con diagnóstico de onicocriptosis que fueron intervenidos quirúrgicamente. Grupo A: onicectomía parcial con matricectomía química con fenol. Grupo B: matricectomía por abrasión mecánica. Se recogen variables demográficas, quirúrgicas, postoperatorias inmediatas y complicaciones a largo plazo. El análisis estadístico se realizó con el programa estadístico SPSS Statics versión 22, considerándose significación estadística un valor de p <0,05. RESULTADOS: Un total de 87 pacientes se incluyeron en el estudio. En el grupo A (12 pacientes), 2 casos (16,7%) presentaron celulitis locales postoperatorias, 4 casos (33%) presentaron recidivas ipsilaterales y uno de ellos, una segunda recidiva. En el grupo B (75 pacientes) no se describen complicaciones postoperatorias inmediatas y 7 pacientes (9%) padecieron recidivas ipsilaterales, de los cuales 3 tuvieron una segunda recidiva. Ambos grupos presentaron diferencias estadísticamente significativas en el índice de recidivas (p= 0,04). CONCLUSIÓN: En nuestra experiencia la onicectomía parcial con matricectomía mecánica por abrasión presenta una baja tasa de complicaciones y de recidivas locales respecto a la fenolización en población pediátrica. Es necesaria la realización de nuevos estudios prospectivos aleatorizados para confirmar esta diferencia

INTRODUCTION: The onychocryptosis in the pediatric population is a highly prevalent pathology. The surgical approach is the treatment of choice in advanced stages with two different techniques, onicectomy with matricectomy by chemical or mechanical abrasion. The purpose of this study is to compare the local recurrences in these two different approaches. MATERIAL AND METHODS: This is an ambispective cohort study between 2010 and 2017 in two groups. Group A: partial onicectomy with matricectomy by chemical abrasion with phenol. Group B: matricectomy by mechanical abrasion. Demographic, surgical, immediate postoperative variables and long-term complications are compared. The statics was performed with the SPSS Static 22 software. P value < 0.05 is consider statistically significant. RESULTS: The study included 87 patients. In group A (12 patients), or chemical matricectomy two cases (16.7%) presented local cellulitis, 4 cases (33%) presented a local recurrence and one of them suffered from a second recurrence. Group B (75 patients) or mechanical matricectomy, did not show immediate postoperative complications and 7 patients (9%) suffered from an ipsilateral recurrence. A second recurrence appeared in three of them. The differences in the recurrence rate between group A and B were statistically significant (p = 0.04). CONCLUSION: In our experience partial onicectomy with matricectomy by mechanical abrasion in onychocryptosis has a low rate of complications and local recurrences compared to phenolization in pediatric patients. It is necessary to perform new randomized and prospective studies to confirm this difference

Cancer survivorship and its association with perioperative opioid use for minor non-cancer surgery.

PURPOSE: Reducing high-risk prescription opioid use after surgery has become a key strategy in mitigating the opioid crisis. Yet, despite their vulnerabilities, we know little about how cancer survivors use opioids for non-cancer perioperative pain compared to those with no history of cancer. The purpose was to examine the association of cancer survivorship with the likelihood of receiving perioperative opioid therapy for non-cancer minor surgery. METHODS: Using 2007-2014 SEER-Medicare data for breast, colorectal, prostate, and non-cancer populations, we conducted retrospective cohort study of opioid-naïve Medicare beneficiaries who underwent one of six common minor non-cancer surgeries. Modified Poisson regression estimated the relative risk of receiving a perioperative opioid prescription associated with cancer survivorship compared to no history of cancer. Stabilized inverse probability of treatment weights were used to balance measurable covariates between cohorts. RESULTS: We included 1486 opioid-naïve older adult cancer survivors and 3682 opioid-naïve non-cancer controls. Cancer survivorship was associated with a 5% lower risk of receiving a perioperative opioid prescription (95% confidence interval: 0.89, 1.00; p = 0.06) compared to no history of cancer. Cancer survivorship was not associated with the extent of perioperative opioid exposure. CONCLUSION: Cancer survivors were slightly less likely to receive opioid therapy for non-cancer perioperative pain than those without a history of cancer. It is unclear if this reflects a reduced risk of opioid-related harms for cancer survivors or avoidance of appropriate perioperative pain therapy. Further examination of cancer survivors' experiences with and attitudes about opioids may inform improvements to non-cancer pain management for cancer survivors.

