Comportamiento de presiones intrapulmonares con inversión de la relación inspiración espiración en colecistectomía laparoscópica / Behavior of intrapulmonary pressures with inversion of the inspiration-expiration ratio in laparoscopic cholecystectomy

Resumen: Objetivo: Evaluar el comportamiento de las presiones intrapulmonares con la inversión del índice inspiración espiración durante la colecistectomía electiva videolaparoscópica. Material y métodos: Se realizó un ensayo clínico controlado fase tres acerca de tales presiones intrapulmonares, durante operaciones de colecistectomía laparoscópica, en el Hospital Universitario «Manuel Ascunce Domenech¼, en el período de septiembre del 2016 a febrero del 2020. El universo estuvo constituido por los pacientes que cumplieron con los criterios de inclusión, y una muestra de 106 de ellos, los cuales se dividieron en dos conjuntos de 53 personas cada uno, por método aleatorio simple. La fuente primaria de obtención de datos la constituyeron las historias clínicas y el resultado de una encuesta. Los datos se recogieron en un modelo diseñado en correspondencia con la bibliografía. Resultados: Se presentó aumentos de la presión inspiratoria pico y presión meseta luego del neumoperitoneo, con descenso de ambas tras la transposición del índice I:E, además de hipertensión arterial, arritmias e hipotensión arterial, sin guardar relación con la aplicación del indicador I:E invertido. Conclusiones: La inversión de la inspiración espiración contribuyó a mejorar los efectos del neumoperitoneo sobre dichas presiones intrapulmonares, manteniendo una oxigenación adecuada y nulos efectos cardiovasculares.

Abstract: Objective: Evaluating the behavior of intrapulmonary pressures with the inversion of the inspiration expiration index, during elective videolaparoscopic cholecystectomy. Material and methods: A phase three controlled clinical trial was conducted on intrapulmonary pressures during laparoscopic cholecystectomies at the «Manuel Ascunce Domenech¼ University Hospital, from September 2016 to February 2020, the universe consisted of patients who met the inclusion criteria, from which a sample of 106 patients was selected, by a simple randomizing method. The primary source of data collection was the medical records and the result of a survey. These data were collected in a model designed in correspondence with the bibliography reviewed. Results: Measured by variation in peak inspiratory pressure and plateau pressure after pneumoperitoneum, with significant decrease of both after inversion of I:E index. More than half of the patients presented arterial hypertension, arrhythmias and arterial hypotension, without them being related to the application of the inverted I:E index. Conclusions: The inversion of inspiratory expiration contributed to improve the effects of pneumoperitoneum on intrapulmonary pressures, with adequate oxygenation and no cardiovascular effects.

Coledocolitiasis insospechada en pacientes con litiasis vesicular / Unsuspected choledocholithiasis in patients with gallbladder stones

Antecedentes: actualmente un punto discutido de la colecistectomía laparoscópica (CL) es la realización sistemática de la colangiografía intraoperatoria (CIO); sin embargo, esta permite el diagnóstico de litiasis coledociana insospechada (LCI). Objetivo: establecer el porcentaje de CIO realizadas, el número de LCI diagnosticadas, describir qué terapéutica se utilizó para resolverlas y establecer si existe relación entre el tamaño de las litiasis diagnosticadas y su tratamiento transcístico. Resultados: de las 1077 CL electivas, la CIO pudo realizarse en el 89,14% de los pacientes. En 2014, el porcentaje de CIO fue el más alto de la serie (95,38%). Se encontraron 38 LCI. El tratamiento realizado incluyó el abordaje transcístico y la colangiopancreatografía retrógrada endoscópica (CPRE) intraoperatoria. La morbilidad global fue del 7,9 % sin mortalidad. Discusión: nuestro porcentaje de CIO se encuentra por debajo del enunciado en otras publicaciones, pero el porcentaje aumentó con los años. La incidencia de LCI en nuestro caso fue del 3,96%. En nuestro servicio primeramente se intenta la resolución transcística (tasa de éxito del 77,42% sin complicaciones). Otra opción es la CPRE intraoperatoria, que se utilizó en 4 casos con una eficacia del 100% sin complicaciones. Conclusión: el tratamiento de la LCI continúa siendo un reto para los cirujanos, debido sobre todo a la imprevisibilidad del cuadro; resulta un factor muy importante para la resolución transcística el tamaño de la litiasis encontrada (más o menos de 6 mm). Consideramos la CPRE intraoperatoria como una herramienta importante en la resolución de esta patología.

