Metronidazole for Prevention of Pelvic Cellulitis and Abscess after Laparoscopic Hysterectomy: A Triple-blinded, Randomized, Placebo-controlled Clinical Trial.

STUDY OBJECTIVE: To determine whether a postoperative 5-day treatment schedule with vaginal metronidazole added to conventional antibiotic prophylaxis with 2 g cefazolin modifies the risk of pelvic cellulitis (PC) and pelvic abscess (PA) after total laparoscopic hysterectomy (TLH). DESIGN: A randomized, controlled, triple-blind, multicenter clinical trial. SETTING: Two centers dedicated to minimally invasive gynecologic surgery in Colombia. PATIENTS: A total of 574 patients were taken to TLH because of benign diseases. INTERVENTION: Patients taken to TLH were divided into 2 groups (treatment group, cefazolin 2 g intravenous single dose before surgery + metronidazole vaginal ovules for 5 days postoperatively, control group: cefazolin 2 g intravenous single dose + placebo vaginal ovules for 5 days postoperatively). MEASUREMENTS AND MAIN RESULTS: The absolute frequency (AF) of PC and PA and their relationship with the presence of bacterial vaginosis (BV) were measured. There was no difference in AF of PC (AF, 2/285 [0.7%] vs 5/284 [1.7%] in the treatment and placebo groups, respectively; risk ratio, 1.75; 95% confidence interval, 0.54-5.65; p = .261), nor for PA (AF, 0/285 [0%] vs 2/289 [0.7%]; p = .159, in the treatment and placebo groups, respectively). The incidence of BV was higher in the metronidazole group than the placebo group (42.5% vs 33.4%, p = .026). CONCLUSION: The use of vaginal metronidazole ovules during the first 5 days in postoperative TLH added to conventional cefazolin prophylaxis does not prevent the development of PC or PA, regardless of the patient's diagnosis of BV.

Barbed Suture versus Conventional Suture for Vaginal Cuff Closure in Total Laparoscopic Hysterectomy: Randomized Controlled Clinical Trial.

STUDY OBJECTIVE: To determine the surgical time, suture time, presence of postoperative dyspareunia, and complications that occur after closing the vaginal cuff with a barbed suture compared with conventional suture. DESIGN: A randomized, controlled clinical trial (Canadian Task Force classification I). SETTING: Private gynecologic clinic in Medellin, Colombia. PATIENTS: One hundred fifty women who underwent total laparoscopic hysterectomy for benign pathology. INTERVENTIONS: The patients underwent total laparoscopic hysterectomy with intracorporeal closure of the vaginal cuff and were randomized to 2 groups, 1 using a barbed suture (V-Loc 90; Medtronic/Covidien, New Haven, CT) and 1 using polyglactin 910 (coated Vicryl suture; Ethicon/Johnson & Johnson, New Brunswick, NJ). MEASUREMENTS AND MAIN RESULTS: The total operative time, closing time of the vaginal vault, presence of complications in the cuff, and incidence of postoperative dyspareunia were recorded. The patients were evaluated at a postoperative office visit 2 weeks after the procedure and by telephone interview at 24 weeks. Seventy-five patients were included in the barbed suture group and 75 patients in the polyglactin 910 group. The average time to complete the suture of the vaginal cuff was 12.01 minutes (± 5.37 standard deviation) for the barbed suture group versus 13.49 minutes (± 6.48) in the polyglactin 910 group (95% confidence interval, -.44 to 3.4; p = .130). Blood loss was 31.56 ± 22.93 mL in the barbed suture group versus 30.82 ± 21.75 mL in the polyglactin 910 group (95% confidence interval, -7.95 to 6.47; p = .840). The frequency of postoperative events such as hematoma, cellulitis, cuff dehiscence, fever, emergency consultation, and hospitalization was not statistically significant between groups. No statistically significant difference was found regarding deep dyspareunia at 24 postoperative weeks. CONCLUSION: No differences were found in surgical time or frequency of adverse events when comparing patients after vaginal cuff closure with barbed suture versus polyglactin 910.

Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial.

