Rinoplastia secundaria: infección nasal en el postoperatorio / Secondary rhinoplasty: postoperative nasal infection

La rinoplastia es una de las intervenciones más comunes en cirugía plástica. Se opera aquí una rinoplastia secundaria por vía abierta injertando los alares y la punta con cartílagos auriculares, mientras el tabique cartilaginoso fue usado para los spreader grafts. Se describe aquí una infección posoperatoria de su punta nasal. Al 9no día de su posoperatorio comienza con la punta nasal congestiva y levemente inflamada. Se medica con una crema con antibióticos, pero el día 14 aparece con la punta nasal muy inflamada y con colección. Cuando en el consultorio el cirujano la ve, como cualquier absceso, decide realizarle drenaje con un trocar 18G, 3 miniincisiones en la piel debajo de la punta nasal, de la que drena un líquido amarronado. Luego con el mismo trocar se realiza un lavado dentro de la cavidad con rifampicina solución. Se medica con trimetoprima-sulfametoxazol (Bactrimforte®) 2 comp/día. Al otro día se observa una notable mejoría. Se continuó con lavado diario durante 4 días con el mismo antibiótico evolucionando rápidamente bien. El Bactrim se lo continúa por 20 días. Al mes la punta nasal está muy bien, deshinchada con cicatrices apenas visibles. A los cuatro meses, la punta está muy blanda, las alas nasales y las narinas normales, la punta con buena proyección igual que el dorso con los spreader graft.

Rhinoplasty is one of the most common interventions in plastic surgery. A secondary open rhinoplasty was carried out grafting the allae and the tip of the nose with conchae cartilage, while the septum was used for spreader grafts. We are here describing this post operatory with a tip of the nose infection.In the control, at the 9th postoperative day, the nasal tip began to be congested and at the 14th post op day the patient showed a clear inflammatory collection. In the office, the surgeon decided to evacuate it with three punctureslike little incisions at the inferior part of the skin tip with a trocar 18G. Through them, drained brownish purulent secretion. With the same trocar, rifampicin solution was injected through these little incisions, like washing the subdermal area. It was medicated with trimethoprim-sulfamethoxazole (Bactrim forte®) 2 tablets/day. The following day, there was a clear improvement in the congestion and erythema of the nose. This procedure of washing was repeated for four days. There was a quick evolution of the inflammatory process and 20 more days, there was no sign of the infection. Four months later, the tip of the nose was soft and the result was considered optimal by the patient and doctors.

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.

Protocolo de Manejo de Cirugía Metabólica y Bariátrica del Hospital de Especialidades Carlos Andrade Marín / Management Protocol for Metabolic and Bariatric Surgery at the Carlos Andrade Marín Specialties Hospital

1. INTRODUCCIÓN. La obesidad mórbida es una enfermedad crónica multifactorial asociada a complicaciones físicas y psicológicas que empeoran la calidad de vida de los pacientes y disminuyen su esperanza de vida; es un problema sanitario de primera magnitud debido al incremento de esta patología en Ecuador y a las dificultades que entraña su prevención y tratamiento. La cirugía de la obesidad es compleja, no exenta de complicaciones, cuyo objetivo es reducir de manera significativa las comorbilidades asociadas y mejorar el bienestar de los pacientes, cuya técnica quirúrgica sea fácil de reproducir, con porcentajes de revisión bajos y que constituya un tratamiento eficaz y seguro para la obesidad clínicamente grave, con evidencia que demuestra reducción de la mortalidad por todas las causas, mejoría en la expectativa y calidad de vida de los pacientes1.

1. INTRODUCTION. Morbid obesity is a multifactorial chronic disease associated with physical and psychological complications that worsen the quality of life of patients and decrease their life expectancy; it is a health problem of the first magnitude due to the increase of this pathology in Ecuador and the difficulties involved in its prevention and treatment. Obesity surgery is complex, not exempt of complications, whose objective is to significantly reduce associated comorbidities and improve the well-being of patients, whose surgical technique is easy to reproduce, with low revision percentages and that constitutes an effective and safe treatment for clinically severe obesity, with evidence that shows a reduction in all-cause mortality, improvement in life expectancy and quality of life of patients1.

Complicaciones posoperatorias inmediatas en pacientes diabéticos tipo 2 operados de catarata por la técnica de facochop / Immediate postoperative complications in type 2 diabetic patients undergoing phaco chop cataract surgery

Objetivo: Describir la posible presencia de complicaciones posoperatorias en pacientes diabéticos tipo 2, operados de catarata por la técnica de facochop. Métodos: Se realizó un estudio observacional, descriptivo, y longitudinal prospectivo, con 128 pacientes diabéticos (168 ojos) operados de catarata en el Centro de Microcirugía Ocular del Instituto Cubano de Oftalmología "Ramón Pando Ferrer", entre septiembre del año 2017 y diciembre de 2018. Las variables clínicas y epidemiológicas objeto del estudio fueron la edad, el sexo, el color de la piel, la queratometría, la profundidad de la cámara, la longitud axial, la dureza del cristalino, la presión intraocular pre- y posoperatoria y las complicaciones posoperatorias en las primeras 72 horas. Resultados: En el estudio predominaron las mujeres (63,3 por ciento), de piel blanca (74,2 por ciento), quienes presentaron ojos biométricamente normales, con una diferencia estadísticamente significativa. La presión intraocular aumentó a las 24 horas de la cirugía. De los 128 pacientes diabéticos tipo 2 operados de catarata senil por la técnica de facochop, se pudo determinar que el promedio y la desviación estándar de la edad se ubicaron en los 69,49 ± 8,96 años, y osciló entre los 50 y 88 años. Conclusiones: Las complicaciones posoperatorias más frecuentes son el edema corneal y la uveítis. Es significativamente más probable encontrar la uveítis posquirúrgica en pacientes menores de 70 años, y el edema corneal en quienes sobrepasan esta edad(AU)

