Manejo de las complicaciones durante la cirugía endoscópica nasosinusal / Complication Management during Nasosinusal Endoscopic Surgery

Introducción: La cirugía endoscópica nasosinusal ha evolucionado de forma importante desde su creación. La posición anatómica que ocupan las cavidades nasosinusales con importantes estructuras adyacentes hacen que sus complicaciones, aunque raras, traigan secuelas irreversibles e incluso la muerte del paciente. Objetivo: Realizar una revisión sobre los tipos de complicaciones, frecuencia y su manejo durante la cirugía endoscópica nasosinusal. Métodos: Revisión documental en bases de datos bibliográficos sobre el tema durante el período de diciembre 2021 a enero 2022. Se seleccionaron 27 artículos relacionados con el objetivo propuesto y se desarrolló un documento resumen con la información recolectada. Desarrollo: La clasificación más utilizada separa las complicaciones en tres grados de severidad y las tasas de complicaciones mayores están por debajo del 1 por ciento en manos de cirujanos experimentados. Reconocer los sitios de mayor riesgo y los síntomas que puedan aparecer en el paciente son fundamentales para el rápido manejo de la complicación. Conclusiones: La cirugía endoscópica nasosinusal ha demostrado ser una excelente herramienta para el tratamiento quirúrgico de las enfermedades de estas cavidades en manos experimentadas. Aunque las tasas de complicaciones son ínfimas, saber reconocerlas y tratarlas a tiempo resulta fundamental(AU)

Introduction: Endoscopic nasosinusal surgery has evolved significantly since its inception. The anatomical position of the nasosinusal cavities, with important adjacent structures, means that its complications, although rare, bring about irreversible sequelae, and even death, for the patient. Objective: To review the types and frequency of complications, as well as their management, during endoscopic nasosinusal surgery. Methods: A documentary review on the subject was conducted in bibliographic databases during the period from December 2021 to January 2022. Twenty-seven articles related to the proposed objective were selected, while a summary document was developed with the collected information. Development: The most commonly used classification separates complications into three degrees of severity and includes major complication rates below 1 percent in the hands of experienced surgeons. Recognizing the sites of greatest risk and the symptoms that may appear in the patient are fundamental for the rapid management of the complication. Conclusions: Endoscopic nasosinusal surgery has proven to be an excellent tool for the surgical treatment of the diseases of these cavities in experienced hands. Although complication rates are minimal, it is essential to know how to identify and treat them(AU)

Z-POEM: ¿Procedimiento ideal para el tratamiento del divertículo de Zenker? / Z-POEM: Ideal procedure for the treatment of Zenker's diverticulum?

Introducción. El divertículo de Zenker es una patología poco frecuente, caracterizada por la presencia de disfagia, halitosis, tos y pérdida de peso, que afectan la calidad de vida de los pacientes. El tratamiento es quirúrgico y las técnicas han evolucionado de forma permanente. El objetivo de este estudio fue evaluar la mejoría de la disfagia en pacientes a quienes se les realizó la técnica de miotomía endoscópica peroral (Z-POEM). Métodos. Estudio descriptivo de una serie de 23 pacientes con divertículo de Zenker diagnosticado por endoscopia y esofagograma, tratados entre mayo de 2018 y noviembre de 2021 en diferentes instituciones de la ciudad de Bogotá, D.C., Colombia, mediante una miotomía endoscópica del cricofaríngeo con la técnica de Z-POEM. Resultados. La mayoría de los pacientes fueron adultos mayores, de sexo masculino. Los síntomas más frecuentes correspondieron a disfagia y regurgitación. El tamaño promedio del divertículo fue de tres centímetros. La estancia hospitalaria fue de un día. Un paciente presentó disfagia postoperatoria en relación con los clips y otro presentó un absceso mediastinal, el cual fue resuelto de manera endoscópica. Actualmente, todos los pacientes se encuentran asintomáticos y no han presentado recurrencia. Conclusiones. El tratamiento endoscópico mínimamente invasivo mediante la miotomía endoscópica peroral (Z-POEM) en el paciente con divertículo de Zenker es una alternativa segura y eficaz, con buenos resultados y poca morbilidad

Introduction. Zenker's diverticulum is a rare pathology characterized by the presence of dysphagia, halitosis, cough, and weight loss, which affect the patients' quality of life. The treatment is surgical and the techniques have evolved permanently. The objective of this study was to evaluate the improvement of dysphagia in patients who underwent peroral endoscopic myotomy technique (Z-POEM). Methods. Descriptive study of a series of 23 patients with Zenker's diverticulum diagnosed by endoscopy and esophagram, treated between May 2018 and November 2021 at different institutions in Bogotá, Colombia, by means of an endoscopic cricopharyngeal myotomy with the Z-POEM technique. Results. Most of patients were older males. The most frequent symptoms corresponded to dysphagia and regurgitation. The average size of the diverticulum was three centimeters. The hospital stay was one day. One patient presented postoperative dysphagia related to the clips and another presented a mediastinal abscess which was resolved endoscopically. Currently, all patients are asymptomatic and have not presented recurrence. Conclusions. Minimally invasive endoscopic treatment by peroral endoscopic myotomy (Z-POEM) in patients with Zenker's diverticulum is a safe and effective alternative, with good results and low morbidity

Oxigenoterapia hiperbárica como tratamiento complementario en mucormicosis asociada a COVID-19: a propósito de dos casos / Hyperbaric oxygen therapy as an adjunctive treatment for COVID-19-associated mucormycosis: a report of two cases

