Recomendaciones en el tratamiento antibiótico empírico de la infección intraabdominal

A significant number of patients with abdominal infection develop advanced stages of infection and mortality is still above 20%. Failure is multifactorial and is associated with an increase of bacterial resitance, inappropriate empirical treatment, a higher comorbidity of patients and poor source control of infection. These guidelines discuss each of these problems and propose measures to avoid the failure based on the best current scientific evidence.     

Desafío y futuro de la cirugía robótica hepática y pancreática. Análisis de 64 casos en una unidad especializada

IntroductionRobotic surgery has proven effective in certain surgical procedures. However, in liver and pancreatic surgery (HBP) its use is still rare. The initial experience in HBP robotic surgery of a specialized unit of a tertiary hospital is presented.MethodThe results of patients undergoing robotic HBP surgery between April 2018 and October 2020 have been prospectively studied. The data analyzed correspond to demographic data, surgical techniques performed, associated morbidity and mortality.Results64 patients were operated, corresponding to 35 hepatectomies (major [6.7%], anatomic [52.9%], limited [34.4%], cystectomies [3%] and marsupialization [3%]), 29 pancreatectomies (distal [48.2%], central [6.9%], cephalic [13.8%], enucleations [24.1%], ampullectomies [3.5%] and duodenal resections [3.5%]).In liver surgery the mean operative time was 204.4 minutes (100-265 min), the median postoperative complications according to the Clavien-Dindo scale was one (1-4), the mean blood losses 166.7 mL (100-300 mL), there was no conversion and the mean postoperative stay was four days (2-14 days).In pancreatic surgery, the mean operative time was 243.8 minutes (125-460 min), the median of postoperative complications was two (1-4), blood loss of 202.3 mL (100-500 mL) associated to a conversion rate 17.8% and an average stay of seven days (3-23 days).ConclusionsRobotic HBP surgery is safe and feasible. It is suggested that its use facilitates parenchymal sparing surgery, access to posterior liver segments and anastomosis in pancreatic reconstruction compared to laparoscopic surgery.     

Tratamiento de las complicaciones hemorrágicas de la nefrolitotomía percutánea en posición de Galdakao

ObjetivePercutaneous Nephrolithotomy (PCNL) is a technique with good results for the treatment of kidney stones, however, bleeding complications derived can be serious if not diagnosed and treated effectively. The aim of this study is to assess bleeding complications resulting from PCNL in Galdakao position and therapeutic management.Material and methodsRetrospective-longitudinal study of 172 PCNL performed in La Ribera Hospital between January 2005 and December 2011, analyzing their bleeding complications and the treatment provided for resolution.ResultsHad bleeding complications 20 patients (11.6%). The need for transfusion in this series was 8.1% and the most common cause of blood transfusion the presence of postoperative retroperitoneal (7.5%). There were 6 arterial injuries (3.5%), 5 of them successfully treated with angiography and arterial selective embolization.ConclusionsThe arterial injuries following PCNL are rare but can be serious. The possibility of an urgent arteriography and selective embolization to the diagnosis permits an effective and safe treatment of bleeding without risk to the affected renal unit.     

Tratamiento de la macromastia sintomática en una unidad de mama. Resultados de la reducción mamaria evaluados mediante el cuestionario BREAST-Q

IntroductionThe BREAST-Q (breast reduction module) is a specific and validated questionnaire to evaluate breast reduction in the treatment of symptomatic macromastia, offering information on their quality of life and degree of satisfaction.MethodsProspective study of a cohort of 34 patients treated by bilateral breast reduction in a breast unit in 2017–2020 surveyed with the Spanish version of BREAST-Q version 2. The statistical study to assess the effect of reduction, changes from the pre to postoperative scores of the domains were performed using the Wilcoxon signed rank test. Statistical significance was determined with P values < .05.ResultsThe mean time elapsed from surgery to the postoperative survey was 16 (SD 9) months. Post-surgical complications or sequelae occurred in 14 (42%) patients with 23 events. The preoperative scores, median and interquartile range, in satisfaction with the breasts (28, 26), psychological (33, 14), physical (42, 19) and sexual (34, 14) well-being improved in the postoperative survey to (82, 15), (81, 29), (82, 30) and (90, 38), respectively. These changes were statistically significant, P < .001.ConclusionsThe first application of the BREAST-Q in its version in Spanish for Spanish women in patients with symptomatic macromastia treated surgically in a breast unit shows that breast reduction improves the quality of life of patients and that they are very satisfied with the outcome of the surgery and its surgeon, although the information received should clearly be improved.     