OBJECTIVE: To determine if transversus abdominis plane anesthetic blockage (TAP block) diminishes early postoperative pain scores and facilitates ambulatory management following total laparoscopic hysterectomy. DESIGN: Randomized triple blind trial. SETTING: Gynecological endoscopy unit at a referral center for laparoscopic surgery. POPULATION: A total of 197 patients. METHODS: Comparison of a treatment group receiving TAP block with bupivacaine 0.25% and placebo group with comparably placed bilateral injection of sterile saline solution. MAIN OUTCOME MEASURES: Pain scores at discharge 24, 48 and 72 h after surgery, opioid requirement after procedure. RESULTS: Patients who had TAP block had a significant reduction in their pain score at discharge compared with the placebo group (p = 0.017). There were no significant differences in the pain scores between groups at 24 h (95% CI 1.36-0.133, p = 0.237), 48 h (95% CI 0.689-0.465, p = 0.702) and 72 h (95% CI -0.631 to 0.223, p = 0.347). No differences were found between the groups regarding opioid requirements following the procedure (χ(2)  = 3.62, p = 0.46). CONCLUSION: Although TAP block after a total laparoscopic hysterectomy reduced the pain score at discharge compared with placebo, its role in this setting is debatable due to the possible lack of clinical significance of the small difference found.

[Sciatic hernia as a cause of chronic pelvic pain]. / Hernia ciática como causa de dolor pélvico crónico.

Sciatic hernia constitutes the scarcest group of hernias of pelvic floor; however, they should be considered in the origin of chronic pelvic pain. The proper diagnosis of sciatic hernias has allowed to surgeons treating successfully patients with acute or chronic pelvic pain, with intestinal or ureteral obstruction and with urinary or gluteus sepsis. It has to be considered as differential diagnosis before the finding of a congenital or acquired gluteus mass. Laparoscopist gynecologist should know the existence of this defect, to be familiar with its aspect in laparoscopic view and to know the laparoscopic treatment of this disease.

Experiencia de la técnica del ganglio centinela en la cirugía del cáncer de mama, Medellín, Colombia, 2009 / Experience with the sentinel node technique in breast cancer in Medellín, Colombia

Introducción. El cáncer de mama es el segundo cáncer más común y una importante causa de muerte entre las mujeres. Uno de los pilares para su tratamiento es la determinación del estadio de los ganglios axilares mediante el vaciamiento axilar completo. Este procedimiento conlleva gran morbilidad, la cual ha disminuido considerablemente con la implementación de la técnica del ganglio centinela. Objetivo. Describir los resultados obtenidos con la técnica del ganglio centinela en la cirugía de cáncer de mama en un centro especializado en patología de mama de Medellín. Metodología. Se llevó a cabo un estudio descriptivo, retrospectivo. Se revisaron las historias clínicas de 164 pacientes con cáncer de mama en estadio temprano. Se creó una base de datos en Microsoft Office Excel®, y se procesó con el programa estadístico SPSS®, versión 13. Resultados. El 86% de las pacientes tenía ganglio centinela negativo en la impronta y 82,3% en la patología final. El 4,3% fueron falsos negativos, y 3,5% correspondió a micrometástasis. No hubo falsos positivos. El 17% requirió vaciamiento axilar; de éstos, 78% no presentó evidencia patológica de compromiso residual. El informe más común de histología fue carcinoma ductal con infiltración, el cual, también, presentó el mayor porcentaje de ganglio centinela positivo (78,3%). De los ganglios centinela positivos en la patología final, 90% presentaron tumores positivos para receptores de estrógenos y de progesterona. Conclusión. La técnica del ganglio centinela es una buena alternativa para el manejo de cáncer temprano de mama, ya que evita intervenciones quirúrgicas que conllevan a mayor morbimortalidad de las pacientes. Con el resultado negativo se puede afirmar con bastante certeza que no hay otros ganglios afectados.

Breast cancer is the second most common cancer and an important cause of mortality in the female population. A key component of breast cancer therapy is the staging of regional lymph nodes via complete axillary lymph node dissection, which carries substantial morbidity. Nevertheless morbidity has significantly been reduced by implementing the technique of the sentinel lymph node biopsy. Objective: Description of results obtained with the technique of sentinel lymph node biopsy in breast cancer surgery in a breast pathology center in Medellín, Colombia. Methods: Retrospective study in which the medical records of 164 patients with early stage breast cancer were review and placed in a data base on Microsoft Office Excel® and statistically analyzed with the program SPSS 13®. Results: 86% of patients were sentinel lymph node negative on imprint and 82.3% on final pathology; 4.3% were false negative (3.5% due to micro-metastasis) and no false positive results were found. 17% of patients required complete axillary lymph node dissection of which 78% had no evidence of disease on final pathology. The most frequently found histological type was the Infiltrating ductal carcinoma, which also had the most sentinel lymph node positive pathology results (78.3%). 90% of patients with positive sentinel lymph nodes were also positive for estrogen and progesterone receptors. Conclusion: sentinel lymph node biopsy is a good alternative for the management of early staged breast cancer given that it prevents patients from invasive surgery that carries substantial morbidity and mortality. A negative sentinel lymph node gives the physician security that there aren’t other lymph nodes involved.