Objective: Describe the possible presence of postoperative complications in type 2 diabetic patients undergoing phaco chop cataract surgery. Methods: An observational prospective longitudinal descriptive study was conducted of 128 diabetic patients (168 eyes) undergoing cataract surgery at the Center for Ocular Microsurgery of Ramón Pando Ferrer Cuban Institute of Ophthalmology from September 2017 to December 2018. The clinical and epidemiological variables analyzed were age, sex, skin color, keratometry, chamber depth, axial length, crystalline hardness, pre- and postoperative intraocular pressure, and postoperative complications in the first 72 hours. Results: A predominance was found of women (63.3 percent) of white skin color (74.2 percent) and biometrically normal eyes, with a statistically significant difference. Intraocular pressure rose 24 hours after surgery. Mean age and standard deviation were 69.49 ± 8.96 years, range of 50-88 years, in the 128 type 2 diabetic patients undergoing senile cataract surgery by the phaco chop technique. Conclusions: The most common postoperative complications are corneal edema and uveitis. It is significantly more probable to find postsurgical uveitis in patients aged under 70 years and corneal edema in patients aged over 70 years(AU)

Síndrome de resección anterior baja en pacientes con cáncer de recto medio e inferior ¿Qué más podemos hacer? / Low anterior resection syndrome in patients with medium and low rectal cancer. What else can we do?

Resumen Durante las últimas décadas los avances en técnicas quirúrgicas, radioterapia y quimioterapia han logrado de forma significativa aumentar la sobrevida y disminuir la recidiva local en el cáncer de recto evitando una colostomía definitiva; sin embargo, este trascendental progreso médico no ha ido acompañado de una mejoría en los resultados funcionales de los pacientes sometidos a una cirugía conservadora de esfínter, siendo el conjunto de síntomas defecatorios posterior a la resección rectal, conocido como síndrome de resección anterior baja (LARS), una secuela prácticamente inevitable, que generalmente se asocia a disfunción sexual, urinaria, dolor crónico, altos costos en rehabilitación y control sintomático, además de una alteración importante en la calidad de vida. En este artículo presentamos una revisión completa y actualizada de las características clínicas y alternativas de tratamiento del LARS, finalizando con una propuesta de manejo integral multidisciplinario que destaca la importancia de la prehabilitación, evaluación objetiva de los síntomas, educación e información adecuada del paciente y su familia, además del trabajo en equipo en unidades especializadas de rehabilitación de piso pélvico, requisito fundamental a la hora de manejar adecuadamente esta patología.

During the last decades, advances in surgical techniques, radiotherapy and chemotherapy have significantly increased survival and reduced local recurrence in rectal cancer, avoiding a definitive colostomy. However, this transcendental medical progress has not been accompanied by an improvement in the functional results of patients after sphincter-preserving rectal resection, being the set of defecatory symptoms after rectal resection, known as low anterior resection syndrome (LARS), a practically inevitable sequel, which is usually associated with sexual or urinary dysfunction, chronic pain, high costs and an important alteration in the quality of life. In this article, we will present a complete and updated review of the clinical and alternative characteristics of LARS treatment, ending with a proposal for multidisciplinary and integral management that highlights the importance of prehabilitation, objective evaluation of symptoms, education and adequate information of the patient and his family, in addition to teamwork in units specialized in pelvic floor rehabilitation, a fundamental requirement when properly managing this pathology.

Tratamento de crescimento epitelial persistente pós-Lasik com debridamento mecânico, uso de álcool a 20% e cola de fibrina / Treatment of persistent epithelial ingrowth after Lasik with mechanical debridement, use of 20% alcohol and fibrin glue

RESUMO O Lasik é a técnica de cirurgia refrativa mais utilizada no mundo. Apesar de segura e efetiva, ela pode levar a algumas complicações. O crescimento epitelial pós-Lasik é uma complicação pós-operatória incomum, com prevalência maior em casos de retratamento. Geralmente, é um achado não progressivo e assintomático, que não requer tratamento, mas, em uma minoria de pacientes, os sintomas podem ser clinicamente significantes e variados. O tratamento é feito com debridamento mecânico do crescimento epitelial, mas alguns recursos adjuvantes também podem ser utilizados. O presente estudo consiste em um relato de caso de paciente com crescimento epitelial pós-Lasik que apresentou quatro recidivas após intervenções de debridamento epitelial, sutura de lamela corneana e ablação a laser. No quinto procedimento, o paciente foi finalmente tratado com combinação de debridamento epitelial, uso de álcool a 20% e cola de fibrina. Entretanto, a regressão do crescimento epitelial e a melhora da acuidade visual só ocorreram ao longo dos meses após a intervenção, o que mostra a importância de esperar um tempo para que ocorra a melhora da visão no pós-operatório, evitando-se reintervenções.