Colangiopancreatografía retrógrada endoscópica: estudio de 8 años en pacientes geriátricos / Endoscopic retrograde cholangiopancreatography: eight-years study in geriatric patients

RESUMEN Introducción: en febrero de 2010 se introdujo la técnica colangiopancreatografía retrógrada endoscópica en la provincia de Matanzas, dando cobertura a los casos con esta indicación, y atendiendo a un importante grupo de pacientes en edad geriátrica. Objetivo: describir los resultados después de ocho años de trabajo. Material y Métodos: se realizó un estudio descriptivo, transversal, en pacientes mayores de 65 años, quienes se realizaron el estudio en el servicio de Cirugía de Mínimo Acceso del Hospital Universitario Clínico Quirúrgico "Comandante Faustino Pérez Hernández", en el período de enero 2010 a enero de 2018. La población de estudio quedó conformada por 698 pacientes, que cumplieron con los criterios de inclusión con 713 informes de colangiopancreatografía retrógrada endoscópica. Resultados: predominó el sexo femenino y la canulación del conducto deseado, se utilizó como técnica complementaria el pre corte, en cuanto a los diagnósticos realizados la litiasis coledociana resultó ser el más frecuente, y la colangiopancreatografía retrógrada endoscópica con acción terapéutica fue la más realizada con la pancreatitis como complicación más encontrada, fallecieron en el período estudiado cuatro pacientes como consecuencia de colangitis aguda grave. Conclusiones: los resultados obtenidos son similares a los realizados, en poblaciones sometidas al proceder en general, independientemente a la edad de los pacientes, resultando ser un proceder seguro en edades geriátricas, siendo la colangiopancreatografía retrógrada endoscópica en este medio un arma con gran utilidad diagnóstica y terapéutica con una frecuencia de morbi-mortalidad que lo garantiza (AU).

SUMMARY Introduction: the endoscopic retrograde cholangiopancreatography technique was introduced in the province of Matanzas in February 2010, for the treatment of the cases with this indication and attending an important group of patients in geriatric age. Objective: to describe the results of this technique after eight years of use. Method: a descriptive, cross-sectional study was carried out in patients aged more than 65 years, who were attended in the service of Minimal Access Surgery of the Clinical Surgical University Hospital "Comandante Faustino Pérez Hernández", in the period January 2010-January 2018. The studied population was 698 patients who fulfilled the inclusion criteria for 713 reports of endoscopic retrograde cholangiopancreatography. Results: female sex and cannulation of the desired duct predominated; pre-cut was used as complementary technique. Choledocholithiasis was the most frequent diagnosis; the most used therapeutic action was endoscopic retrograde cholangiopancreatography, and pancreatitis was the most commonly found complication. In the studied period, four patients died as a consequence of severe acute cholangitis. Conclusions: the obtained results are similar to those obtained in populations undergoing the procedure in general, patients´ age-independent. It is a safe procedure in geriatric ages. The endoscopic retrograde cholangiopancreatography is a tool of a great diagnosis and therapeutic usefulness in our midst, with a morbid-mortality frequency guarantying it (AU).

Implementation and Evaluation of an Opioid Risk Questionnaire in the Outpatient Plastic Surgery Setting.

Most patients undergoing plastic and cosmetic surgery are prescribed an opioid for postoperative pain control. With the advent of the opioid epidemic in our country, screening for opioid risk has become a topic of many health care discussions. However, there has been little mention of using an opioid risk questionnaire specific to the outpatient plastic surgery setting. This project consisted of distribution of an opioid risk questionnaire to adult patients undergoing outpatient plastic surgery. Data were collected at preoperative appointments from participating patients (n = 27). Although the sample size was small, two patients (7%) were identified as having a history of substance abuse, and both of those patients reported they had also received treatment for their substance abuse. In addition, six patients (22%) reported having a family history of substance abuse. Such findings suggest that clinicians working in outpatient plastic surgery should screen their patients for substance abuse and misuse.