Reportamos los dos primeros casos, en Perú, sobre el uso del tratamiento con oxigeno hiperbárico coadyuvante (TOHC) en pacientes con mucormicosis asociado a COVID-19 (MAC). El primer caso es una mujer de 41 años, con dolor en hemicara y región palatina izquierdas con rinorrea purulenta de un mes de evolución. Al examen físico, solo evidencia fístula oroantral. El segundo caso se trata de un varón de 35 años, con disminución de agudeza visual izquierda y dolor palatino con fístula que drena secreción purulenta de cuatro meses de evolución. Ambos pacientes tienen el antecedente de diabetes, tuvieron COVID-19 moderado cuatro meses antes del ingreso, y recibieron corticoterapia por este diagnóstico. Ambos pacientes tuvieron una evaluación tomográfica que mostró compromiso del seno maxilar y tejido óseo circundante, con endoscopia nasal diagnóstica y terapéutica para desbridamiento. Se obtuvieron muestras compatibles con mucormicosis en estudio histológico. Los pacientes fueron tratados con limpieza quirúrgica y anfotericina B desoxicolato, sin embargo, presentaron evoluciones tórpidas. Por lo tanto, se adicionó la TOHC y mostraron una mejoría evidente tras cuatro semanas de tratamiento con controles subsiguientes sin presencia de mucormicosis. Resaltamos la evolución de estos pacientes con TOHC, en una enfermedad con importante morbimortalidad, que ha sido emergente durante la pandemia.

We present the first two cases reported in Peru of the use of adjuvant hyperbaric oxygen therapy (HBOT) in patients with COVID-19-associated mucormycosis (CAM). The first case is a 41-year-old woman, with pain in the left side of the face and palatine region with purulent rhinorrhea for a month. Only an oroantral fistula was found during physical examination. The second case is a 35-year-old male, with decreased left visual acuity and palatal pain with a fistula, draining purulent secretion for four months. Both patients have history of diabetes, had moderate COVID-19 four months prior to admission, and received corticosteroid therapy for this diagnosis. Tomographic evaluation of both patients showed involvement of the maxillary sinus and surrounding bone tissue; both received diagnostic and therapeutic nasal endoscopy for debridement. Histological analysis showed that the samples were compatible with mucormycosis. The patients underwent debridement and were treated with amphotericin B deoxycholate; however, they presented torpid evolution. Then, HBOT was added and the patients showed an evident improvement after four weeks of treatment with subsequent controls without the presence of mucormycosis. We highlight the favorable evolution of these patients while receiving HBOT as treatment for a disease with high morbimortality, which emerged during the pandemic.

Hemicraniectomía endonasal por estesioneuroblastoma: informe de un caso / Endonasal hemicraniectomy by esthesioneuroblastoma: report of a case

El estesioneuroblastoma es una neoplasia maligna que se origina del epitelio olfatorio. El tratamiento se establece de acuerdo con su extensión y el grado histológico de atipia y puede incluir cirugía, cirugía más radioterapia o más radioquimioterapia. Se han utilizado diferentes abordajes quirúrgicos que incluyeron incisiones faciales y craneotomía pero, con la mayor experiencia adquirida en cirugía endoscópica de senos paranasales y el trabajo en equipo con el neurocirujano, se han desarrollado técnicas endonasales que posibilitan realizar resecciones oncológicas en pacientes seleccionados, con menos morbilidad, internación breve y sin comprometer el control local de la enfermedad. Describimos el caso clínico de una paciente con un estesioneuroblastoma con invasión intracraneal, que fue tratada con éxito mediante una hemicraniectomía endonasal preservando el bulbo olfatorio contralateral. (AU)

Esthesioneuroblastoma is a malignant neoplasm that originates from the olfactory epithelium. Treatment is established according to its extension and the histological degree of atypia and may include surgery, surgery more radiotherapy or more chemoradiation therapy. Different surgical approaches have been used, including facial incisions and craniotomy, but with the greater experience acquired with endoscopic sinus surgery and teamwork with the neurosurgeon, endonasal techniques have been developed that make it possible to perform oncological resections in selected patients, with less morbidity, brief hospitalization and without compromising local control of the disease. We describe the clinical case of a patient with an esthesioneuroblastoma with intracranial invasion who was successfully treated by endonasal hemicraniectomy preserving the contralateral olfactory bulb. (AU)

Tratamiento endoscópico del esófago de Barrett con displasia de bajo y alto grado / Endoscopic treatment of Barrett's esophagus with low- and high-grade dysplasia

RESUMEN Introducción: El esófago de Barrett es una condición esofágica adquirida, que puede evolucionar a un adenocarcinoma. Con el paso de los años, la terapia endoscópica ha remplazado la cirugía en el tratamiento de esta afección. Objetivos: Mostrar los resultados de la aplicación de la técnica de resección endoscópica de la mucosa y la ablación con Hibrid-APC en pacientes portadores de esófago de Barrett con displasia de bajo o alto grado. Métodos: Se realizó un estudio descriptivo y retrospectivo en 29 pacientes entre los años 2014-2019, en el Servicio de endoscopias del Centro Nacional de Cirugía de Mínimo Acceso. Se estudiaron variables sociodemográficas, se estableció la clasificación endoscópica del esófago de Barrett, se describieron las características de la lesión, el diagnóstico histológico, la terapéutica endoscópica, la presencia de complicaciones, la resección incompleta y recidiva. Se aplicaron técnicas de estadística descriptiva y métodos no paramétricos. Resultados: Predominó el sexo masculino (58,62 %) y el grupo de 41-60 años (58,62 %). El segmento corto con lesiones planas y el largo con lesiones elevadas fueron más frecuentes (37,93 %). Se realizaron 15 resecciones y 14 ablaciones con Hibrid-APC; se observó una estenosis como complicación de la resección endoscópica de la mucosa y recidivas con ambas técnicas (5 pacientes, 17 %), tres relacionadas con la resección y dos con el Hibrid-APC. El Hibrid-APC alcanzó una efectividad terapéutica del 85,71 % y la resección del 80 %. Conclusiones: El tratamiento endoscópico con displasia de bajo y alto grado, mostró ser un procedimiento efectivo y seguro, con bajo porciento de complicaciones y recidivas.