El educador como investigador de su práctica pedagógica: la importancia de la reflexión en la educación para la salud / Teacher as researcher of its own practice: the importance of reflection for health educaction

Objetivo: presentar el proceso y los resultados de una inves-tigación-acción en el ámbito de la educación, en el programa de crecimiento y desarrollo de una institución prestadora de servicios de salud de la ciudad de Medellín. Metodología: si¬guiendo los planteamientos de Stenhouse sobre un educador-investigador, se llevó a cabo un proceso reflexivo donde los miembros de los equipos del programa, investigaron sus prác¬ticas pedagógicas y las analizaron a la luz de su propia expe¬riencia y de la teoría proveniente de investigaciones realizadas en su institución, y de la literatura científica. Resultados: me¬diante la reflexión y la investigación de su práctica pedagó¬gica los educadores lograron concebir el programa desde una perspectiva más amplia: la crianza. Así mismo consiguieron situarse de manera diferente hacia la educación y el educando y generar propuestas alternativas. Discusión: la experiencia investigativa muestra la dificultad para realizar cambios en las perspectivas pedagógicas en el ámbito de de la educación para salud, generalmente sustentadas en modelos tradicionales o conductistas. Teniendo en cuenta los resultados obtenidos, se presenta esta propuesta investigativa como una vía para avan¬zar en el fortalecimiento de la dimensión educativa en el ámbi¬to de salud desde una perspectiva alternativa.

Objective: to present the process and results of an action research in the educational dimension, the growth and development program of a health institution in Medellin. Methodology: following Stenhouse’s ideas about a teacher-researcher, it was developed a reflective process where the program’s teams, researched their pedagogical practices, and analyzed them taking in consideration their own experience as well as theory coming from past research done in their institution, and the scientific literature. Results: through a reflective process and by investigating their pedagogical process, educators were able to design the program from a wider perspective: child rearing. Also they were able to locate themselves in a different way with respect to education and to parents generating alternative proposal for education Discussion: research experience shows the difficulty of making changes in pedagogical perspectives in health education, usually based on traditional or behavioral models. According to the results, this research proposal is presented as a way to forward in the strengthening of a educational dimension in health field from an alternative perspective.

Endometriosis profunda infiltrante: seguimiento a un año luego de tratamiento laparoscópico / Deep infiltrating endometriosis: one year of follow-up after laparoscopic treatment

Objetivo: conocer la evolución a un año de las pacientes a quienes se les ha realizado tratamiento quirúrgico laparoscópico de la endometriosis profunda infiltrante. Metodología: cohorte de 24 pacientes con edades comprendidas entre 22 y 51 años a quienes se les realizó tratamiento quirúrgico de la endometriosis profunda infiltrante en la Unidad de Endoscopia Ginecológica de la Clínica del Prado y Profamilia, en Medellín, entre septiembre del 2007 y febrero del 2008. Se evaluaron las variables sociodemográficas, síntomas dolorosos, localización anatómica de la endometriosis profunda infiltrante, características de la lesión, tratamiento, tiempo quirúrgico, complicaciones. Resultados: se presentó una lesión de recto como única complicación en esta serie (4,1%). Hubo una disminución estadísticamente significativa de los síntomas dolorosos. Tres pacientes (12%) tuvieron recurrencias al año de seguimiento. Conclusión: el tratamiento laparoscópico de la endometriosis profunda infiltrante surge como una alternativa para el tratamiento de la endometriosis infiltrativa profunda.

Objective: making a one-year evaluation of the evolution of patients who underwent laparoscopic surgery for treating deep infiltrating endometriosis.Methodology: a cohort of twenty-four patients aged between 22 and 51 was included; they had had been diagnosed as suffering from deep infiltrating endometriosis. This took place in Clínica del Prado’s gynaecological endoscopy unit and in Profamilia in Medellín between September 2007 and February 2008. Minimally invasive treatment was undertaken with one-year follow-up. The following variables were evaluated: sociodemographic data, painful symptoms, anatomical localization of deep infiltrating endometriosis, lesion characteristics, surgical treatment, surgical time and complications. Results: colonic lesion was the only complication reported in this series (4.1%). There was a statistically significant reduction in painful symptoms. Three patients (12%) suffered recurrences during the year-long follow-up. Conclusions: laparoscopic treatment of deep infiltrating endometriosis is an option which alleviates the painful symptoms of endometriosis.