Effects of preoperative oral carbohydrate intake on catabolism, nutrition and adipocytokines during minor surgery: A randomized, prospective, controlled clinical phase II trial.

BACKGROUND: We investigated the effects of preoperative oral carbohydrate loading on intraoperative catabolism, nutritional parameters, and adipocytokine levels during anesthesia. METHODS: Study participants were randomized to two groups who were allowed to consume either no more than 250 mL of 18% oral carbohydrate solution (Arginaid Water: AW group) or no more than 500 mL of plain water (PW group) within the 2 hours before surgery, with no intraoperative glucose administration. Percentage changes from preoperative values of resting metabolic rate (RMR) and total body water (TBW), determined by bioelectrical impedance analysis (BIA), were compared. Blood levels of serum ketone bodies, free fatty acids (FFAs), insulin, 3-methyl histidine, blood glucose, retinol binding protein, adiponectin, and leptin were measured. BIA measurement and blood sampling were performed on entry to the operating room (M1) and 2 hours after the induction of anesthesia (M2). Chi squared test, Mann-Whitney U test, and Wilcoxon's test were used for comparisons of parameters. P values less than 0.05 constituted a significant difference. RESULTS: Seventeen patients per group (34 patients total) were enrolled. RMR and TBW values did not differ between M1 and M2 measurements. Participants in the AW group had lower blood ketone body and FFA levels and higher insulin levels at M1. However, their ketone body and FFA levels rose and insulin levels fell after 2 hours, although ketone body and FFA levels in the AW group were still lower than those in the PW group. Although retinol binding protein, adiponectin, and leptin levels were not different in terms of preoperative oral carbohydrate loading, the levels of these substances in both groups were lower after 2 hours compared with levels on operating room entry. CONCLUSIONS: Preoperative oral carbohydrate loading without intraoperative glucose administration appears to suppress catabolism for 2 hours after the start of surgery.

Management of Bartholin Duct Cysts and Gland Abscesses.

Bartholin duct cysts and gland abscesses can affect a woman's day-to-day functioning and be challenging to manage. Many Bartholin duct cysts that are not infected remain asymptomatic and resolve spontaneously without intervention. However, an infected Bartholin duct cyst or glandular abscess should be drained when larger than 2 cm because such cysts or abscesses do not tend to resolve spontaneously and can recur. Management options fall under 3 broad categories: expectant, medical, or surgical. With special training, midwives and women's health nurse practitioners can manage many women who present with Bartholin duct cysts or gland abscesses. Rarely, a woman with a severe or recurrent infection will need referral to a surgeon. Knowing which management option to choose may be challenging at first; this article is aimed at providing evidence-based knowledge about Bartholin duct cysts and gland abscesses for clinicians so that they can make the diagnosis and management plan with confidence. A clinical case is used to illustrate the identification, diagnosis, and management of Bartholin duct cysts and gland abscesses. The range of interventions, from expectant management with comfort measures to surgical intervention, is be explored to assist the clinician in choosing the correct management approach.

Is it safe to re-access sodium bicarbonate bottles for use in minor surgery?

BACKGROUND/PURPOSE: Sodium bicarbonate is added to lidocaine to reduce injection pain. In Canada, it is available in vials exceeding the injection volume 100-fold. These are single-use vials that should be disposed of after one access. Some surgeons re-use vials to reduce waste, potentially causing contamination. This study aims to review the safety of sodium bicarbonate and assess alternatives to current practice. METHODS: Strains of Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Burkholderia cepacia were used to assess bacterial growth in vials of sodium bicarbonate. Each pathogen was inoculated into a vial for 14 days at room temperature. At several time points, 1 mL of solution was removed and diluted. One hundred microliters were transferred to blood agar plates and incubated at 35 °C. Colony counts were calculated, averaged and plotted onto a logarithmic graph. RESULTS: Colony counts of all strains fell below observational threshold after 7 days in sodium bicarbonate. CONCLUSIONS: Although all strains were reduced, bacteria can survive in sodium bicarbonate for several days, during which transmission may occur. Sodium bicarbonate vials should be treated as single-dose, as indicated by the manufacturers. To reduce waste, hospital pharmacies can repackage sodium bicarbonate into smaller vials or pre-alkalize lidocaine with sodium bicarbonate.