ABSTRACT Introduction: Barrett's esophagus is an acquired esophageal condition that can evolve into an adenocarcinoma. Over the years, endoscopic therapy has replaced surgery in the treatment of this condition. Objectives: to show the results of the application of the endoscopic mucosal resection and Hybrid-APC ablation technique in patients with Barrett's esophagus with low-grade or high-grade dysplasia. Methods: a descriptive and retrospective study was carried out in 29 patients between 2014 and 2019, in the Endoscopy service of the National Center for Minimal Access Surgery. Social and demographic variables were studied; endoscopic classification of Barrett's esophagus was established, as well as the characteristics of the lesion, histological diagnosis, endoscopic therapy, the presence of complications, incomplete resection and recurrence were described. Descriptive statistics techniques and non-parametric methods were applied. Results: male gender (58.62%) and the group aged 41-60 years (58.62%) predominated. The short segment with flat lesions and the long segment with raised lesions were more frequent (37.93%). A number of 15 resections and 14 ablations were performed with Hybrid-APC; one stricture was observed as a complication of endoscopic mucosal resection and recurrences with both techniques (5 patients, 17%), three related to resection and two to Hybrid-APC. The Hybrid-APC achieved a therapeutic effectiveness of 85.71% and the resection one of 80%. Conclusions: endoscopic treatment with low- and high-grade dysplasia proved to be an effective and safe procedure, with a low percentage of complications and recurrences.

Evaluación del olfato en pacientes operados por adenoma hipofisario con acceso transesfenoidal en el Instituto de Neurocirugía Dr. Asenjo / Olfactory evaluation in patients operated for pituitary adenoma with transsphenoidal access at the Instituto de Neurocirugía Dr. Asenjo

Introducción: El olfato tiene una gran importancia en la calidad de vida. Los accesos quirúrgicos selares pueden realizarse por vía transcraneal, transeptal y transnasal, y pueden generar hiposmia al incluir resecciones que afectan a la mucosa olfatoria. Objetivo: Determinar la existencia de alteración persistente en el olfato ocasionado por los accesos quirúrgicos transeptal y transnasal en pacientes operados por adenoma hipofisiario en el Instituto de Neurocirugía Dr. Asenjo. Material y Método: Estudio prospectivo de cohorte con comparación de resultados olfatorios ("sniffin' sticks" versión extendida) y encuesta SNOT-22 pre y poscirugía por adenoma hipofisiario por vía transeptal o transnasal. Se utilizaron medidas estadísticas de comparación de pruebas pareadas paramétricas y no paramétricas según las características de las variables evaluadas. Resultados: Se reclutaron 60 pacientes, completando el seguimiento 39. En 21 se realizó acceso transeptal y en 18 transnasal. Al analizar el total de pacientes y por cada técnica quirúrgica, no hubo diferencias significativas en los puntajes del "sniffin' sticks" versión extendida y tampoco en SNOT-22. Conclusión: La literatura describe incidencia de hiposmia posoperatoria muy variable, entre 0% y 88%, con mediciones subjetivas y objetivas. Existe una predilección por la técnica endoscópica a nivel internacional, por lo que cuenta con estudios de mejor calidad. A nivel nacional existen dos estudios previos que han encontrado tasas de hiposmia posoperatoria de 10% y 14%. En este estudio no hubo diferencias significativas en los puntajes obtenidos en la prueba de olfato entre el pre y posoperatorio.

Introduction: Olfaction is of great importance in quality of life. Surgical accesses to the sellar region can be performed by transcranial, transseptal, and transnasal routes, which can generate hyposmia when including resections that affect the olfactory mucosa. Aim: To determine the existence of persistent alteration in olfaction caused by transseptal and transnasal surgical accesses in patients operated for pituitary adenoma at the Instituto de Neurocirugía Dr. Asenjo. Material and Method: Prospective cohort study with comparison of olfactory results ("sniffin' sticks" extended version) and SNOT-22 survey pre and post transseptal or transnasal surgery for pituitary adenoma. Parametric and non-parametric paired test comparison statistics were used according to the characteristics of the variables evaluated. Results: 60 patients were recruited and 39 completed follow-up. 21 patients underwent transseptal access and 18 underwent transnasal access. When analyzing the total number of patients and for each surgical technique, there were no significant differences in the scores obtained in the "sniffin' sticks" extended version and neither for the SNOT-22. Conclusion: The literature describes a highly variable incidence of postoperative hyposmia, between 0% and 88%, with subjective and objective measurements. There is a predilection for the endoscopic technique at an international level, which is why it has better quality studies. At the national level there are two previous studies that have found postoperative hyposmia rates of 10% and 14%. In this study there were no significant differences in the scores obtained between pre and postoperative olfaction test.