Background: currently a discussed point of laparoscopic cholecystectomy (LC) is the systematic implementation of intraoperative cholangiography (IOC); however, it allows the diagnosis of unsuspected common bile duct stones (UBDS). Objective: to establish the percentage of IOC performed, the number of UBDS diagnosed, to describe what therapeutic was used to solve them and to establish if there is a relationship between the size of the diagnostic lithiasis and the transcystic treatment of the same. Results: of the 1077 elective LC, IOC could be performed in 89.14% of patients. In 2014 the percentage of IOC was the highest in the series (95.38%). 38 UBDS were found. The treatment included the transcritical approach and intraoperative ERCP. Overall morbidity was 7.9% without mortality. Discussion: our IOC percentage is below the utterance in other publications, but the percentage has increased over the years. The incidence of UBDS in our case was 3.96%. In our service we first try the transcritical resolution (success rate of 77.42% without complications). Another option is intraoperative ERCP that was used in 4 cases with 100% efficacy without complications. Conclusion: the treatment of the UBDS continues being a challenge for the surgeons, mainly due to the unpredictability of the picture; a very important factor for transcystic resolution is the size of the stone found (more or less than 6 mm). We consider intraoperative ERCP as an important tool in the resolution of this pathology.

Relación inspiración-espiración inversa en la colecistectomía laparoscópica / Inverse inspiration/expiration ratio in laparoscopic cholecystectomy

Introducción: el desarrollo de la cirugía y la anestesiología, requiere de avances en la tecnología de la ventilación mecánica para su ejecución. La cirugía laparoscópica utiliza la insuflación de bióxido de carbono en la cavidad peritoneal, lo cual origina repercusión en el sistema respiratorio y, necesita de ventilación mecánica efectiva para control de dicho gas y del incremento de las presiones pulmonares impuestas por el neumoperitoneo; Para lograrlo se pudiera emplear modalidades ventilatorias de empleo no habituales, resultando una mejoría en las alteraciones fisiopatológicas del aparato respiratorio y así garantizar una óptima ventilación. Objetivos: revisar la actualización de la temática relacionada con la ventilación mecánica, con modificación de la relación inspiración-espiración, y explicar sus beneficios en la anestesia para la colecistectomía laparoscópica. Desarrollo: se examinaron los aspectos conceptuales y técnicos de la relación inspiración-espiración, y la historia de su aplicación en el síndrome de dificultad respiratoria del adulto, particularmente sus efectos en los parámetros ventilatorios y de oxigenación. Se vincularon sus beneficios con las afectaciones originadas durante la ventilación mecánica, para la colecistectomía video-laparoscópica. Conclusiones: la ventilación con modificación de la relación inspiración-espiración es factible durante el tiempo anestésico para la colecistectomía video-laparoscopia.

Introduction: advances in mechanical ventilation are crucial to the implementation of developments in surgery and anesthesiology. Insufflation of carbon dioxide into the peritoneal cavity during laparoscopic surgery has an impact on the respiratory system. Effective mechanical ventilation is required to control the gas and the increase in pulmonary pressure created by the pneumoperitoneum. Non-habitual ventilation modes could be used to achieve this end, ameliorating the physiological alterations of the breathing apparatus and achieving optimal ventilation. Objectives: review updates on mechanical ventilation and modified inspiration/expiration ratio, and explain its benefits regarding anesthesia for laparoscopic cholecystectomy. Content: an examination was conducted of the conceptual and technical aspects of the inspiration/expiration ratio and the history of its application in the adult respiratory distress syndrome, particularly its effects on ventilatory and oxygenation parameters. Benefits were associated with disorders appearing during mechanical ventilation for videolaparoscopic cholecystectomy. Conclusions: ventilation with a modified inspiration/expiration ratio is feasible during the anesthesia time required for videolaparoscopic cholecystectomy.

Conducta anestésica en la colecistectomía video-laparoscópica de un paciente propuesto para trasplante pulmonar / Anesthetic management of videolaparoscopic cholecystectomy in a patient proposed for lung transplantation