Physostigmine Reversal of Dysarthria and Delirium After Iatrogenic Atropine Overdose From a Dental Procedure.

BACKGROUND: Sublingual atropine, dosed at 0.4-0.8 mg, is used by dentists as an antisialogogue to facilitate and increase the speed of procedures. Concentrated ophthalmic atropine drops (10 mg/mL) are commonly used off-label for this purpose. These highly concentrated drops may result in medication errors, atropine toxicity, and the antimuscarinic toxidrome. We report a case of a man who suffered acute delirium and dysarthria (from dry mouth) after an iatrogenic overdose from a dental procedure. His symptoms were initially interpreted as a stroke, but they completely resolved with physostigmine. CASE REPORT: A 57-year-old man presented with acute dysarthria and delirium after a dental procedure; 4 hours earlier he was fitted for a temporary replacement of some premolar/molar teeth. He received sublingual atropine to assist in gingival drying for molding of his prosthesis, but a calculation error resulted in the administration of approximately 113 mg. A stroke evaluation was initially planned; however, 2.5 mg of intravenous physostigmine completely reversed his symptoms. His symptoms reoccurred and were successfully treated twice more with physostigmine; the patient was observed overnight with no additional symptoms and safely discharged the next morning. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ophthalmic atropine drops are highly concentrated and may cause an overdose after ingestion of small amounts. This novel case highlights the importance of considering antimuscarinic poisoning in cases of acute delirium or dysarthria after dental procedures and stands as a reminder to inquire about the use of atropine drops in such cases. Timely recognition of the antimuscarinic toxidrome and appropriate use of physostigmine may prevent unnecessary testing while providing an effective therapy. This case also highlights the need for observation after resolution of delirium treated with physostigmine.

Optimal dose of combined rocuronium and cisatracurium during minor surgery: A randomized trial.

BACKGROUND: Combined rocuronium and cisatracurium have synergistic effects. We investigated whether reduced doses are effective during coadministration, by monitoring neuromuscular relaxation during surgery. METHODS: This randomized, controlled clinical trial was registered at http://clinicaltrials.gov (registration number NCT02495038). The participants were 81 patients scheduled for elective mastoidectomy and tympanoplasty. Participants were assigned to groups, including the intubating dose group (Group I, n = 27; combined ED95 rocuronium and ED95 cisatracurium), the small reduction group (Group S, n = 27; dose reduced by 10% of each ED95), or the large reduction group (Group L, n = 27; dose reduced by 20% of each ED95). Drugs were administered to patients and a timer was started using TOF-Watch monitoring. TOF (train-of-four) was monitored at the ulnar nerve, at a setting of 2 Hz/12 s. We recorded the time to TOF ratio = 0 (onset), time to first TOF ratio > 25% (duration 25%), and TOF 25-75% (recovery index) under total intravenous anesthesia. One-way analysis of variance was used for statistical analyses (α = 0.05, ß = 0.2). RESULTS: There were no significant demographic differences between groups. Group L had a longer duration to onset (mean ±â€Šstandard deviation, 399.3 ±â€Š147.8 seconds) and shorter duration 25% (39.4 ±â€Š6.8 minutes) compared to Group I (212.8 ±â€Š56.0 s and 51.3 ±â€Š8.47 minutes, respectively) and Group S (230.7 ±â€Š60.6 s and 47.9 ±â€Š10.7 minutes, respectively). There were no other significant differences between groups. CONCLUSION: Our findings contribute to determining clinically effective combinations of rocuronium and cisatracurium, as well as to predicting the pharmacokinetic characteristics of the synergistic effects. We suggest that reducing doses of both drugs by approximately 10% of their respective ED95 values is sufficient to maintain neuromuscular relaxation during minor surgery.