Nariz en silla de montar poscirugía transesfenoidal de hipófisis. Reconstrucción con cartílago costal / Saddle nose after transsphenoidal pituitary surgery. Reconstruction with rib cartilage

Durante los últimos años, la cirugía endoscópica transesfenoidal se ha convertido en el procedimiento quirúrgico de elección para el tratamiento de tumores hipofisarios. La técnica de abordaje actual es el resultado de una evolución histórica de vía por craneotomía a vía endonasal con ingreso a través del seno esfenoidal. Aunque la cirugía de tumores hipofisarios vía transesfenoidal endoscópica ha permitido disminuir las complicaciones graves asociadas a los abordajes externos, no está exenta de complicaciones, como la fístula de líquido cefalorraquídeo. A nivel del abordaje nasal, hay escasas descripciones de complicaciones y el compromiso del cartílago septal con deformidad en silla de montar no es una complicación documentada. Se presenta un caso de rinodeformidad en silla de montar poscirugía transesfenoidal de hipófisis en una paciente de 32 años a quien se le practicó una reconstrucción nasal con cartílago costal autólogo. En nuestra búsqueda bibliográfica es el primer caso registrado en Iberolatinoamérica

In recent years, transsphenoidal endoscopic surgery has become the surgical procedure of choice for the treatment of pituitary tumors. The current approach technique is the result of an historical evolution from craniotomy surgery to an endonasal procedure with entry through the sphenoid sinus. Although endoscopic transsphenoidal surgery has made it possible to reduce serious complications associated with external approaches, it is not without complications, such as cerebrospinal fluid fistula. At the level of the nasal approach, there are few descriptions of complications and involvement of the septal cartilage with saddle deformity is not a documented complication. We present a case of saddle rhinodeformity after transsphenoidal pituitary surgery in a 32-year-old patient who underwent nasal reconstruction with autologous costal cartilage. In our bibliographic search, it is the first case registered in IberoLatin America.

Endoluminal Vacuum Therapy (EVAC) in Managing Esophagogastric Anastomosis Fistula / Terapia de vacío endoluminal (Endo-Vac) en el manejo de la fístula de anastomosis esofagogástrica

Abstract Endoluminal vacuum therapy (EVAC) is a promising alternative for the endoscopic management of gastrointestinal fistulas or perforations that do not respond to endoscopic procedures using clips and stents or are even refractory to surgical procedures. In this case report, we describe the successful endoscopic closure of an esophagogastric anastomotic fistula using EVAC, connected to a vacuum system through a probe in the cavity, which did not close with clip management given the friability and edema of the peri-wound tissue. In conclusion, it is a successful alternative to treat these complications, which are sometimes difficult to resolve.

Resumen La terapia de vacío endoluminal (Endo-Vac) es una alternativa promisoria en el manejo endoscópico de las fístulas o perforaciones gastrointestinales, que no responden a procedimientos endoscópicos cuando se utilizan técnicas como clips, stents o incluso refractarias a procedimientos quirúrgicos. En este reporte de caso describimos el cierre endoscópico exitoso de una fístula anastomótica esofagogástrica, utilizando la terapia Endo-Vac, conectada a un sistema de vacío mediante una sonda en la cavidad, que no presentó cierre inicial a manejo con clips, dada la friabilidad y el edema del tejido perilesional. Se concluye que esta es una alternativa exitosa en el cierre de estas complicaciones, que en ocasiones son de difícil resolución.

Advantages of organ protection in colorectal tumor specimen collection through natural orifice specimen extraction surgery / 中华胃肠外科杂志

In recent years, natural orifice specimen extraction surgery (NOSES) has been widely used in surgery of colorectal cancer. The rapid development of NOSES is mainly attributed to its own great advantages and values, including the reduction of surgical trauma, the acceleration of postoperative recovery and the reduction of adverse psychological reactions for patients. These advantages of NOSES are also important embodiment and perfect interpretation of the organ functional protection. Organ functional preservation is a hot topic in surgery today, and it is also an inevitable requirement for minimally invasive surgery. Essentially, NOSES and organ functional preservation are proposed in the same background, and the goals are highly compatible. NOSES is an important practitioner of organ functional preservation, and organ functional preservation is also the vane of the development of the theoretical system of NOSES. These two items complement each other and together constitute the important element in the development of modern minimally invasive surgery. In order to comprehensively discuss the relationship between NOSES and organ functional protection, we elaborate the important role and value of functional protection in NOSES from five key procedures of colorectal surgery, namely surgical approach, extent of resection, lymph node dissection, digestive tract reconstruction and specimen extraction.

¿Cuándo deben operarse los quistes de retención en los senos paranasales? Revisión de la literatura / When should retention cysts in paranasal sinuses be operated? Literature review

Introducción: Los quistes de retención mucoso de los senos paranasales son un hallazgo imagenológico incidental muy frecuente. Usualmente comprometen el seno maxilar. Metodología: Se realizó una amplia búsqueda de la literatura, sobre quistes de retención mucoso nasosinusales, en enero de 2021 en múltiples bases de datos. Se seleccionaron 21 artículos sobre el tema para la realización de la revisión. Discusión: En la mayoría de los casos el tratamiento de los quistes de retención mucoso nasosinusales debe ser expectante debido a su tendencia a la involución y curso asintomático. Sin embargo, en la práctica clínica se observa con frecuencia un manejo quirúrgico sin una indicación clara. Conclusiones: Las indicaciones quirúrgicas de los quistes de retención mucoso son: obstrucción del ostium del seno paranasal, compromiso del complejo ostiomeatal o compromiso del nervio infraorbitario con síntomas secundarios. Es importante que el cirujano reconozca la naturaleza y comportamiento de esta patología para evitar procedimientos quirúrgicos innecesarios.