Introducción: el tratamiento quirúrgico de la litiasis en la vesícula biliar por cirugía video-laparoscópica, minimiza la estadía hospitalaria y permite incluir muchos de estos pacientes en regímenes ambulatorios. Objetivo: presentar la evolución clínica de un paciente con una enfermedad pulmonar obstructiva crónica (EPOC) severa, propuesto para trasplante pulmonar. Caso clínico: paciente masculino de 55 años, con diagnóstico de litiasis vesicular, fumador inveterado, con EPOC severa y linfoma de Hodgkin. Al examen físico presentaba murmullo vesicular disminuido, sibilantes, taquipnea y uso activo de los músculos accesorios del cuello para la respiración. Tiempo quirúrgico de 1 hora y 20 minutos. Recuperación satisfactoria. Al tercer día de posoperatoria se le constató íctero. En ultrasonido abdominal (US) se observó dilatación de la vía biliar principal y se realizó colédoco pancreatografía retrograda endoscópica de urgencia con anestesia general endovenosa, por medio de esta se constató lesión de la vía biliar principal. Se decidió realizar hepato-yeyunostomía por cirugía convencional con anestesia combinada (epidural continua-general orotraqueal). Luego de su traslado a la sala de Cuidados Posquirúrgicos, se mantuvo intubado para su recuperación y su seguimiento posterior, egresó del centro a los 21 días de su primera intervención con evolución satisfactoria. Conclusiones: en los pacientes portadores de EPOC grave, se puede utilizar cirugía mínimamente invasiva y se vigile de cerca, se realice anestesia con estabilidad de todos sistemas, vigilancia perioperatoria adecuada, control del dolor, prescindiendo de recuperarlos en salas de cuidados posquirúrgicos especializados.

Introduction: videolaparoscopic surgical treatment of gallstone disease reduces hospital stay to a minimum and makes it possible to treat many of the cases on an outpatient basis. Objective: describe the clinical evolution of a patient with severe chronic obstructive pulmonary disease (COPD) proposed for lung transplantation. Clinical case: 55-year-old male patient diagnosed with gallstone disease, inveterate smoker with severe COPD and Hodgkin lymphoma. The physical examination revealed diminished vesicular murmur, sibilants, tachypnea and active use of accessory neck muscles for breathing. Surgical time was 1 hour 20 minutes. Recovery was satisfactory. Jaundice was observed on the third day of the postoperative period. Abdominal ultrasonography revealed dilatation of the main bile duct, and emergency endoscopic retrograde cholangio-pancreatography performed under general intravenous anesthesia showed a lesion on the main bile duct. It was decided to perform an hepaticojejunostomy by conventional surgery under combined anesthesia (continuous epidural-general orotracheal). After transfer to the postoperative care unit, the patient remained intubated with a view to his recovery and eventual follow-up, and was discharged from hospital 21 days after his first surgery exhibiting a satisfactory evolution. Conclusions: minimally invasive surgery may be used in patients with severe COPD as long as it is closely watched and the following requirements are met: anesthesia with stability of all systems, adequate perioperative surveillance, pain control and recovery in specialized postoperative care units.

Comparação entre a anestesia geral isolada ou associada à peridural no controle da dor pós-operatória após colecistectomia videolaparoscópica / Comparison between general anesthesia alone or associated to epidural anesthesia to control postoperative pain after videolaparoscopic cholecystectomy.

JUSTIFICATIVA E OBJETIVOS: O trauma cirúrgico envolvido na colecistectomia videolaparoscópica é sabidamente menor que o do método convencional aberto, entretanto as queixas de dor pós-operatória têm sido relatadas por vários autores. Dentre as técnicas analgésicas a anestesia peridural é eficiente na redução da dor pós-operatória no método convencional, mas raramente é utilizada como método complementar nas colecistectomias por via laparoscópica. O objetivo deste estudo foi avaliar a eficácia da anestesia peridural associada com anestesia geral para controle da dor pós-operatória em pacientes submetidos à colecistectomia videolaparoscópica. MÉTODO: Cinquenta e dois pacientes submetidos à colecistectomia videolaparoscópica foram divididos aleatoriamente em dois grupos. Um grupo recebeu anestesia geral e o outro recebeu anestesia geral associada à anestesia peridural. A avaliação da intensidade da dor foi feita com a escala numérica de dor na sala de recuperação pós-anestésica, nas primeiras 24 horas e após as 48 horas que sucederam a cirurgia. RESULTADOS: Em ambos os grupos a qualidade da analgesia pós-operatória foi similar nos momentos avaliados. O grupo que recebeu anestesia peridural associada à anestesia geral apresentou a vantagem de consumir menos anestésico inalatório, mas com maior ocorrência de retenção urinária. CONCLUSÃO: Os resultados do estudo não evidenciaram razão para a associação da anestesia geral com a peridural em colecistectomia videolaparoscópica, pois a analgesia pós-operatória foi semelhante, porém com mais riscos para o paciente.Descritores: Anestesia peridural, Anti-inflamatório não esteroide, Dor pós-operatória, Colecistectomia videolaparoscópica.