ABSTRACT Lasik is the most often performed laser refractive surgery worldwide. Despite its efficacy and safety, some complications may occur. Epithelial ingrowth is a rare postoperative complication of Lasik, with an increased prevalence in cases of retreatment. Epithelial ingrowth is usually a nonprogressive and asymptomatic finding, which requires no treatment; however, in a minority of cases, symptoms may be clinically significant and diverse. Treatment is done with mechanical debridement of the affected interface, and additional interventions may be required. This study reported a case of recalcitrant epithelial ingrowth after Lasik, whichrelapsed four times after mechanical debridement, flap lift and laser ablation. In the fifth intervention, the patient was finally treated with a combined scraping/use of 20% alcohol and fibrin glue. However, regression of epithelial ingrowth and better visual acuity were only observed some months after the intervention, which shows the importance of waiting for better vision in the postoperative period, thus avoiding new reinterventions.

Resultado del tratamiento quirúrgico del cáncer de tiroides Hospital Universitario Comandante "Faustino Pérez Hernández" Matanzas / Outcome of thyroid cancer surgical treatment. University Hospital ¨Comandante Faustino Pérez Hernández. Matanzas

RESUMEN Introducción: el cáncer de tiroides representa un 1% del total de todos los tipos de cáncer. Su incidencia parece aumentar un 4% cada año, y en la actualidad es el octavo cáncer más frecuente en mujeres. Objetivo: evaluar el resultado del tratamiento quirúrgico en el cáncer de tiroides. Materiales y métodos: se realizó un estudio observacional, descriptivo y retrospectivo que incluye todos los pacientes operados de cáncer tiroides en el servicio de Cirugía General del Hospital Universitario "Comandante Faustino Pérez Hernández", en el período desde enero de 1993 a diciembre del 2018. Se empleó un modelo recolector de datos con las variables de interés para el estudio y los resultados se presentaron en tablas de frecuencia, números y porciento. Resultados: el cáncer de tiroides fue más frecuente en el grupo etario de 31 a 50 años, predomino el sexo femenino, la variedad histológica papilar fue la más frecuente, la técnica quirúrgica más empleada fue la tiroidectomía total. El hipotiroidismo fue la complicación más encontrada. Conclusiones: el cáncer de tiroides es más frecuente en pacientes relativamente jóvenes y del sexo femenino, la variedad papilar, la tiroidectomía total y el hipotiroidismo como complicación posquirúrgica son los de más incidencia (AU).

SUMMARY Introduction: thyroid cancer represents 1% of the total of all kinds of cancer. Its incidence seems to increase 4% every year, and at the present time it is the eighth more frequent cancer in women. Objective: to evaluate the results of the thyroid cancer surgical treatment. Materials and methods: a retrospective, descriptive, observational study was carried out including all patients who underwent a surgery of thyroid cancer in the service of General Surgery of the University Hospital ¨Comandante Faustino Perez Hernandez¨ in the period from January 1993 to December 2018. A data collector model was used with the variables of interest for the study and the results were presented by charts of frequency, numbers and percent. Results: the thyroid cancer was more frequent in the age group of 31 to 50 years; the female sex prevailed; the most frequent variety was the histological papillary one; the most used surgical technique was total thyroidectomy. Hypothyroidism was the most commonly found complication. Conclusions: thyroid cancer is more frequent in relatively young, female patients; the papillary variety, total thyroidectomy and hypothyroidism as surgical complication are the ones with higher incidence (AU).

Cirugía bariátrica en adolescentes con obesidad severa: recomendaciones de la Rama de Nutrición, Sociedad Chilena de Pediatría / Bariatric surgery in adolescents with severe obesity: recommendations of the Nutrition Branch, Chilean Pediatric Society

Resumen: En los últimos años, la obesidad severa en adolescentes ha aumentado a nivel mundial y Chile no es la excepción a este fenómeno. Es conocido que esta condición aumenta exponencialmente los riesgos para la salud y se asocia a mortalidad prematura. Desde el año 2008, diversas guías de tratamiento de obesidad pediátrica han incluido a la cirugía bariátrica como una estrategia de tratamiento para adolescentes obesos severos seleccionados. Estos procedimientos han mostrado ser seguros y eficaces en adultos. Un cuerpo emergente de evidencia demuestra que, en centros especializados, en el corto y mediano plazo se obtendrían resultados similares en adolescentes. Sin embargo, en este grupo de pacientes, la cirugía bariátrica tiene implícitos otros riesgos inherentes a la etapa de desarrollo en que se encuentran, y los resultados y complicaciones especialmente de largo plazo en gran medida son aún desconocidos. Por lo anterior y para el logro de los resultados esperados, es muy importante que la selección de pacientes, la cirugía y el seguimiento, sean realizados por equipos multidisciplinarios calificados, en centros hospitalarios que cuenten con la infraestructura adecuada, siendo imprescin dible la adherencia de por vida al seguimiento médico y nutricional. El objetivo de este documento es presentar la postura de la Rama de Nutrición de la Sociedad Chilena de Pediatría (SOCHIPE) frente a las diversas aristas a considerar para la adecuada indicación de estos procedimientos en adolescentes obesos severos.