Introduction: Mucous retention cysts of the paranasal sinuses are a very common incidental imaging finding. They usually involve the maxillary sinus. Methodology: An extensive literature search on nasosinusal mucosal retention cysts was conducted in January 2021 through multiple databases. 21 articles on the subject were included as evidence for this paper. Discussion: In most cases, treatment should be expectant due to its tendency to involution and asymptomatic course. However, in clinical practice, surgical management is frequently observed without a clear indication. Conclusions: Surgical indications for mucosal retention cysts are: obstruction of the sinus ostium, involvement of the ostiomeatal complex, or involvement of the infraorbital nerve with secondary symptoms. It is important for the surgeon to recognize the nature and behavior of this pathology in order to avoid unnecessary surgical procedures.

Characteristics of patients undergoing robotic-assisted prostatectomy. Observational study / Características de pacientes sometidos a prostatectomía robótica. Estudio observacional

Abstract Introduction Prostatectomy is the standard treatment for patients with clinically localized prostate cancer. Currently, robot-assisted radical prostatectomy (RARP) is widely used for its advantages, as it provides better visualization, precision, and reduced tissue manipulation. However, RARP requires a multidisciplinary approach in which anesthesia and analgesia management are especially important. Objective This study aims to describe our experience delivering anesthesia for the first cases of patients undergoing RARP in a teaching hospital in Bogotá, Colombia. Methodology An observational study was conducted. We included all patients undergoing RARP from September 2015 to December 2019 at Fundación Santa Fe de Bogotá. All patients with incomplete data were excluded. Patient demographics were recorded, and significant perioperative events were reviewed. Results A total of 301 patients were included. At our institution, the mean age for patients undergoing RARP was 61.4 ± 6.7 years. The mean operative time was 205 ± 43 min and mean blood loss was 300 [200400] mL. Only 6 (2%) patients required transfusion. Age and BMI were not associated with clinical outcomes. Conclusions An adequate perioperative approach in RARP is important to minimize complications, which in this study and in this institution were infrequent.

Resumen Introducción La prostatectomía es el tratamiento estándar para pacientes con cáncer de próstata localizado. Actualmente, la prostatectomía radical asistida por robot es ampliamente utilizada por sus ventajas en visualización, precisión y manipulación de los tejidos. Sin embargo, este abordaje requiere un manejo multidisciplinario, pues el enfoque analgésico y anestésico es fundamental para optimizar los desenlaces. Objetivo Describir los primeros casos de prostatectomía radical asistida por robot realizadas en un hospital universitario de cuarto nivel en Bogotá, Colombia. Metodología Estudio observacional en el cual se incluyeron todos los pacientes sometidos a prostatectomía radical asistida por robot (PRAR) en el hospital Fundación Santa Fe de Bogotá entre septiembre de 2015 y diciembre de 2019. Se excluyeron los pacientes con historia clínica incompleta. Se registraron los datos demográficos y se revisaron los eventos perioperatorios importantes. Resultados Se analizaron 301 pacientes. La edad media de pacientes sometidos a PRAR fue 61,4 ± 6,7 años. El tiempo quirúrgico promedio fue 205 ± 43 minutos y la pérdida sanguínea media fue 300 [200-400] mL. Solo 6 pacientes (2 %) requirieron transfusión. La edad y el IMC no mostraron una asociación relevante con los desenlaces clínicos. Conclusiones El adecuado abordaje perioperatorio en PRAR es importante para minimizar las complicaciones, las cuales en este estudio y en esta institución fueron infrecuentes.

Pterygopalatine Fossa: Microsurgical Anatomy and its Relevance for Skull Base Surgery

Introduction The purpose of this study was to define the anatomical relationships of the pterygopalatine fossa (PPF) and its operative implications in skull base surgical approaches. Methods Ten cadaveric heads were dissected at the Dianne and M Gazi Yasargil Educational Center MicrosurgicaLaboratory, in Little Rock, AK, USA. The PPF was exposed through an extended dissection with mandible and pterygoid plate removal. Results The PPF has the shape of an inverted cone. Its boundaries are the pterygomaxillary fissure; themaxilla, anteriorly; themedial plate of the pterygoid process, and greater wing of the sphenoid process, posteriorly; the palatine bone,medially; and the body of the sphenoid process, superiorly. Its contents are the maxillary division of the trigeminal nerve and its branches; the pterygopalatine ganglion; the pterygopalatine portion of the maxillary artery (MA) and its branches; and the venous network. Differential diagnosis of PPF masses includes perineural tumoral extension along the maxillary nerve, schwannomas, neurofibromas, angiofibromas, hemangiomas, and ectopic salivary gland tissue. Transmaxillary and transpalatal approaches require extensive resection of bony structures and are narrow in the deeper part of the approach, impairing the surgical vision and maneuverability. Endoscopic surgery solves this problem, bringing the light source to the center of the surgical field, allowing proper visualization of the surgical field, extreme close-ups, and different view angles. Conclusion We provide detailed information on the fossa's boundaries, intercommunications with adjacent structures, anatomy of the maxillary artery, and its variations. It is discussed in the context of clinical affections and surgical approaches of this specific region, including pterygomaxillary disjunction and skull base tumors.

