Evolución del dolor postoperatorio en la colecistectomía laparoscópica bajo anestesia-analgesia multimodal en régimen ambulatorio / Pain after outpatient laparoscopic cholecystectomy under multimodal anesthesia-analgesia

OBJETIVO: Valorar la cinética del dolor postoperatorio y la convalecencia de los pacientes sometidos a colecistectomía laparoscópica electiva utilizando un régimen multimodal de anestesia-analgesia. MATERIAL Y MÉTODO: Se utilizó un protocolo anestésico y analgésico consistente en ketoprofeno i.m. durante la inducción, anestesia con uso mínimo de opiáceos e irrigación intraperitoneal con bupivacaína a 84 pacientes sometidos a colecistectomías laparoscópicas electivas consecutivas. Se valoraron el índice de sustitución, estancia hospitalaria en horas, tiempo libre de dolor, número diario de analgésicos orales en domicilio, grado de dolor diario y grado de actividad física postoperatoria diaria según escala analógica. RESULTADOS: El índice de sustitución fue del 90,5 por ciento y la estancia hospitalaria postoperatoria media de 7,2 ñ 0,9 horas. 8 pacientes requirieron estancia de una noche. El 27,3 por ciento de los pacientes no requirieron analgesia postoperatoria. Entre los pacientes que precisaron consumo de analgésicos ambulatoriamente el tiempo medio hasta la toma de la primera dosis fue de 17,3 ñ 11,8 horas tras el alta. Más del 80 por ciento no requerieron analgésicos y más del 75 por ciento refirieron dolor leve o ausente al tercer día postoperatorio. El 50 por ciento de los pacientes podía realizar sin ayuda sus actividades cotidianas al cuarto día postoperatorio y el 50 por ciento se reincorporó a su trabajo habitual al undécimo día postoperatorio. CONCLUSIONES: El régimen de anestesia-analgesia multimodal propuesto permite un alto porcentaje de régimen ambulatorio de los pacientes tras la colecistectomía laparoscópica y un buen control del dolor y náuseas postoperatorios con una rápida reincorporación de los pacientes a sus actividades habituales (AU)

[Course of postoperative pain in laparoscopic cholecystectomy under multimodal anesthesia-analgesia in ambulatory care]. / Evolución del dolor postoperatorio en la colecistectomía laparoscópica bajo anestesia-analgesia multimodal en régimen ambulatorio.

OBJECTIVE: To evaluate the evolution of postoperative pain and convalescence in a group of patients undergoing elective laparoscopic cholecystectomy under a multimodal anesthesia-analgesia treatment protocol. MATERIAL AND METHOD: Eighty-four consecutive patients undergoing elective laparoscopic cholecystectomy were given intramuscular ketoprofen during induction, anesthesia, with minimal use of opioids, and intraperitoneal irrigation with bupivacaine. We assessed the rate of conversion to hospitalization, hospital stay in hours, duration of the pain-free interval, oral analgesics per day at home, and intensity of postoperative pain and physical activity daily on a visual analog scale. RESULTS: The procedures were carried out on an outpatient basis in 90.5% of the cases, and the mean postoperative hospital stay was 7.2 +/- 0.9 hours. Eight patients required an overnight stay. No postoperative analgesics were required by 27.3% of the patients. Patients requiring analgesics had pain-free intervals lasting 17.3 +/- 11.8 hours after discharge. On the third day after surgery 80% had used no analgesics and over 75% had no pain or only minor pain. On the fourth postoperative day 50% were able to perform activities of daily living without help, and 50% returned to work on the eleventh day after surgery. CONCLUSIONS: The multimodal analgesia-anesthesia treatment proposed allows a high percentage of laparoscopic cholecystectomies to be performed on an outpatients basis. The protocol provides good control of postoperative pain and nausea and rapid return to habitual activity.

Outpatient laparoscopic cholecystectomy. Four years of experience.