Revisión sistemática del tratamiento activo de la fístula urinaria después de la nefrectomía parcial

IntroductionUrinary fistula is expected to become more frequent in urological practice as a result of expanding indication of partial nephrectomy given it?s oncological results equivalent to those of radical nephrectomy but at a lower risk of progression to chronic kidney disease, lower cardiovascular morbidity, and overall mortality.ObjectivesReview and compare different techniques of contemporary active management for urinary fistula after partial nephrectomy.MethodsA systematic literature search on the MEDLINE database was conducted in March 2020, combining the terms: «urine leak», «urine leakage», «urinary leak» and «urinary fistula», with: «partial nephrectomy», «nephron sparing surgery» and «renal sparing surgery». The review of the literature was performed accordingto the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only articles related to active treatment were eligible. Abstracts in English and Spanish from the last two decades were screened. No restriction based on study design nor the length of follow-up. Primary outcomes: 1) Leak resolution rate 2) Time course of leak resolution and 3) Number of interventions needed for resolution.ResultsMultiple studies were found. There were no randomized controlled trials. Urinary fistula can be solved in many ways with active treatment, with a high success rate (97.5%), an average of 1.4 intervention-per-patients and a mean time for leak resolution of 11 days (median of 3 days).ConclusionThere is a high risk of bias due to the study's methodology. There is a broad range of effective alternatives and various approaches to solve urinary fistula in an appropriate timing.     

Realidad aumentada en cirugía hepato-bilio-pancreática. Una tecnología al alcance de la mano

Augmented reality is a technology that opens new possibilities in surgery. Its implementation in a hepatobiliary-pancreatic surgery unit is presented in relation to preoperative planning, intraoperative support and teaching.For surgical planning, 3D CT and MRI reconstructions have been used to evaluate complex cases, making the interpretation of the anatomy more precise and the planning of the technique simpler.At an intraoperative level, it has allowed remote holographic connection between specialists, the substitution of physical elements for virtual elements, and the use of virtual consultation models and surgical guides.In teaching, new lessons include the retransmission of a surgery with the support of virtual elements for a better understanding by the students.Being the experience satisfactory, augmented reality could be applied in the future of hepatobiliary-pancreatic surgery to improve its results.     

Metodología de una revisión sistemática

Context

The objective of evidence-based medicine is to employ the best scientific information available to apply to clinical practice. Understanding and interpreting the scientific evidence involves understanding the available levels of evidence, where systematic reviews and meta-analyses of clinical trials are at the top of the levels-of-evidence pyramid.

Hemotórax masivo derecho por rotura espontánea idiopática de una arteria frénica tras cirugía cardiaca

We report a case of a 35-years-old man who presented a massive haemothorax and hypovolemic shock following cardiac surgery, from spontaneous rupture of a phrenic artery. A quick diagnosis and immediate intervention is crucial to manage the patient.     

Estándares de calidad en la cirugía oncológica pancreática en España

Introduction

To establish quality standards in oncologic surgery is a complex but necessary challenge to improve surgical outcomes. Unlike other tumors, there are no well-defined quality standards in pancreatic cancer. The aim of this study is to identify quality indicators in pancreatic oncologic surgery in Spain as well as their acceptable limits of variability.

Cirugía citorreductora en pacientes con cáncer de próstata oligometastásico. Revisión sistemática de la literatura científica

IntroductionInterest in oligometastatic prostate cancer has spiked due to the emergence of new evidence regarding more specific and accurate imaging, and the wider use of minimally invasive techniques. Nevertheless, the optimal management of this pathology is yet to be determined.ObjectiveAssess the efficacy and safety of cytoreductive surgery in patients suffering from oligometastatic prostate cancer.Evidence gatheringSystematic review of the scientific literature (01/01/2010-31/12/2021) within the MedLine, Embase, Cochrane Library, Cinahl, Scopus, Spanish Healthcare Technology Assessment Agencies (AETS, Agencias de Evaluación de Tecnologías Sanitarias) and ClinicalTrials.gov databases. The keywords used were prostatectomy, prostatic neoplasm, radical prostatectomy; the free search terms were prostatectomy and oligometastatic prostate. The inclusion criteria comprised studies on patients with oligometastatic prostate cancer who had been operated on using radical cytoreductive prostatectomy.Evidence synthesisThe systematic review included 4 observational studies, 2 clinical trials, and 2 case series, of moderate quality. The results observed suggest that oligometastatic prostate cancer patients who had undergone cytoreductive prostate surgery obtained a benefit in terms of efficacy. Conversely, the majority of these studies showed a reduction in the number of localized complications, when compared to the best systemic treatments.ConclusionsCytoreductive surgery in this group of patients is a safe procedure that reduces the incidence of localized complications and that presents promising results with regard to survival rates. To date, the lack of prospective trials limits the use of this therapeutic option to experimental environments.