Endonasal Endoscopic Pituitary Adenoma Resection in light of the COVID-19 Pandemic: A Technical Report

Introduction The endoscopic endonasal transsphenoidal approach (EETA) is routinely used to treat sellar and suprasellar tumors. It provides safe and direct access to tumors in these locations, with wide visualization of anatomical landmarks and great surgical results. With the COVID-19 pandemic, despite the high risk of transmission involved, various surgical procedures cannot be postponed due to their emergency. Case Report A 62-year-old female presented in the previous two months with headaches, followed by bilateral severe visual loss. In 2016, she was submitted to subtotal resection of a non-secretorymacroadenoma. Because of the progressive visual deficits, the EETA was used to the resect the pituitary adenoma. Technical Note We developed a low-cost adaptation to the surgical fields, covering the patient's head and superior trunk with a regular surgicalmicroscope bag with a tiny slit to enable the endoscope and surgical instruments to enter the nose, thus protecting the personnel in the operating room from the aerosolization of particles. This makes surgery safer for the surgical team and for the patient. Conclusion In view of the lack of literature on this subject, except for some reports of experiences from some services around the world, we describe the way we have adjusted the EETA in the context of the COVID-19 pandemic.

Tumores de Fosa Pterigopalatina: Tipos de abordajes quirúrgicos y complicaciones / Pterygopalatine Fossa Tumors: Types of surgical approaches and complications

INTRODUCCIÓN. La fosa pterigopalatina es una zona anatómica de difícil acceso, que al presentar masas tumorales genera un alto riesgo de morbimortalidad en población juvenil y adulta, que precisa determinar las complicaciones asociadas a cirugía. OBJETIVO. Evaluar los tipos de abordaje quirúrgico, complicaciones e identificar la estirpe histológica de los tumores de fosa pte-rigopalatina. MATERIALES Y MÉTODOS. Estudio transversal retrospectivo. Población y muestra conocida de 29 Historias Clínicas de pacientes con hallazgos de imagen e histopatológico de tumores con invasión a fosa pterigopalatina divididos en dos grupos: A) resección de masa tumoral y B) biopsia de masa tumoral, operados en el Hospital de Especialidades Carlos Andrade Marín en el período de enero 2017 a diciembre de 2020. RESULTADOS. El 82,76% (24; 29) fueron hombres, con promedio de edad de 30,6 años. El 82,76% (24; 29) de las masas tumorales se originaron en nasofaringe; no se reportaron casos primarios. El tumor más frecuente fue el Angio-fibroma Nasofaringeo Juvenil 68,97% (20; 29), seguido por los tumores malignos con el 20,69% (6; 29), siendo usual el carcinoma adenoideo quístico. En el 62,07% (18; 29) el tumor invadió Fosa Infratemporal y en el 44,83% (13; 29) hacia esfenoides. En el grupo A, el abordaje quirúrgico empleado en el 20,83% (5; 24) fue mediante técnica abierta y en el 79,17% (19; 24) con técnica endoscópica, tanto uni 31,58% (6; 19) como multiportal 68,42% (13; 19). La complicación fue la hiposensibilidad facial en el 12,5% (3; 24), todos en abordajes abiertos. CONCLUSIÓN. Se evaluó los tipos abordaje quirúrgico y se identificó la estirpe histológica de los tumores de fosa pterigopalatina

INTRODUCTION. The pterygopalatine fossa is an anatomical area of difficult access, which when presenting tumor masses generates a high risk of morbimortality in the juvenile and adult popula-tion, which needs to determine the complications associated with surgery. OBJECTIVE. To eva-luate the types of surgical approach, complications and identify the histologic type of pterygopala-tine fossa tumors. MATERIALS AND METHODS. Retrospective cross-sectional study. Population and known sample of 29 Clinical Histories of patients with imaging and histopathological findings of tumors with invasion to pterygopalatine fossa divided into two groups: A) resection of tumor mass and B) biopsy of tumor mass, operated at the Carlos Andrade Marín Specialty Hospital in the period from january 2017 to december 2020. RESULTS. The 82,76% (24; 29) were men, with an average age of 30,6 years. 82,76% (24; 29) of the tumor masses originated in nasopharynx; no primary cases were reported. The most frequent tumor was juvenile nasopharyngeal angiofibroma 68,97% (20; 29), followed by malignant tumors with 20,69% (6; 29), being usual the adenoid cystic carcinoma. In 62,07% (18; 29) the tumor invaded the Infratemporal Fossa and in 44,83% (13; 29) into the sphenoid. In group A, the surgical approach used in 20,83% (5; 24) was by open technique and in 79,17% (19; 24) by endoscopic technique, both uni 31,58% (6; 19) and multiportal 68,42% (13; 19). The complication was facial hyposensitivity in 12,5% (3; 24), all in open approaches. CONCLUSION. The types of surgical approach were evaluated and the histologic type of pterygo-palatine fossa tumors was identified.