Reconstrução de parede abdominal: série de casos / Reconstruction of the abdominal wall: a case series

Introdução: Os pacientes com defeitos de parede abdominal chegam ao consultório do cirurgião plástico em situações muitas vezes complexas, necessitando de abordagem cirúrgica avançada. Métodos: Estudo primário, retrospectivo e descritivo de pacientes submetidos a procedimentos cirúrgicos de reconstrução de parede abdominal pelo Serviço de Cirurgia Plástica do Hospital das Clínicas da Universidade Federal de Pernambuco (HC-UFPE). Resultados: Foram revisados e incluídos os prontuários de 18 pacientes, 15 (83,3%) do sexo feminino e 3 (16,7%) do masculino, com idade variando de 16 a 79 anos (média de 41 anos). Dezessete pacientes possuíam histórico de cirurgia prévia (94,4%), sendo a cesárea presente em 8 dos casos (44,4%), seguida de cirurgia oncológica com 6 (33,3%), cirurgia do trauma com 2 (11,1%) e bariátrica com 2 (11,1%). Em relação à etiologia do defeito, 8 (44,4%) eram decorrentes de fasciite necrosante, 4 (22,2%) de hérnia incisional, 2 (11,1%) por trauma, 2 (11,1%) por infecção de ferida operatória e 2 (11,1%) por neoplasia de parede abdominal, sendo somente um (5,5%) paciente com defeito de espessura total. A técnica cirúrgica de separação dos componentes foi realizada em 7 dos casos (38,9%), seguida de retalho de avanço simples em 6 (33,3%), fechamento com tela associado à abdominoplastia em 3 (16,7%), e expansor tecidual em 2 (11,1%). Quanto às complicações, houve 4 casos (22,2%). Conclusões: Defeitos de parede abdominal são casos desafiadores para o cirurgião plástico, seu tratamento se mostra árduo, porém com resultados satisfatórios mesmo nos casos mais severos.

Introduction: Patients with abdominal wall defects present challenging complications that require the use of advanced surgical approaches. Methods: This primary, retrospective, and descriptive study evaluated patients who underwent abdominal wall reconstruction at the Plastic Surgery Service of the Clinics Hospital of the Federal University of Pernambuco. Results: The medical records of 18 patients were reviewed, including 15 women (83.3%) and 3 men (16.7%), with a mean age of 41 years (range, 16-79 years). Seventeen patients (94.4%) had a history of previous surgery. The causes of abdominal injury were cesarean section in eight cases (44.4%), oncologic surgery in six (33.3%), trauma surgery in two (11.1%), and bariatric surgery in two (11.1%). The etiology of the defect was necrotizing fasciitis in eight cases (44.4%), incisional hernia in four (22.2%), trauma in two (11.1%), surgical wound dehiscence in two (11.1%), abdominal wall neoplasia in two (11.1%), and total thickness defect in one (5.5%). The surgical interventions included the component separation technique in seven cases (38.9%), simple VY advancement flap in six (33.3%), closure with abdominoplasty in three (16.7%), and tissue expander in two (11.1%). Four patients (22.2%) presented complications. Conclusions: Abdominal wall defects are challenging cases for plastic surgeons, as their treatment is difficult, but the results are satisfactory even in the most severe cases.

Nova classificação para hipertrofia dos pequenos lábios vaginais e correlação com as técnicas cirúrgicas indicadas / New classification of hypertrophy of the labia minora and correlation with indicated surgical techniques

Introdução: Primeira colocada entre as mais procuradas cirurgias plásticas genitais, a ninfoplastia ou labioplastia visa a correção da hipertrofia dos pequenos lábios vaginais e prepúcio, retirando seu excesso, sem interferir na sua função de proteção da vagina e auxílio na lubrificação genital. Diversos tipos de classificações foram propostos para facilitar a compreensão do grau de hipertrofia dos pequenos lábios vaginais e ajudar na escolha da técnica da labioplastia. Após analisar várias classificações, o autor propõe uma nova classificação, no intuito de facilitar a compreensão da hipertrofia das ninfas, capuz do clitóris e prepúcio e ajudar na escolha da técnica apropriada para labioplastia. Métodos: Foi feita uma busca na literatura médica PubMed/Medline com os termos hipertrofia lábios vaginais, labioplastia, labiaplasty, labioplasty, lábia minora hipertrophy, labial protrusion. Foram analisadas todas as classificações descritas nos trabalhos encontrados. Resultados: Uma nova classificação foi proposta. A hipertrofia dos pequenos lábios vaginais foi classificada em 4 graus: Grau 0 (≤ 1 cm), Grau 1 (> 1 cm e ≤ 3 cm), Grau 2 (> 3 cm e ≤ 5 cm) e Grau 3 (> 5 cm). Conclusões: A nova classificação, além de facilitar a compreensão do tamanho e extensão da hipertrofia das ninfas, também auxilia na escolha da técnica a ser escolhida para a labioplastia.

