Optimización de neumoperitoneo preoperatorio en hernia ventral: Uso de un dispositivo de compresión externa

La hernia incisional compleja es un desafío para el cirujano. Son ampliamente conocidos los factores que han permitido mejorar los resultados de la reparación herniaria, entre ellos el neumoperitoneo preoperatorio. Durante la insuflación preoperatoria, el aire difunde tanto en la cavidad abdominal como en el saco herniario. Sin embargo, gran porcentaje del contenido administrado, se distribuye mayormente en el saco herniario y no en la cavidad abdominal. En Latinoamérica, diversos equipos de cirujanos de pared abdominal han compartido experiencias en lo que respecta a la optimización de esta técnica como adyuvancia para el manejo de las hernias complejas. En este contexto, y para optimizar la distribución del aire insuflado hacia la cavidad abdominal, se comenzó a utilizar un dispositivo externo de compresión. Este trabajo busca estandarizar por primera vez esta técnica durante el neumoperitoneo preoperatorio buscando disminuir el volumen de aire insuflado, los días de neumoperitoneo y, por lo tanto, los días de hospitalización previo a la cirugía.

Complicated incisional hernia is challenging for surgeons. The factors that have improved the results of hernia repair are widely known, including preoperative pneumoperitoneum. During preoperative insufflation, air diffuses into both the abdominal cavity and the hernia sac. However, a large percentage of the administered content is distributed mainly in the hernia sac and not in the abdominal cavity. Latin-American teams of abdominal wall surgeons have shared experiences regarding the optimization of this technique as an adjuvant for the management of complicated hernias. In this context and to optimize the distribution of the insufflated air into the abdominal cavity, an external compression device began to be used. This article aims to standardize this technique for the first time during preoperative pneumoperitoneum. The target is to reduce the volume of air insufflated, the days of pneumoperitoneum and, therefore, the days of hospitalization prior to surgery.

Tumores de glándulas salivales: enfrentamiento diagnóstico inicial / Salivary gland tumors: initial diagnostic confrontation

It is described that salivary gland tumors account for up to 3-6% of head and neck tumors, 80% of these being located in the parotid gland. Broadly speaking, the smaller the gland, the greater the probability of malignancy. The most common clinical manifestation in tumor pathology is the appearance of a painless mass. Indicators of malignancy should be considered: chronic volume increase or rapid growth, facial paralysis, cranial nerve involvement, ulceration, and cervical lymphadenopathy. Ultrasonography should be the first imaging study, however, it provides limited information. MRI is the exam of choice for salivary gland tumors, whereas CT and PET-CT allow the study of local and remote invasion. FNA is controversial, it is not indicated for all patients, in parotid tumors a cytological examination is usually not necessary prior to surgery. Excisional biopsy is not recommended due to the risk of tumor seeding, neural damage, and salivary fistula. The goal of treatment in gland tumors is the removal of the glands, associated with lymph node dissection and adjuvant radiation therapy in indicated cases. The general practitioner must comprehensively address these pathologies to achieve a timely referral to the specialist. (AU)

Histerectomía total vía abdominal: revisión de la literatura / Total abdominal hysterectomy: a literature review

Hysterectomy is the most common gynecological surgery in non-pregnant women. There are different surgical approaches for total hysterectomy, abdominal, vaginal, laparoscopic and robotic routes. The choice is determined by different factors such as uterine size, malformations, surgical risks, skill of the surgeon, expected postoperative quality of life, and monetary costs. The surgical technique is well described in the literature, however, there are certain anatomical and functional considerations that must be known before performing the hysterectomy to avoid complications. The most frequent complications are hemorrhage, infections, thromboembolism, urinary and gastrointestinal tract injuries. Majority can be avoided with an adequate procedure and management of pre-existing comorbidities. (AU)

Traqueostomía en pacientes con COVID-19: recomendaciones actuales / Traqueostomy in COVID-19 patients: current recomendations

Resumen El nuevo coronavirus (SARS-CoV-2), causante de la enfermedad COVID-19, es una pandemia con alta morbimortalidad mundial. Uno de los factores más importantes es su alta tasa de transmisibilidad por gotitas, aerosoles y fómites. La tendencia actual es el aumento progresivo de pacientes contagiados en nuestro país y, por consiguiente, de mayor cantidad de enfermos en unidades de cuidados intensivos (UCI) con uso de ventilación mecánica invasiva (VMI). La traqueostomía (TQT) se utiliza en pacientes críticos para facilitar la VMI a largo plazo y el destete de la ventilación. Una TQT temprana, definida como la realizada en los primeros 7 días después de la intubación orotraqueal (IOT), se asocia a una reducción en el tiempo de la VMI, mortalidad y permanencia en UCI. La TQT es una técnica quirúrgica con alta generación de aerosoles la cual implica medidas especiales frente a la realización de ésta en pacientes con COVID-19. Para limitar el contagio del SARS-CoV-2 en los trabajadores de salud es necesario el uso de elementos de protección personal (EPP) adecuados según la intervención a realizar. Es por esta razón que en el presente artículo se propone utilizar el acrónimo C-O-RO-NA para no olvidar elementos y pasos fundamentales al momento de realizar esta técnica, minimizando de esta manera el contagio en los trabajadores de salud.