Complications of transoral endoscopic thyroidectomy vestibular approach (TOETVA) / Tireoidectomia endoscópica transoral por acesso vestibular (TOETVA) e complicações

ABSTRACT The thyroidectomy is the most frequently executed procedure in head and neck surgery. Since its first description by Kocher, the transverse cervical incision has been the main access to the thyroid site, as it provides broad exposure of the central neck compartment. Despite the meticulous suture of the incision, the development of a scar with variable dimensions is unavoidable and, hence, some patients might not agree to the approach, due to this consequence. The transoral endoscopic thyroidectomy vestibular access (TOETVA) gains importance as an alternative to the traditional surgery, since it avoids the formation of visible scars. The objective of this study is to develop a systematic review on the currently available literature to evaluate possible complications related to the TOETVA. The systematic review was based on the databases of Medline, Cochrane library, Embase and Scielo/Lilacs, resulting in the selection of six studies, which were compared in regard of the type of study duration of the study and identified complications. Our study showed that TOETVA is related to complications similar to the ones identified in the conventional approach, such as hematoma, seroma, recurrent laryngeal nerve injury, hypoparathyroidism, surgical site infection. The TOETVA was associated to a higher risk of thermic injury of the skin and mentual nerve paresthesia. Moreover, it was possible to conclude that TOETVA is a safe procedure for well selected patients, with favorable conditions and concerned about the aesthetic outcome. The risk of complications of the procedure should always be explained to those patients.

RESUMO A tireoidectomia é o procedimento cirúrgico mais frequentemente realizado na cirurgia de cabeça e pescoço. Desde sua descrição por Kocher, a incisão cervical transversa constitui o principal acesso à loja tireoideana e permite ampla exposição à região central do pescoço. Apesar do fechamento meticuloso da incisão, uma cicatriz de dimensões variáveis é inevitável, e certos pacientes podem discordar de tal abordagem. A tireoidectomia vestibular endoscópica transoral (TOETVA) ganha importância como alternativa à cirurgia tradicional, pois evita a formação de cicatrizes visíveis. O objetivo de estudo é realizar uma revisão sistemática da literatura das possíveis complicações da TOETVA. Foi realizada revisão sistemática da literatura nas bases de dados Medline, The Cochrane Library, Embase e SciElo/Lilacs, sendo selecionados seis artigos e tabulados os dados de tipo de estudo, período do estudo e complicações apresentadas. O estudo mostra que a TOETVA apresenta complicações semelhantes à técnica convencional, como hematoma, seroma, lesão de nervo laríngeo recorrente, hipoparatireoidismo, além de infecção de sítio cirúrgico, com maior risco de lesão térmica da pele e parestesia por lesão do nervo mentual. Em adição, foi possível concluir que a TOETVA é uma técnica segura para pacientes bem selecionados, com condições favoráveis e com especial preocupação com resultados estéticos, devendo sempre ser orientados sobre possíveis complicações.

A novelty in laparoscopic total colectomy with natural orifice specimen extraction using a plastic cover / Uma novidade na colectomia total laparoscópica com extração de espécime em orifício natural usando uma cobertura plastic

Abstract Introduction: Minimally invasive colectomy has been performed for some years for many patients worldwide without much complications compared to the open approach. In this study we explained our experience regarding a modification in laparoscopic total colectomy and removing the specimen with Natural Orifice Specimen Extraction (NOSE) through rectum using a plastic cover for the first time. Methods and material: This was an experimental study on a new technique of total colectomy with a small modification. Total colectomy was performed based on 7 port laparoscopic approach. Rectum was sparred. Colon was then taken out through the anal canal using a plastic cover. Results: Thirteen patients underwent laparoscopic total colectomy by removal of the specimen through rectum. Mean age of patients was 42.23 ± 8.15 years. Mean duration of operation was 130 ± 32.4 min. All patients had an uneventful postoperative hospitalization. Discussion: Laparoscopic total colectomy has been proven to have superior benefits than the open approach. In NOSE technique, colon is removed from the anal canal without any complication or consuming much time. This technique might have less pain and removes the complications associated with an incision on the skin to remove the specimen. Also, due to low price of a usual plastic cover, it can be used instead of other techniques to remove the specimen through the rectum.

Resumo Introdução: A colectomia minimamente invasiva vem sendo realizada há alguns anos em muitos pacientes no mundo inteiro, apresentando menos intercorrências do que a abordagem aberta. Neste estudo, os autores relatam sua experiência com uma modificação da colectomia total laparoscópica e extração de espécime em orifício natural (NOSE) pelo reto, usando uma cobertura plástica pela primeira vez. Métodos e materiais: Este foi um estudo experimental sobre uma nova técnica de colectomia total com uma pequena modificação. A colectomia total foi realizada com base na abordagem laparoscópica de sete portas. O reto foi poupado. O cólon foi então retirado pelo canal anal usando uma cobertura plástica. Resultados: Treze pacientes foram submetidos a colectomia total laparoscópica por remoção do espécime pelo reto. A idade média dos pacientes foi de 42,23 ± 8,15 anos. A duração média da operação foi de 130 ± 32,4 minutos. Para todos os pacientes, a internação pós-operatória transcorreu sem intercorrências. Discussão: Foi comprovado que a colectomia total laparoscópica apresenta benefícios superiores à abordagem aberta. Na técnica NOSE, o cólon é removido mais rapidamente do canal anal, sem nenhuma intercorrência. Essa técnica pode causar menos dor e remove as complicações associadas a uma incisão na pele para remover o espécime. Além disso, devido ao baixo preço de uma cobertura plástica comum, ela pode ser usada no lugar de outras técnicas para remover o espécime pelo reto.