Abstract: In recent years, severe obesity in adolescents has been rising worldwide, and Chile is no exception to this phenomenon. This condition exponentially increases health risks and it is associated with prema ture mortality. Since 2008, several guidelines on pediatric obesity treatment have included bariatric surgery as a treatment strategy for certain severely obese adolescents. These procedures have proven to be safe and efficient in adults. Recent evidence shows that, when done in specialized centers, the re sults would be similar in adolescents in the short and medium term. Nonetheless, in this group of pa tients, bariatric surgery has risks related to their stage of development, and data on long-term results and complications are still lacking. Therefore, to achieve the expected results, the patient selection, surgery, and follow-up must be carried out by qualified multidisciplinary teams, in hospitals centers that have the appropriate infrastructure, It is essential for the patients a life-long adherence to medi cal and nutritional monitoring. The objective of this document is to present the position statement of the Nutrition Branch of the Chilean Society of Pediatrics on the different issues to be considered for the adequate indication of these procedures in severely obese adolescents.

Pre-emptive low-dose ketamine with local anesthesia reduces postoperative morbidity after third molar surgery: a systematic review and meta-analysis / Ketamina en dosis bajas con anestesia local reduce la morbilidad postoperatoria de la cirugía del tercer molar: revisión sistemática y metanálisis

Objective: This review addresses a clinical research question related to lower third molar surgery (L3MS): does the combination of pre-emptive low-dose ketamine with local anesthesia (KLA) reduce postoperative complications compared with local anesthesia (LA) alone? Material and methods: A systematic literature search was performed to identify eligible articles by electronic searches of PubMed, Cochrane Central Register of Controlled Trials, EBSCO Library, Web of Science and grey literature through June 2019 without data or language restrictions. We analyzed all randomized controlled clinical studies (RCTs) comparing use of KLA with use of LA in L3MS regarding pain, swelling, and trismus outcomes. The quality of evidence was rated according to Cochrane's tool for assessing risk of bias. Results: Five RCTs encompassing 230 extraction sites (KLA = 115, LA = 115) were included in this study. The standardized mean difference (SMD) with the 95% confidence interval (CI) was used to synthesize the results. The data show that there were significant differences between the two groups in post-operative pain (SMD -1.464, 95% CI -1.683 to -0.949, p= 0.001) and swelling (SMD -0.450, 95% CI -0.758 to -0.142, p= 0.004, all low quality evidence). However, there was no significant difference in the trismus (SMD -0.754, CI -1.487 to -0.022, p = 0.043, very low quality evidence). Conclusion: The combination of pre-emptive low-dose ketamine with LA significantly decreased pain and swelling within the first 24 hours after L3MS compared with the control group.

Objetivo: Esta revisión aborda una pregunta de investigación clínica relacionada con la cirugía del tercer molar inferior (L3MS): ¿la combinación de ketamina preventiva en dosis bajas con anestesia local (KLA) reduce las complicaciones postoperatorias en comparación con la anestesia local (AL) sola? Material y Métodos: Se realizó una búsqueda bibliográfica sistemática para identificar artículos elegibles mediante búsquedas electrónicas en PubMed, Registro Cochrane Central de Ensayos Controlados, Biblioteca EBSCO, Web of Science y literatura gris hasta junio de 2019 sin restricciones de datos ni de idioma. Se analizaron todos los estudios clínicos controlados aleatorios (ECA) que compararon el uso de KLA con el uso de LA en L3MS con respecto a los resultados de dolor, hinchazón y trismo. La calidad de la evidencia se clasificó de acuerdo con la herramienta Cochrane para evaluar el riesgo de sesgo. Resultados: Se incluyeron en este estudio cinco ECA que abarcan 230 sitios de extracción (KLA = 115, LA = 115). La diferencia de medias estandarizada (DME) con el intervalo de confianza (IC) del 95% se utilizó para sintetizar los resultados. Los datos muestran que hubo diferencias significativas entre los dos grupos en el dolor posoperatorio (DME -1,464; IC del 95%: -1,683 a -0,949; p= 0,001) e hinchazón (DME -0,450; IC del 95%: -0,758 a -0,142, p= 0,004, todas las pruebas de baja calidad). Sin embargo, no hubo diferencias significativas en el trismo (DME -0,754; IC: -1,487 a -0,022; p= 0,043, evidencia de muy baja calidad). Conclusión: La combinación de ketamina preventiva en dosis bajas con LA disminuyó significativamente el dolor y la hinchazón dentro de las primeras 24 horas después de la L3MS en comparación con el grupo de control.