Asociación entre el índice de masa corporal y los resultados perioperatorios y posoperatorios en pacientes sometidas a histerectomía laparoscópica total: Medellín (Colombia) 2002-2008 / The association between body mass index and perioperative and postoperative outcomes in patients undergoing total laparoscopic hysterectomy: Medellin, Colombia 2002-2008

Objetivos: evaluar la posible asociación entre el mayor índice de masa corporal (IMC) y los resultados peri y posoperatorios en pacientes a las que se les realizó histerectomía laparoscópica total (HLT). Metodología: cohorte histórica de pacientes a quienes se les practicó HLT en un período de 5 años en un centro de referencia para endoscopia ginecológica. Fueron incluidas todas las pacientes con HLT y con la información completa. Las pacientes fueron divididas en tres grupos según su masa corporal: IMC menor de 24,9 kg/m2, normal (n = 339); IMC entre 25-29,9 kg/m2, sobrepeso (n = 243) e IMC mayor de 30 kg/m2, obesidad (n = 94). Se compararon el tiempo quirúrgico, las complicaciones, la pérdida sanguínea, la necesidad de transfusión, la tasa de laparoconversión y el tiempo de estancia hospitalaria. Los tres grupos se contrastaron por medio de la prueba ANOVA. Resultados: 676 pacientes cumplieron los requisitos para el estudio. No hubo diferencias significativas en cuanto a la pérdida sanguínea, el tiempo quirúrgico, la estancia hospitalaria, la tasa de complicaciones o de laparoconversión. Conclusión: no se encontró asociación entre el índice de masa corporal y malos resultados peri y posoperatorios.

Objectives: evaluating the possible association between body mass index (BMI) and peri-and post-operative results in patients undergoing total laparoscopic hysterectomy (TLH). Methodology: a historical cohort of patients was taken over a 5-year period; they had undergone TLH in a referral centre for gynaecological laparoscopy. All patients who had undergone TLH and about whom complete information was available were included. Patients were divided into three groups according to body mass as follows: BMI below 24.9 kg/m2: “normal” (n = 339), BMI 25 -29.9 kg/m2: “overweight” (n = 243) and BMI greater than 30 kg/m2: “obese” (n = 94). Surgical time, complications, blood loss, transfusion requirement, laparoconversion rate and length of hospital stay were compared. ANOVA was used for comparing the three groups. Results: 676 patients met the study requirements. No significant differences regarding blood loss, operating time, hospital stay, complication rate or laparoconversion were found. Conclusion: no association was found between BMI and poor results during peri-and postoperative periods.

Study of the prevalence of female sexual dysfunction in sexually active women 18 to 40 years of age in Medellín, Colombia.

INTRODUCTION: The prevalence of female sexual dysfunction (FSD) in Colombia has not been adequately studied. A reliable estimate of the prevalence of FSD can be helpful for the adequate planning of reproductive health and research activities. AIM: Measure the prevalence of female sexual complaints in a sample of sexually active women aged 18-40 years in a city of Colombia. METHODS: A self-administered validated questionnaire, the Female Sexual Function Index (FSFI), was administered to 410 sexually active women at different focal groups. A cutoff value of 26.5 was used to define female sexual complaint. Ten questions on age, educational level, socioeconomic status, marital status, cohabitation, depressive feelings, use of antidepressive drugs, menstrual cycle, offspring, and contraception were included. MAIN OUTCOME MEASURES: The primary end point was the percentage of women having a score equal or less than 26.5. RESULTS: In the study group, 117 of 391 women scored less than 26.5 for a prevalence of sexual complaints of 30%. The independent variables associated with sexual complaints were low educational level, the feelings of depression, and the use of antidepressive drugs. CONCLUSION: The present study found a low FSFI score in 30% of sexually active women aged 18-40 years in the city of Medellin, Colombia, which could be indicative of sexual complaints.

Histerectomía laparoscópica total en la unidad de endoscopia ginecológica de la Clínica del Prado, Medellín (Colombia) 2002 - 2008 / Total laparoscopic hysterectomy at the Clínica del Prado’s Gynaecological Endoscopy Unit in Medellín, Colombia 2002 - 2008