Introduction: Nymphoplasty or labioplasty is the most common genital plastic surgery. The objective of labioplasty is to correct hypertrophy of the labia minora and clitoral prepuce, removing excess tissue without affecting their function of protecting the vagina and aiding in genital lubrication. Several types of classifications have been proposed to facilitate the understanding of the degree of hypertrophy of the labia minora and assist in selecting the most suitable procedure in labioplasty. After analyzing several classifications, the author proposes a new classification to facilitate the understanding of hypertrophy of the labia minora, clitoral hood, and vaginal prepuce and help select the best labioplasty procedure. Methods: A literature search was conducted in PubMed/Medline using the following terms: hipertrofia lábios vaginais, labioplastia, labiaplasty, labioplasty, labia minora hypertrophy, and labial protrusion. All the classifications described in the identified studies were analyzed. Results: A new classification has been proposed. Hypertrophy of the labia minora was classified in four grades: grade 0 (≤ 1 cm), grade 1 (> 1 cm and ≤ 3 cm), grade 2 (> 3 cm and ≤ 5 cm), and grade 3 (> 5 cm). Conclusions: The new classification improves the understanding of the size and extent of hypertrophy of the labia minora and helps select the best procedure in labioplasty.

A simple, novel technique for fixing Penrose drains in minor surgeries, with advantages for remote outpatient clinics: a retrospective comparison with conventional drain fixation in North Ibaraki, Japan.

INTRODUCTON: In rural areas with few doctors, Penrose drains in minor surgeries for soft tissue trauma or small subcutaneous tumors are sometimes avoided, even though the drain would prevent hematoma, because of the limited availability of professional postsurgical care. The authors developed a simple fixation method for Penrose drains that can be used even in remote areas where a doctor is not present to remove the drain. A retrospective study was conducted to compare this new method of fixing Penrose drains with instances in which the Penrose drain was fixed to skin by conventional suturing. METHODS: The medical records of patients who underwent minor surgeries using Penrose drains were reviewed. The surgeries were performed from April 2012 to March 2015 in remote outpatient clinics in Ibaraki Prefecture, Japan. The cases were divided into two groups: those using the new method, in which the Penrose drains were sewn onto the wound dressings and could be automatically removed while changing the dressing, and those in which the Penrose drains were conventionally fixed to the skin and removed one or several days after surgery by another doctor at the outpatient clinic. The rates of drain-related complications and of automatic drain removal (ie removal without a doctor's assistance) between the two groups were compared. RESULTS: A total of 54 Penrose drains used for 48 lesions in 44 patients (25 men, 19 women) in the new-method group, and 36 Penrose drains for 25 lesions in 21 patients (12 men, 9 women) in the conventional-method (control) group were analyzed. All 54 Penrose drains in the new-method group were removed automatically, while none of the 36 drains in the control group were removed automatically. There were no drain-related complications, such as massive hematoma, retrograde infection, seroma, or drain breakage or straying, in any of the new-method or control cases. CONCLUSIONS: This new Penrose-drain fixation method is safe and is particularly suitable for minor surgeries in rural areas where there are no resident doctors. The wide use of this method for appropriate minor surgeries in doctorless rural areas has the potential to reduce surgical complications and the time burden for both patients and surgeons.