BACKGROUND AND OBJECTIVES: Surgical trauma of videolaparoscopic cholecystectomy is knowingly lower as compared to the conventional open method, however postoperative pain complaints have been reported by several authors. Among analgesic techniques, epidural anesthesia is efficient to decrease postoperative pain of the conventional method, but is seldom used as additional method for laparoscopic cholecystectomies. This study aimed at evaluating the effectiveness of epidural anesthesia associated to general anesthesia to control postoperative pain in patients submitted to videolaparoscopic cholecystectomies. METHOD: Participated in this study 52 patients submitted to videolaparoscopic cholecystectomy, who were randomly distributed in two groups. One group received general anesthesia and the other received general anesthesia associated to epidural anesthesia. Pain intensity was evaluated with the pain numeric scale at the post-anesthetic care unit, in the first 24 and 48 hours after surgery completion. RESULTS: Postoperative analgesia quality was similar for both groups in evaluated moments. The group receiving epidural anesthesia associated to general anesthesia had the advantage of consuming less inhalational anesthetics, but there has been more urinary retention. CONCLUSION: Study results have not evidenced a reason to associate general and epidural anesthesia for videolaparoscopic cholecystectomy because postoperative analgesia was similar, however with higher risks for patients.

Cirurgia videolaparoscópica nas doenças biliopancreáticas / Laparoscopic surgery in pancreatobiliary diseases

Com a experiência adquirida na cirurgia da vesícula biliar, a videocirurgia está sendo indicada cada vez mais em outras doenças. Decorridos 15 anos da primeira cirurgia, os autores avaliam os resultados e analisam as perspectivas deste procedimento nas doenças biliopancreáticas. Seguem a proposta que divide este procedimento em procedimentos de rotina, avaliação e desenvolvimento. Nas doenças da vesícula biliar, a colecistectomia laparoscópica é considerada padrão ouro, levando vantagem em todos os itens sobre a laparotômica, excluídas as lesões da via biliar e o vazamento biliar pelo coto cístico. Enfatizam situaçõesespeciais: da colecistite aguda, da colecistectomia durante a gravidez, da vesícula em porcelana e do câncerda vesícula. Comentam as perspectivas da videocirurgia nas complicações da colecistectomia laparoscópica. No tratamento da coledocolitíase, consideram o procedimento como em avaliação pela falta de ensaios clínicos prospectivos randomizados com grupo controle comparáveis e acompanhados por prazo de tempo maior. Nas doenças do pâncreas, a videocirurgia é um procedimento em desenvolvimento, com exceção da pancreatite aguda biliar não complicada, que se beneficia com a colecistectomia laparoscópica. O mesmoocorre com as cirurgias de derivação para desobstrução da via biliar. Embora factíveis dentro dos princípios da cirurgia convencional, faltam estudos comparativos com outras técnicas existentes analisando eficácia e efetividade.

With the acquired experience with laparoscopic cholecystectomy, videosurgery has been used more andmore for treatment of other diseases. Since the first surgery, nearly 15 years ago, the authors evaluate the outcome and the perspectives of this procedure in pancreatic-billiary diseases. They followed the proposition which divides these procedures in routine procedures, in evaluation and in development. In gallbladder diseases the laparoscopic cholecystectomy is considered gold-standard, taking advantage upon opencholecystectomy, excluding bile duct injury and cystic stump leakage. They emphasize the aspects related to acute cholecystitis, cholecystectomy during pregnancy, calcified gallbladder and cancer. The laparoscopic cholecystectomy during pregnancy is considered as a procedure in evaluation. Long term effects of pneumoperitonium on foetus are not well known. The approach in calcified gallbladder, because the high incidence of adenocarcinoma, remains questionable. Perspectives of videosurgery in complications of laparoscopic cholecystectomy are commented. Cystic stump leakage, misplaced clips and partial section or laceration of main biliary tract could be treated by new videosurgery in selected situations. In the treatment of choledocolithiasis, they consider the procedure as one for evaluation, due to the lack ofrandomized prospective trials. Until now, videocholedocolitotomy is reserved to specialized centers. Inpancreatic diseases, videosurgery is a procedure in development, except for the non-complicated acute biliary pancreatitis, in which benefits with laparoscopic cholecystectomy has been shown. The same occurs with diversion surgeries for desobstruction of the biliary tree. Although performed within the conventional surgery principles there is a lack of comparative studies with other techniques analysingefficacy and efficiency.