Extubación fallida postoperación de Norwood en pacientes con síndrome de hipoplasia de ventrículo izquierdo / Extubation failure after Norwood procedure in hypoplastic left heart syndrome patients

Resumen: Introducción: En pacientes con Síndrome de Hipoplasia de Ventrículo Izquierdo (SHVI) la primera etapa hacia una fisiología univentricular de Fontan es la operación de Norwood, cuya mortalidad es 10-30%. En estos pacientes la extubación fallida se presenta en un 18% y se ha asociado a aumento de la mortali dad. Objetivo: Describir la frecuencia de extubación fallida y sus factores de riesgo en pacientes con SHVI operados (Norwood). Pacientes y Método: Estudio de casos y controles que incluyó a todos los pacientes con SHVI manejados con cirugía de Norwood en el Hospital Clínico de la Pontificia Universidad Católica (enero-2000 a febrero-2018). Se define como casos a pacientes con falla en la extubación y como controles a los pacientes sin esta complicación. Se registraron variables demográficas, quirúrgicas, y post-quirúrgicas, y se realizó análisis univariado y multivariado (regresión logística) para determinar los factores de riesgo asociados a la falla en la extubación. Resultados: De un total de 107 pacientes, 26 pacientes tuvieron extubación fallida (24,3%). En el análisis univariado los factores asociados a extubación fallida fueron: mayor tiempo de ventilación mecánica postquirúrgico, desarrollar atelectasias, derrame pleural, quilotórax, tener otras comorbilidades respiratorias (apnea y traqueítis), y mayor tiempo de uso de morfina y midazolam. En el análisis multivariado, la presencia de quilotórax, otras comorbilidades respiratorias, y mayor tiempo de uso de midazolam fueron variables asociadas a extubación fallida (p<0,03). La extubación fallida no se asoció a mayor mortalidad. Conclusiones: La presencia de quilotórax, complicaciones respiratorias y uso de mida zolam prolongado deben considerarse para definir el momento de la extubación, con el objetivo de evitar su fracaso.

Abstract: Introduction: Hypoplastic left heart syndrome (HLHS) is the main cause of mortality due to congenital heart disea se. The Norwood surgery is the first procedure of the surgical staging process towards a single ventri cle physiology or Fontan-type operation and has a mortality rate of 10% to 30%. Extubation failure during the postoperative period occurs in up to 18% of these patients and is associated with increased mortality. Objective: To describe extubation failure rates and risk factors in pediatric patients with HLHS who underwent Norwood procedure. Patients and Method: Case-control study that included all the patients with HLHS managed with Norwood surgery at the Hospital Clínico de la Pontificia Universidad Catolica between January 2000 and February 2018. Cases and controls were defined as patients with extubation failure and as patients without this complication, respectively. The following variables were recorded demographic, surgical, and post-surgical ones, and univariate and multivariate analyses (logistic regression) were performed to determine risk factors associated with extubation failure. Results: Out of 107 patients, 26 of them presented extubation failure (24.3%). In the univariate analysis, longer mechanical ventilation time during the postsurgical period, atelectasis, pleural effusion, chylothorax, other respiratory morbidities (i.e. apneas and tracheitis), and longer infusion times of morphine and midazolam, all were associated with a higher extubation failure rate in this population. In the multivariable analysis, chylothorax, other respiratory comorbidities, and longer infusion time of midazolam remained associated with this complication, however, it was not associated with higher mortality. Conclusions: Chylothorax, respiratory comorbidities, and longer use of Midazolam should be addressed before planning airway extubation in order to avoid failure.

Queratoplastia penetrante con y sin terapia antiviral en la queratopatía herpética / Penetrating keratoplasty with and without antiviral therapy in herpetic keratopathy

RESUMEN Objetivo: Identificar el resultado óptico o terapéutico de la queratoplastia penetrante en pacientes con queratopatía herpética. Métodos: Se realizó una investigación descriptiva, transversal, donde se expusieron los resultados del alcance de la queratoplastia penetrante por queratopatía herpética, operados en el Hospital Clínico Quirúrgico "Hermanos Ameijeiras", de La Habana. Resultados: La muestra fue de 33 queratoplastias penetrantes. Con fines ópticos sumaron 24 (72,7 por ciento) y tectónicas 9 (27,3 por ciento). En 5 de estas la agudeza visual fue menor o igual a 0,3. En el total de la muestra, 9 opacificaron, 11 sufrieron complicaciones posquirúrgicas, 8 recurrieron en queratoplastias penetrantes ópticas y 6 en queratoplastias penetrantes terapéuticas. Se rechazaron 7 queratoplastias penetrantes ópticas (33,3 por ciento) y 4 queratoplastias penetrantes terapéuticas (4 por ciento). Presentaron complicaciones 5 (25 por ciento) con queratoplastias penetrantes ópticas y 6 (55,6 por ciento) con queratoplastias penetrantes terapéuticas. En el posquirúrgico 22 (66,6 por ciento) tenían agudeza visual mayor o igual a 0,3 (p= 0,0000). Conclusiones: La inactividad de la enfermedad viral corneal beneficia el pronóstico del injerto por queratopatía herpética en las opacidades de las queratoplastias con fines ópticos. Queda demostrado que el uso de antivirales pre y posoperatorios disminuye la recidiva de la enfermedad herpética sobre el injerto y el rechazo, al lograr mejor agudeza visual y mayor viabilidad. La severidad inflamatoria posquirúrgica se asocia con la enfermedad viral activa o afección de origen inmune al realizar el trasplante, conexos a las complicaciones post queratoplastia(AU)