Objetivo: describir la experiencia en la práctica de Histerectomía Laparoscópica Total (HLT) con énfasis en las complicaciones presentadas. Metodología: el presente es un estudio de cohorte histórica en el cual se incluyeron las pacientes que fueron intervenidas entre diciembre de 2002 y abril de 2008 y en quienes, además, se completó al menos 90% de la información requerida en un formulario prediseñado. Durante la investigación, se evaluaron las características sociodemográficas, las indicaciones de cirugía, el porcentaje de laparoconversión y las causas de la misma, el tiempo quirúrgico, la pérdida sanguínea estimada, el tiempo de hospitalización, el número de dosis de analgésicos requeridos, los días de incapacidad y las complicaciones intraoperatorias y postoperatorias. Resultados: en total se incluyeron 837 pacientes, cuya edad promedio fue 42,7 años. 83,8% de las mujeres eran ASA I (American Society of Anesthesiologists) y la principal enfermedad de base fue la hipertensión arterial (9,9%). En 822 de ellas, el procedimiento se llevó a cabo por laparoscopia mientras que 15 (1,7%) requirieron laparoconversión. Las indicaciones más frecuentes para la cirugía fueron miomatosis (43,8%) y hemorragia uterina anormal (36,1%). Adicional a esto, el tiempo quirúrgico promedio fue 85,9 minutos, la pérdida sanguínea media fue de 60,6 mL y la tasa total decomplicaciones llegó a ser 12,5%; de lacuales, 3,1% lo constituyeron complicaciones mayores. Conclusiones: la tasa de complicaciones de la histerectomía laparoscópica total es similar a la informada en la literatura y está acompañada de una estancia hospitalaria breve.

Objective: describing accumulated experience gained from performing Total Laparoscopic Hysterectomy (TLH) at the Clínica del Prado. Methodology: this was a descriptive, retrospective study (evidence level III) which involved patients who underwent TLH in the Gynaecological Endoscopic Unit at Clínica del Prado, Medellín, Colombia. 1,150 medical records from patients operated on between December 2002 and April 2008 were reviewed; those in which at least 90% of the data required by a predesigned instrument could be recovered were included for analysis. Main outcomes measured: demographic data, surgical indication, laparoconversion rate and causes, surgical time, estimated blood loss, uterine weight and height, time of hospital stay and complications. Results: 837 patients were included; TLH was entirely performed on 822 of them by laparoscopy whilst 15 (1.7%) required laparoconversion. The most frequent indications for surgery were fibroids (43.8%) and abnormal uterine bleeding (36.1%). Mean age was 42.7. 83.8% of the patients were ASA I (American Society of Anesthesiologists); the main comorbidity found was hypertension (9.9%). Mean surgical time was 85.9 minutes; mean estimated blood loss was 60.6 mL. The commonest histological diagnosis was fibroids (57.1%). Mean uterine weight was 180 grams and mean uterine height 10.2 cm. Complications affected 12.5% of the 837 patients, 3.1% of them being major ones.

Fertilidad después del tratamiento laparoscópico del embarazo ectópico, en la Clínica del Prado en Medellín, Colombia. Estudio de cohorte / Fertility following laparoscopic treatment of ectopic pregnancy at the Prado Clinic in Medellín, Colombia. A cohort study

Objetivo: conocer y comparar los índices de fertilidad luego de salpingostomía vs. salpingectomía laparoscópicas en pacientes con embarazo ectópico.Diseño y población: cohorte concurrente de pacientes sometidas a cirugía de embarazo ectópico por laparoscopia en la Unidad de Cirugía Endoscópica Ginecológica, Clínica del Prado, Medellín, Colombia.Metodología: revisión de historias clínicas e interrogatorio telefónico a pacientes que cumplieron criterios de inclusión.Variables principales: tasa global de embarazo intrauterino, tasa acumulada por año de embarazo intrauterino, tasa de recurrencia de ectópico, tasa de persistencia de ectópico.Resultados: 31 pacientes en el grupo de salpingostomía y 14 pacientes en el grupo de salpingectomía. La tasa global de embarazo intrauterino después de salpingostomía fue de 54,8 por ciento comparada con 57,1 por ciento para salpingectomía (p = 0,88). Se presentaron recurrencias en el 10,5 por ciento de las salpingostomías y en el 20 por ciento de las salpingectomías (p = 0,77). La tasa de persistencia de ectópico después de manejo conservador fue de 9,6 por ciento.Conclusiones: este estudio no demuestra diferencias significativas en los índices reproductivos al comparar salpingostomía vs. salpingectomía laparoscópicas.

Impactos de la Virtualidad y Sociedad de la información en los procesos educativos de hoy / Virtuality impact and information society en today’s educational processes

Los términos virtual y virtualidad se han convertido en elementos centrales de esta era denominada "La Sociedad de la Información". que no es más que la expresión de realidades y capacidades de los nuevos medios de comunicación permeados por los desarrollos tecnológicos logrados en la última década. La televisión, el almacenamiento de información, el video, sonido y textos, han podido agruparse en soportes de almacenamiento como CD o a través de señales que solo transmiten datos digitales