The new coronavirus (SARS-CoV-2), which causes COVID-19 disease, is a high mortality pandemic illness. One of the most important factors is its high rate of transmissibility by respiratory droplets, aerosols and fomites. The reigning trend of this disease is progressively increasing infected patients in our country, therefore, more patients in intensive care units (ICU) with invasive mechanical ventilation (IMV). Tracheostomy (TQT) is used in critical patients to facilitate long-term IMV and ventilation weaning. An early TQT, defined as performed in the first 7 days after orotracheal intubation (IOT) is associated with a reduction IMV duration, mortality rate and length of stay in ICU. TQT is a surgical procedure which generates a huge amount of aerosols that need special measures to perform in COVID-19 patients. It is necessary to use appropriate personal protection elements (PPE) according to the intervention, limiting the spread of SARS-CoV-2 in health workers. It is for this reason that this article proposes to use the acronym C-O-RO-NA to remember fundamental elements and steps when performing this technique in order to minimize health workers infection.

Enfrentamiento a una masa cervical no tiroidea en Atención Primaria / Confrontation with a non-thyroid cervical mass in Primary Care

The clinical approach to non-thyroid cervical masses in primary care has always been considered a diagnostic challenge. In the absence of specific diagnostic methods, the general practitioner must rely on clinic and general tests in order to achieve a suspected diagnosis and timely referral. On initial approach to cervical masses, one must first analyze each case according to patient age, associating an exhaustive anamnesis focused on the growth pattern and aggregate symptoms, along with a physical examination focused on signs of malignancy. Once completed, the etiology of the mass can be classified as probable congenital, inflammatory or tumoral origin. And also try to determine localization, temporality and discriminate between benign and malignant causes. Once the clinical interrogation has been completed, basic complementary tests and/or directed test according to suspicion can be requested. The foregoing allows the primary care physician a proper referral to specialist and/or initiation of appropriate treatment. (AU)

Variación de dosis de radioyodo en pacientes con cáncer diferenciado de tiroides post implementación de guías ATA 2015 / Variation of radioiodine dose in patients with differentiated thyroid cancer after implementation of the ATA 2015 guidelines

Introducción: El cáncer diferenciado de tiroides (CDT), es actualmente la neoplasia endocrina más frecuente. Su tratamiento estándar es la resolución quirúrgica, asociado a ablación con radioyodo (RI) según la clasificación propuesta por la American Thyroid Association (ATA). Las indicaciones y dosis de este último, han ido variando en los últimos años según avanzan las investigaciones en este ámbito. Objetivo: En el siguiente estudio se compararon las dosis de RI utilizadas previo y posterior a la implementación de las últimas guías de la ATA. Materiales y métodos: Estudio retrospectivo observacional de 70 pacientes con diagnóstico de CDT del Hospital Clínico de la Universidad de Chile entre 2012 y 2017. Se agruparon los pacientes en dos cohortes, los operados entre los años 2012-2015 y los 2016-2017 clasificándolos según riesgo ATA, TNM y riesgo de recurrencia. Se consignaron las dosis de RI utilizadas y se compararon entre las cohortes. Análisis estadístico: Mann Whithney. Resultados: Al comparar la dosis de RI entre ambas cohortes, según TNM y riesgo ATA, se obtuvo los siguientes resultados: los pacientes T1b de la cohorte 2012-2015 presentaron dosis de RI significativamente mayores que los de la cohorte 2016-2017; también se evidenció que en pacientes N0 hubo una diferencia estadísticamente significativa, mostrando una tendencia a disminuir la dosis de RI; además, en los pacientes de la cohorte 2012-2015 con riesgo ATA intermedio, se obtuvo que las dosis de RI fueron significativamente mayores que las utilizadas en la cohorte 2016-2017. Conclusión: Se concluye que las variaciones de las dosis de RI utilizadas en pacientes con CDT en un hospital universitario van acorde a las recomendaciones internacionales actuales, particularmente la publicación de la guía ATA 2015, aplicándose radioablación con menor dosis de RI. Dado este cambio, se ha evidenciado igualdad de efectos con dosis menores de RI y consecuentemente menos efectos adversos.

Introduction: Differentiated thyroid cancer (CDT) is currently the most frequent endocrine neoplasia. Its standard of care is surgical treatment, associated with radioiodine ablation (IR) according to the classification proposed by the American Thyroid Association (ATA). The indications and doses of the latter have changed in recent years as research in this area advances. Objective: In the following study, the doses of IR used before and after the implementation of the latest ATA guidelines were compared. Materials and methods: Retrospective observational study of 70 patients with a diagnosis of CDT from the Clinical Hospital of the University of Chile between 2012 and 2017. Patients were grouped into two cohorts, those surgically intervened between the years 2012-2015 and 2016-2017, classifying them according to ATA risk, TNM and recurrence risk. The IR doses used were reported and compared between the cohorts. Statistical analysis: Mann Whithney. Results: When comparing the IR dose between both cohorts, according to TNM and ATA risk, the following results were obtained: T1b patients in the 2012-2015 cohort had significantly higher IR doses than those in the 2016-2017 cohort; It was also evidenced that N0 patients showed a statistically significant tendency to decrease the IR dose; In addition, the 2012-2015 cohort with intermediate ATA risk, revealed IR doses significantly higher than those used in the 2016-2017 cohort. Conclusion: It is concluded that the variations in IR doses, used in patients with CDT in a university hospital, are in accordance with current international recommendations, particularly the publication of the ATA 2015 guidelines, applying radioablation with a lower dose of IR. Given this change, equality of effects has been evidenced with lower doses of IR and consequently fewer adverse effects.