ABSTRACT Objective: Identify the optical or therapeutic outcome of penetrating keratoplasty in patients with herpetic keratopathy. Methods: A descriptive cross-sectional study was conducted in which a presentation was made of the results of the scope of penetrating keratoplasties for herpetic keratopathy performed at Hermanos Ameijeiras Clinical Surgical Hospital in Havana. Results: The sample was 33 penetrating keratoplasties: 24 optical (72.7 percent) and 9 tectonic (27.3 percent). Visual acuity was lower than or equal to 0.3 in 5 of them. Of the total sample, 9 opacified, 11 had postoperative complications, 8 recurred in optical penetrating keratoplasties, and 6 in therapeutic penetrating keratoplasties. Rejection occurred in 7 optical penetrating keratoplasties (33.3 percent) and 4 therapeutic penetrating keratoplasties (4%). Complications were observed in 5 (25 percent) optical penetrating keratoplasties and 6 (55.6 percent) therapeutic penetrating keratoplasties. In the postoperative period 22 (66.6 percent) had a visual acuity greater than or equal to 0.3 (p= 0.0000). Conclusions: Inactivity of corneal viral disease benefits the prognosis of grafting due to herpetic keratopathy in opacities of optical keratoplasties. Pre- and postoperative antivirals were found to reduce the recurrence of herpetic disease on the graft and rejection, achieving better visual acuity and greater viability. Postoperative inflammatory severity is associated to an active viral disease or an immune disorder at the time of the grafting resulting in post keratoplasty complications(AU)

Successful cure of a patient with urosepsis using a combination of extracorporeal membrane oxygenation and continuous renal replacement therapy: A case report and literature review / 中华创伤杂志(英文版)

Holmium laser lithotripsy (HLL) is one of the common surgical methods for urolithiasis. It causes minor surgical trauma, but complications are not rare. Extracorporeal membrane oxygenation (ECMO) treatment of sepsis is common, but venoarterial (VA)-ECMO treatment of urosepsis has not been reported yet. In this article, we reported a 67-year-old female patient with refractory septic shock caused by HLL under percutaneous nephroscope, involving breathing, heart, kidney and other organs, and organs support treatment was ineffective for the patient. Finally, we successfully treated the patient under VA-ECMO with continuous renal replacement therapy (CRRT). Combined ECMO and CRRT may provide a solution for addressing refractory sepsis. Here we present the case and review relevant literature, so as to provide a treatment strategy for patients with refractory urogenic sepsis and to reduce the mortality rate.

Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report / Sepse aguda pós-operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso

Abstract Background: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. Objective: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. Case report: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. Conclusions: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Resumo Justificativa: A sepse é uma disfunção orgânica fatal com características clínicas inespecíficas que podem imitar outras condições clínicas com quadro hipermetabólico, como a hipertermia maligna. Os cenários são extremamente desafiadores para a anestesia perioperatória e requerem intervenção urgente. Objetivo: Ilustrar a necessidade de intervenção e consulta precoces para uma assistência adicional na abordagem e exclusão de hipertermia maligna e outras possíveis causas durante tal cenário. Relato de caso: Paciente do sexo masculino, 63 anos, submetido à cistoscopia eletiva com cistoscópio flexível e biópsia transretal da próstata guiada por ultrassom sem intercorrências. No pós-operatório, o paciente desenvolveu sintomas que levantaram a suspeita de hipertermia maligna. O protocolo de hipertermia maligna foi imediatamente iniciado, inclusive a administração de dantrolene e uma consulta pela linha direta da associação de hipertermia maligna, juntamente com outros diagnósticos e manejos intervencionistas com vistas ao aprimoramento do paciente. Enquanto a administração precoce de dantrolene ajudou na estabilização hemodinâmica do paciente, a consulta com outros anestesistas e com a Associação de Hipertermia Maligna, juntamente com repetidos exames físicos e laboratoriais, ajudou a excluir a hipertermia maligna como o possível diagnóstico. O paciente recuperou-se mais tarde na unidade de terapia intensiva, onde recebeu tratamento para a bacteremia detectada em suas hemoculturas. Conclusões: A sepse compartilha sintomas clínicos que mimetizam a hipertermia maligna. Enquanto a sepse progride rapidamente para lesões secundárias, a hipertermia maligna é uma ameaça à vida. Proporcionar o tratamento ideal requer um bom julgamento clínico e um alto nível de suspeita quanto aos cuidados oportunos e apropriados, como a administração precoce de dantrolene e a consulta pela linha direta da Associação de Hipertermia Maligna para assistência adicional, que podem resultar em desfechos positivos.