Descripción de la concordancia clinicopatológica y satisfacción del paciente en la cirugía menor en un centro de atención primaria / Description of clinical pathological concordance and patient satisfaction in minor surgery in a Primary Care centre

OBJETIVO: Describir las características de la cirugía menor (CM) en un centro de atención primaria (AP) evaluando la concordancia anatomopatológica y clínica, así como la satisfacción del paciente. DISEÑO: Estudio descriptivo y retrospectivo. EMPLAZAMIENTO: Atención primaria, Centro de Salud (CS) urbano en Almería. PARTICIPANTES: La población fueron los usuarios pertenecientes al CS urbano derivados por sus médicos de familia o pediatras para realización de CM a la consulta durante el año 2013 que consintieron la intervención. Se obtuvo una muestra de 223 pacientes. MEDICIONES PRINCIPALES. Las variables analizadas fueron: sexo, edad, localización de las lesiones, tipo de intervención realizada, diagnóstico clínico, diagnóstico anatomopatológico, complicaciones y satisfacción del paciente. Los datos fueron extraídos de la historia clínica, de los informes de anatomía patológica y mediante encuesta de satisfacción realizada vía correo y telefónica a los pacientes. RESULTADOS: En nuestra población la mayoría fue del sexo masculino 53,8%, la edad media fue de 51,12 años con desviación típica de 19,02, la localización de las lesiones que más se intervinieron fue en la cabeza (35,4%). El procedimiento más utilizado fue la electrocirugía (62,8%), biopsiándose solo el 16,9% de las lesiones, de las cuales las más frecuentes fueron los fibromas (32,3%), obteniéndose una correlación clinicopatológica >80% con un índice Kappa de 0,783 (p < 0,001). El número de complicaciones fue bajo. La satisfacción del paciente fue alta. CONCLUSIONES: Aunque se han generalizado técnicas sencillas de CM, como la electrocoagulación, en AP la CM sigue siendo segura y satisfactoria para el usuario

AIM: To describe the minor surgery (MS) characteristics in a Primary Care (PC) centre, and to evaluate the clinical pathological concordance and patient satisfaction. DESIGN: Descriptive and retrospective study. SETTING: Primary Care, urban health care centre, Almería, Spain. PARTICIPANTS: The population were the patients belonging to urban Primary Health Care centre, referred by their family physicians or paediatricians for the performing of MS during year 2013, and who consented to the intervention. A sample of 223 patients was obtained. MAIN MEASUREMENTS: Variables analysed were: sex, age, locations of the lesions, type of intervention, clinical diagnosis, histopathology diagnosis, complications, and patient satisfaction. The data were extracted from the medical history, the histopathology reports, and by using a satisfaction questionnaire completed by post or telephone by the patients. RESULTS: The population consisted of 53.8% males, and had a mean age of 51.12 years (SD 19.02). The location of the most intervened lesions was in the head (35.4%). Electro-surgery was the most used procedure (62.8%), with only 16.9% of the lesions being biopsied, of which the most frequent was fibroids (32.3%). The clinical pathological concordance was > 80% and the Kappa index was 0.783 (P <.001). The complications presented were low. The patient's satisfaction was high. CONCLUSIONS: Although a simple MS technique like electro-surgery has become more extensive, MS in PC remains safe and satisfactory for the user

Impacto de las acciones emprendidas por un equipo de mejora sobre la utilización de sedación farmacológica en la reparación de heridas en niños / Impact of a quality of care improvement team on the use of sedatives during wound repair in young children

Objetivo: Analizar el impacto de las acciones promovidas por un equipo de mejora (EM) sobre utilización de sedación farmacológica (SDF) en menores de 5 años en los que se repara quirúrgicamente una herida. Método: Estudio quasiexperimental realizado con la inclusión de los niños menores de 5 años que consultaron en un servicio de urgencias pediátricas (SUP) por una herida por la que precisaron reparación quirúrgica con sutura. Un EM creado en urgencias para promover SDF en procedimientos menores programó las siguientes acciones: talleres de formación, elaboración y difusión de un protocolo sobre SDF e inclusión de una alarma informática. Se realizó un primer análisis a los dos meses y un segundo a los 9 meses, utilizando dos indicadores, porcentaje de pacientes menores 2 años y porcentaje de pacientes de 2 a 5 años, a los que se administró SDF durante la reparación de una herida, que se compararon con la fase preintervención. Resultados: Durante el periodo de estudio, se registraron 22.958 episodios en menores de 5 años, 548 (2,4%) con heridas no complicadas. De ellos 350 (63,8%) pacientes precisaron reparación quirúrgica, 75 (21,4%) eran menores de 2 años. Previo a la intervención, un 10% de los menores de 2 años recibieron SDF, 22% a los 2 meses y 31,4% a los 9 meses (p < 0,01). Entre 2 y 5 años, los porcentajes fueron 4,4%, 10% y 25% respectivamente (p < 0,01). El 82% de familias y 69% de médicos presentes consideraron que el control de la ansiedad había sido adecuado. Conclusiones: Las acciones diseñadas por un EM multidisciplinar son eficaces para incrementar la SDF durante la reparación quirúrgica de heridas en menores de 5 años (AU)