Tiroidectomía transoral endoscópica por abordaje vestibular / Transoral endoscopic thyroidectomy by vestibular approach

La cirugía endoscópica transluminal a través de orificios naturales (NOTES) ha sido aplicada por primera vez por K. Witzel en el año 2008, introduciendo el abordaje transoral para la patología tiroidea en cadáveres y puercos. En el año 2016, A. Anuwong publicó la primera serie de casos en seres humanos por abordaje vestibular. Referimos en esta ocasión el caso de una paciente de 37 años, quien acudió a la consulta por presentar una tumoración cervical anterior de dos meses de evolución. Ecografía tiroidea con bocio polinodular. Punción aspiración con aguja fina: lesión con hiperplasia folicular en lóbulo derecho e izquierdo. Se decide realizar tiroidectomía transoral endoscópica por abordaje vestibular. La duración de la intervención fue de 180 minutos, la pérdida sanguínea fue de 20 mL. El dolor, escaso y el tiempo de internación, 36 horas. En el presente trabajo se propone el desarrollo de esta técnica y la experiencia en nuestro primer caso de tiroidectomía total en patología tiroidea benigna.

Natural orifice transluminal endoscopic surgery (NOTES) was applied for the first time by K. Witzel in 2008, introducing the transoral endoscopic resection of the thyroid gland in human cadavers and living pigs. In 2016, A. Anuwong published the first case series using the vestibular approach in humans. We report the case of a 37-year-old female patient with a mass in the anterior aspect of the neck which appeared two months before consultation. The thyroid ultrasound reported multinodular goiter. The fine-needle aspiration (FNA) biopsy reported hyperplastic follicular nodule in both lobes. The patient underwent transoral endoscopic thyroidectomy by vestibular approach. Operative time was 180 minutes and blood loss was 20 mL. Pain was minimal and hospital stay was 36 hours. We report our first experience with total thyroidectomy in a patient with benign thyroid nodules.

Efecto de la intervención nasal y nasosinusal en calidad de sueño en el Hospital Edgardo Rebagliati Martins 2017 / Effect of nasal and sinus surgery on sleep quality at the Hospital Edgardo Rebagliati Martins during 2017

Objetivo: Determinar el efecto de la cirugía nasal y nasosinusal endoscópica sobre la calidad de sueño en el Servicio de Otorrinolaringología del Hospital Edgardo Rebagliati Martins durante el año 2017.Materiales y métodos: Estudio retrospectivo y longitudinal. La muestra es de 92 pacientes operados en quienes se evaluó la calidad de sueño mediante el Índice de calidad de sueño de Pittsburgh. Los datos fueron analizados con SPSS versión 24 y se realizó análisis univariado, Mann-Whitney, correlación de Spearman y prueba de rango con signo de Wilcoxon. Resultados: La calidad de sueño mejoró después de la operación nasal y nasosinusal endoscópica (p<0,01), al igual que la obstrucción nasal (p<0,01). En los datos preoperatorios, se encontró correlación entre IMC (índice de masa corporal) y obstrucción nasal con calidad de sueño.Conclusiones: Las operaciones nasal y nasosinusal endoscópica tienen un efecto positivo sobre calidad de sueño en pacientes del Servicio de Otorrinolaringología del Hospital Edgardo Rebagliati Martins 2017.

Objective: To determine the effect of nasal and sinus endoscopic surgery on sleep quality at the Otorhinolaryngology Department of the Hospital Edgardo Rebagliati Martins during 2017. Materials and methods: A retrospective and longitudinal study was conducted with a sample of 92 patients who underwent surgery and whose sleep quality was assessed using the Pittsburgh Sleep Quality Index. The data was analyzed using software SPSS version 24. Additionally, a univariate analysis, Mann-Whitney U test, Spearman ́s rank correlation coefficient and Wilcoxon signed rank test were used in the study.Results: Both sleep quality (p <0.01) and nasal obstruction (p <0.01) improved after nasal and sinus endoscopic surgery. The preoperative data shows that BMI (body mass index) and nasal obstruction have a correlation with sleep quality.Conclusions: Nasal and sinus endoscopic surgery had a positive effect on sleep quality in patients of the Otorhinolaryngology Department of the Hospital Edgardo Rebagliati Martins during 2017.

Total Endoscopic Transcanal Cartilage Myringoplasty: A Prospective Study

Introduction: Middle ear surgeries, including myringoplasty, have increasingly utilized endoscopes as an adjunct to or as a replacement for the operative microscope. Objectives: The objective of the present study was to evaluate the graft uptake rate and to evaluate the hearing results. Methods: This is a prospective study. We have analyzed 139 patients who underwent surgery for chronic otitis media (COM) of the mucosal type. All of the surgeries were performed exclusively under total endoscopic transcanal approach using tragal cartilage as graft, underlay technique. We have evaluated the postoperative graft uptake and performed a hearing evaluation at 6 weeks, at 12 weeks, and at 6 months. Results: During the study period, 139 patients were included, out of which 13 were lost to follow-up; therefore, only 126 patients were assessed. All of the cases were performed under total endoscopic approach. As for the surgical outcome at the postoperative otoscopy, 3 cases had initial uptake at 3 months and failed later; therefore, complete closure of the perforation was observed in 97.6% ( n = 123) of the patients 6 months after the intervention. Four patients presented with preoperative anacusis; therefore, only 122 patients were included for hearing evaluation. The preoperative air conduction threshold (ACT) and airbone gap (ABG) were 43.34 ± 11.53 and 24.73 ± 7.89, respectively. Postoperatively, the ACT and ABG closure were 28.73 ± 15.75 and 11.91 ± 8.41, respectively. This difference was statistically significant ( p < 0.001). Conclusion: The endoscopic approach for myringoplasty offers excellent visualization; avoids postaural approach, enables a faster recovery, requires less hospital stay, with excellent graft closure rate and improved functional outcomes (AU)