OBJECTIVE: To evaluate the feasibility of an ambulatory laparoscopic cholecystectomy program. DESIGN: Prospective analysis of ambulatory cases, overnight stay percentage, unexpected admission rate, postoperative complications and readmissions. PATIENTS: 271 consecutive patients undergoing elective laparoscopic cholecystectomy. RESULTS: Ambulatory laparoscopic cholecystectomy was completed in 193 out of 271 patients, reaching a 71.2 percent for the whole series. Ambulatory patients increased along with the experience of the team from a 22.9 percent in 1997 to 91.4 per cent in 2000. Sixty four patients (23.6%) had to be hospitalized overnight. Finally 14 patients had to be admitted (5.2%). The percentage of postoperative complications was 7.7%. CONCLUSIONS: Ambulatory laparoscopic cholecystectomy is a feasible and safe procedure with no increase in morbidity that can be performed in up to 90 per cent of patients.

Cuatro años de experiencia en colecistectomía / Outpatient laparoscopic cholecystectomy. Four years of experience

Objetivo: evaluación de la capacidad de implantación y éxito de un programa de colecistectomía laparoscópica ambulatoria. Diseño del estudio: evaluación prospectiva de índice de sustitución, porcentaje de estancia "de una noche", porcentaje de ingresos no esperados, incidencia de complicaciones postoperatorias e índice de reingresos. Pacientes: 271 colecistectomías laparoscópicas electivas consecutivas. Resultados: el índice de sustitución pasó de un 22,9 por ciento del primer año a un 91,4 por ciento en el ultimo año, alcanzando un 71,2 por ciento para el global de la serie (193/271). En 64 pacientes se precisó régimen de estancia "de una noche" (23,6 por ciento de la serie). En tan sólo 14 casos fue necesario el ingreso de los pacientes (5,2 por ciento de la serie). El porcentaje de complicaciones postoperatorias fue del 7,7 por ciento. Conclusiones: la colecistectomía ambulatoria es factible hasta en más de un 90 por ciento de los pacientes, no suponiendo este nuevo sistema un incremento en la tasa de complicaciones (AU)

[The indications for and results of video thoracoscopic surgery. Reflections on 152 procedures]. / Indicaciones y resultados de la cirugía videotoracoscópica. Consideraciones sobre 152 procedimientos.

Since thoracoscopy was first described in 1910, its application has been confined mainly to diagnosis and symptomatic treatment of pleural diseases. Recent technological advances in endoscopy and the refinement of surgical technique have brought wider applications, giving rise to video-assisted thoracoscopy (VAT). VAT surgery allows us to view, access and act upon internal thoracic organs without recourse to thoracotomy, thus circumventing inherent risk. We have reviewed our experience from April 1994 through November 1998 in 152 procedures with 141 consecutive patients. Diagnoses were pneumothorax in 94 cases, sympathetic nervous system alteration in 10, diffuse lung disease in 10, lung tumors in 9, pulmonary metastasis in 4, pleural tumors in 5, mediastinal tumors in 2, pericardial effusion in 2, spinal disease in 2 and chronic pancreatitis in 1. No deaths associated with the procedure occurred. The incidence of non-fatal postoperative complication was 11%. The most common complications were prolonged air leak (5%) and bloody pleural effusion (3.5%). The mean length of postoperative hospital care was 3.8 days (range 1 to 18 days). Our experience indicates that VAT is increasingly used to diagnose and treat a variety of chest lesions. Complications are fewer than in procedures in which thoracotomy is needed. Prolonged air leakage does not occur significantly more often with VAT than with thoracotomy. VAT is apparently safe and is particularly useful in some situations, as postoperative morbidity is low and clinical tolerance good.

[Usefulness of isoflurane in anesthesia in elective cesarean section]. / Utilidad del isofluorano en la anestesia de la cesárea electiva.

A series of 25 patients undergoing iterative cesarean section under general anesthesia received isoflurane at 0.75% together with a mixture of O2 and N2O at 50% for anesthetic maintenance. The inhalant agent was withdrawn when closing fascia. There was no case of regaining of consciousness during the operations. Uterine contraction was acceptable as evaluated by the surgeon at the end of the operation. Mean hematocrit value was 31.43 (SD 1.27) at 6 hours of operation. Fetal arterial gasometric values and Apgar score at 5 and 10 minutes fell within acceptable limits.