Enfoque minimalista en el implante de válvula aórtica percutánea / A minimalist approach for transcatheter aortic valve replacement

RESUMEN INTRODUCCIÓN: En pacientes con estenosis Aórtica (EA) severa sintomática, el implante de válvula aórtica percutánea transcatéter (TAVI) por vía transfemoral constituye el estándar de tratamiento en aquellos de riesgo quirúrgico intermedio o alto. El uso de un abordaje minimalista ha demostrado ser seguro y efectivo, si bien no existen reportes sobre la realidad nacional Métodos: Estudio descriptivo sobre la experiencia con pacientes sometidos al implante de TAVI bajo un protocolo minimalista en Unidad de Cardiología Intervencional y Hemodinamia del Hospital Sótero del Río desde Enero de 2018. Se analizaron las variables clínicas de los pacientes y del procedimiento así como desenlaces clínicos intrahospitalarios y seguimiento alejado. Resultados: Entre Enero 2018 hasta Abril 2019, un total de 10 pacientes fueron sometidos al implante de TAVI por vía transfemoral. El score STS-PROM promedio fue de 7,1. Se logró un implante exitoso en el 100% de los casos con un gradiente medio residual de 8 mmHg y sin leak moderado a severo en ningún paciente. No hubo eventos cerebrovasculares isquémicos perioperatorios ni muerte en este grupo. Se requirió implante de marcapasos definitivo en 3 pacientes y un paciente presentó hematoma femoral perioperatorio que requirió transfusión de glóbulos rojos. La mediana de la estadía hospitalaria fue de 2 días. Conclusiones: El uso de una estrategia minimalista para el implante de TAVI en nuestra realidad nacional es seguro y aplicable. Los resultados perioperatorios y a 30 días fueron comparables a los descritos en experiencias internacionales.

ABSTRACT BACKGROUND: In patients with symptomatic severe aortic stenosis, transcatheter percutaneous aortic valve implant (TAVI) is the standard treatment in those with intermediate or high surgical risk. The use of a minimalist approach has proven to be safe and effective, although there are no reports on the national reality Methods: Descriptive study on the experience with patients undergoing TAVI implantation under a minimalist protocol at the Interventional Cardiology and Hemodynamics Unit of the Hospital Sótero del Río since January 2018. Clinical characteristics of the patients and the procedure were analyzed as well as intrahospital outcomes and at 30-days follow up. Results: Between January 2018 and April 2019, a total of 10 patients underwent TAVI implantation by transfemoral approach in our institution. The average STS-PROM score was 7.1. A successful implant was achieved in 100% of cases with an average residual gradient of 8 mmHg and no moderate to severe leak in any patient. There were no perioperative ischemic cerebrovascular events nor death in this group. A definitive pacemaker implant was required in 3 patients and one patient developed femoral hematoma that required red blood cell transfusion. The median hospital stay was 2 days. Conclusions: The use of a minimalist strategy for TAVI implantation in our national reality is safe and applicable. Immediate results and at 30-days follow up were comparable to those described in international experiences.

Pioderma gangrenoso após mamoplastia redutora: desafios diagnóstico e terapêutico / Pyoderma gangrenosum after reduction mammoplasty: diagnostic and therapeutic challenges

O pioderma gangrenoso (PG) é doença inflamatória da pele, que pode se desenvolver espontaneamente, associado a certas doenças sistêmicas e neoplásicas, ou ao trauma cirúrgico, incluindo os das mamas. Há relatos cada vez mais frequentes, considerando o aumento desse procedimento nos dias atuais. A manifestação clínica das úlceras é característica e deve ser lembrada nas evoluções cicatriciais desfavoráveis com intensa reação inflamatória, perdas teciduais, secreção sanguinolenta e/ ou purulenta, fundo granuloso e bordas elevadas. Relatase o caso de paciente que teve pioderma gangrenoso após mamoplastia redutora. Respondeu ao corticosteroide sistêmico, e vem evoluindo sem recidivas até o momento.

Pyoderma gangrenosum (PG) is an inflammatory disease of the skin that may develop spontaneously. It is associated with certain systemic and neoplastic diseases, including those of the breasts. PG is also associated with surgical trauma. It has been increasingly reported, along with the increase in the incidence of reduction mammoplasty procedures. The clinical manifestation of ulcers is characteristic of PG and it should be considered in cases of poor healing with intense inflammatory reaction, tissue loss, bloody and/ or purulent secretion, granular background, and lesions with high edges. We describe a patient who developed PG after reduction mammoplasty. She has since responded to systemic corticosteroids and has had no relapse to date.

Rinomodelação ou rinoplastia não-cirúrgica: uma abordagem segura e reprodutível / Rhinomodelation or non-surgical rhinoplasty: a safe and reproducible approach

Introdução: A rinoplastia é uma cirurgia que muitas vezes apresenta resultados imprevisíveis, mesmo em mãos de cirurgiões experientes. Neste sentido, a rinomodelação com preenchedores é um procedimento não-cirúrgico para corrigir pequenas alterações externas nasais em casos específicos. Métodos: Os autores descrevem a técnica de aplicação de preenchedores (ácido hialurônico ou hidroxiapatita de cálcio) para modelação nasal. Foram incluídos todos os pacientes submetidos ao preenchimento nasal, entre 2009 e 2012. Foi avaliado o edema da ponta nasal, a dor e o grau de satisfação dos pacientes com o resultado. Resultados: Foram incluídos 39 pacientes no estudo. Com relação aos desfechos analisados com ácido hialurônico: 52% apresentaram edema leve; 74% tiveram dor leve; 15% se mostraram muito satisfeitos e 74% satisfeitos com o resultado. Com relação aos pacientes submetidos à rinomodelação com hidroxiapatita de cálcio: 67% apresentaram edema moderado; 50% dor moderada; 17% dor intensa e 84% se mostraram satisfeitos com o resultado. Conclusão: A rinomodelação com preenchedores reabsorvíveis é um procedimento simples, com resultados estéticos aceitáveis, sendo necessário um profundo conhecimento anatômico para diminuir o risco de complicações.