Objective: To analyze the impact of actions organized by a quality of care improvement team on the use of sedatives when treating wounds in children under the age of 5 years. Methods: Quasiexperimental pre/post study enrolling children under the age of 5 years brought to a pediatric emergency department with wounds requiring surgical repair with suturing. A team to promote the use of sedation in such minor procedures in these children was established. The team organized the following interventions: training workshops, development and circulation of a sedation protocol, and establishment of a computerized alert. The first analysis of results was done at 2 months and the second at 9 months. The quality of care indicators, the use of sedatives while wounds were treated in children, was analized in 2 age groups: (under the age of 2 years and between 2 and 5 years) and results were compared with the preintervention phase. Results: A total of 22 958 emergencies were registered in children under 5 years old; 548 (2.4%) involved uncomplicated wounds. Of the 548 patients, 350 (63.8%) required surgical repair, 75 of them (21.4%) in children under the age of 2 years. Ten percent of these children had received a sedative in the period before the team’s intervention; 22% had been sedated at the 2-month analysis and 31.4% at 9 months (P<.01). For children between 2 and 5 years old, the percentages were 4.4% (pre-intervention), 10% (2 months), and 25% (9 months) (P<.01). Eighty-two percent of the families and 69% of the physicians thought that anxiety was adequately controlled. Conclusion: Actions designed by a multidisciplinary quality of care team are effective for increasing the use of sedatives while wounds are treated in children under the age of 5 years (AU)

The Resident-Run Minor Surgery Clinic: A Pilot Study to Safely Increase Operative Autonomy.

OBJECTIVE: General surgery training has evolved to align with changes in work hour restrictions, supervision regulations, and reimbursement practices. This has culminated in a lack of operative autonomy, leaving residents feeling inadequately prepared to perform surgery independently when beginning fellowship or practice. A resident-run minor surgery clinic increases junior resident autonomy, but its effects on patient outcomes have not been formally established. This pilot study evaluated the safety of implementing a resident-run minor surgery clinic within a university-based general surgery training program. DESIGN: Single institution case-control pilot study of a resident-run minor surgery clinic from 9/2014 to 6/2015. Rotating third-year residents staffed the clinic once weekly. Residents performed operations independently in their own procedure room. A supervising attending surgeon staffed each case prior to residents performing the procedure and viewed the surgical site before wound closure. Postprocedure patient complications and admissions to the hospital because of a complication were analyzed and compared with an attending control cohort. SETTING: Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program. PARTICIPANTS: Ten third-year general surgery residents. RESULTS: Overall, 341 patients underwent a total of 399 procedures (110 in the resident clinic vs. 289 in the attending clinic). Minor surgeries included soft tissue mass excision (n = 275), abscess incision and drainage (n = 66), skin lesion excision (n = 37), skin tag removal (n = 15), and lymph node excision (n = 6). There was no significant difference in the overall rate of patients developing a postprocedure complication within 30 days (3.6% resident vs. 2.8% attending; p = 0.65); which persisted on multivariate analysis. Similar findings were observed for the rate of hospital admission resulting from a complication. Resident evaluations overwhelmingly supported the rotation, citing increased operative autonomy as the greatest strength. CONCLUSIONS: Implementation of a resident-run minor surgery clinic is a safe and effective method to increase trainee operative autonomy. The rotation is well suited for mid-level residents, as it provides an opportunity for realistic self-evaluation and focused learning that may enhance their operative experience during senior level rotations.

Fluidoterapia: conceptos y racionalidad en su aplicación / Intravenous fluids: Concepts and rationality of use

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