Introduction: Rhinoplasty often leads to unpredictable results, even in the hands of experienced surgeons. However, in specific cases, rhinomodelation with fillers, a non-surgical procedure to correct minor nasal external changes, can be used. Methods: This study describes the application technique of fillers (hyaluronic acid or calcium hydroxyapatite) for nasal modeling. Patients undergoing nasal filling between 2009 and 2012 were included. Edema of the nasal tip, pain, and the degree of patient satisfaction with the outcome were assessed. Results: Thirty-nine patients were included in the study. Regarding the outcomes of rhinomodelation with hyaluronic acid, 52% patients presented with mild edema, 74% had mild pain, 15% were very satisfied, and 74% were satisfied with the result. For the outcomes of rhinomodelation with calcium hydroxyapatite, 67% patients presented with moderate edema, 50% had moderate pain; 17% had severe pain, and 84% were satisfied with the result. Conclusion: Rhinomodelation with resorbable fillers is a simple procedure with acceptable esthetic results. However, a deep anatomical knowledge is necessary to decrease the risk of complications.

Condutas na ritidoplastia e apontamentos histológicos na pele da face do paciente pós-bariátrica / Rhytidoplasty practices and histological notes for the facial skin of post-bariatric patients

Introdução: O número de pacientes classificados com sobrepeso ou obesos e, com isso, dos pacientes pós-bariátricas vem aumentando, gerando uma demanda por ritidoplastias neste perfil de público. O objetivo é expor a rotina e táticas cirúrgicas em um hospital de ensino, o perfil destes pacientes, além de um comparativo superficial histológico da pele, tecido celular subcutâneo e SMAS, entre os pacientes pós e não pós-bariátrica. Métodos: Foi realizado revisão de dados do centro cirúrgico e de prontuário entre os anos de 2012 e 2016 em um hospital público na cidade de Goiânia-GO, com levantamento de 32 casos. Resultados: A tática de ritidoplastia utilizada nos pacientes pós-bariátrica não apresenta grandes diferenças entre a utilizada nos pacientes não pós-bariátrica. A análise histopatológica das amostras colhidas evidenciou diferenças marcantes entre os pacientes pós e não pós-bariátrica. Conclusão: Percebeu-se que a técnica operatória na ritidoplastia do paciente pós-bariátrica sustentou detalhes específicos, com resultado cirúrgico pós-operatório satisfatório, uma pele de pior qualidade histológica, com complicações perioperatórias dentro do esperado e com necessidade de maiores estudos para avaliar durabilidade do procedimento.

Introduction: The number of patients classified as overweight or obese has resulted in an increased number of post-bariatric patients, generating a demand for rhytidoplasty in this public profile. The objective is to expose the routine and surgical tactics in a teaching hospital, patient profiles, subcutaneous cellular tissue, and the superficial musculoaponeurotic system are compared between post-bariatric and non-post-bariatric patients, as well as histological superficial comparison of the skin. Methods: A review of the data of 32 cases treated in 2012­2016 was conducted in a public hospital in Goiânia-GO. Results: The tactics of rhytidoplasty used in post-bariatric patients do not differ significantly from those used in nonpost- bariatric patients. A histopathological analysis of the collected samples showed marked differences between post-bariatric and non-post-bariatric patients. Conclusion: The surgical technique of rhytidoplasty of post-bariatric patients sustained specific details with satisfactory postoperative surgical results, skin with worse histological quality, perioperative complications within the expected range, and the need for further studies to assess the procedure's durability

Acute kidney injury after cardiac surgery: risk factors and novel biomarkers

Abstract Acute kidney injury (AKI) is a common and severe complication after cardiac surgery. Currently, a series of novel biomarkers have favored the assessment of AKI after cardiac surgery in addition to the conventional indicators. The biomartkers, such as urinary liver fatty acid binding protein (L-FABP), urinary neutrophil gelatinase-associated lipocalin (NGAL), serum L-FABP, heart-type FABP, kidney injury molecule 1 (KIM-1), and interleukin-18 were found to be significantly higher in patients who developed AKI after cardiac surgery than those who did not. Apart from urinary interleukin-18, the novel biomarkers have been recognized as reliable indicators for predicting the diagnosis, adverse outcome, and even mortality of AKI after cardiac surgery. The timing of the renal replacement therapy is a significant predictor relating to patients' prognoses. In patients with AKI after cardiac surgery, renal replacement therapy should be performed as early as possible in order to achieve promising outcomes. In children, AKI after cardiac surgery can be managed with peritoneal dialysis. AKI after cardiac surgery has received extensive attention as it may increase early mortality and impact long-term survival of patients as well. The purpose of this article was to analyze the changes of the pertinent biomarkers, to explore the related risk factors leading to the occurrence of AKI after cardiac surgery, and to provide a basis for the clinical prevention and reduction of AKI.