Morfina/ketamina versus morfina en el control del dolor postoperatorio de cirugía renal electiva / Morphine/ketamine versus morphine in postoperative pain control for elective renal surgery

Resumen: Introducción: el dolor agudo postoperatorio demora la recuperación funcional del paciente. Objetivo: evaluar utilidad de la ketamina asociada a morfina administrados en bolos intravenosos en el control del dolor agudo postoperatorio de pacientes sometidos a cirugía renal electiva. Material y métodos: realizamos estudio doble ciego en pacientes con dolor postoperatorio moderado-severo sometidos a cirugía renal electiva. Se conformaron dos grupos: grupo MK administramos morfina 0.05 mg/kg más ketamina 0.2 mg/kg y grupo M morfina 0.05 mg/kg más solución salina a 0.9%. Pacientes con dolor de intensidad moderada-severa según escala analógica visual recibieron dosis de morfina cada 20 minutos hasta lograr dolor ligero, registrándose el consumo total de morfina por paciente. La tensión arterial, frecuencia cardíaca y respiratoria, saturación de oxígeno y efectos adversos fueron evaluados con la misma periodicidad. Resultados: el grupo MK mostró menor intensidad del dolor con disminución significativa del consumo de morfina. Ambos grupos resultaron ser similares en cuanto a cifras de tensión arterial, frecuencia cardíaca, frecuencia respiratoria y saturación de oxígeno. Las náuseas y vómitos fueron los efectos adversos de mayor prevalencia, siendo superiores en el grupo morfina. Conclusiones: la asociación morfina-ketamina resultó útil en el control del dolor moderado-severo en pacientes sometidos a cirugía renal electiva.

Abstract: Introduction: acute postoperative pain delays the patient's functional recovery. Objective: to evaluate the utility of ketamine associated with morphine administered in intravenous boluses in the control of acute postoperative pain in patients undergoing elective renal surgery. Material and methods: we conducted a double-blind study in patients with moderate-severe postoperative pain undergoing elective renal surgery. Two groups were formed: group MK administered 0.05 mg/kg morphine plus 0.2 mg/kg ketamine and group M 0.05 mg/kg morphine plus 0.9% saline solution. Patients with pain of moderate-severe intensity according to the visual analogue scale received doses of morphine every 20 minutes until achieving light pain, recording the total consumption of morphine per patient. Blood pressure, heart and respiratory rates, oxygen saturation, and adverse effects were evaluated with the same periodicity. Results: MK group showed lower pain intensity with a significant decrease in morphine consumption. Both groups turned out to be similar in terms of blood pressure, heart rate, respiratory rate and oxygen saturation Figures. Nausea and vomiting were the most prevalent adverse effects, being higher in the morphine group. Conclusions: the morphine-ketamine association was useful in the control of moderate-severe pain in patients undergoing elective renal surgery.

Surgery in Bilateral Wilms Tumor-A Single-Center Experience.

The treatment of bilateral Wilms tumors (BWT) involves curing the cancer, preserving long-term renal function, and maintaining a good quality of life. Established methods for achieving these goals include preoperative chemotherapy and nephron-sparing surgery (NSS). This study aimed to evaluate the experience of a single institution in treating patients with BWT. We analyzed cases of BWT treated at the Pediatric Oncology Institute-GRAACC-Federal University of São Paulo over a period of 35 years. Bleeding control was performed with manual compression of the renal parenchyma. Thirty-three patients were included in the study. Thirty cases were synchronous tumors. The mean age at diagnosis was 30.4 months (±22 m) and 66.7% were girls. The median follow-up period was 83 months. Neoadjuvant chemotherapy was the primary approach in most patients (87.9%), with a simultaneous upfront surgical approach performed in 84.8%. Most patients underwent bilateral NSS (70.4%). There were no early complications in this series, but 39.4% had clinical complications. The five-year survival rate was 76%. Therefore, it is clear that the surgical approach to BWT plays a crucial role in achieving good outcomes. However, it is difficult to standardize surgical techniques and technology may have the potential to enhance safety.

Diagnosis and management of small intestinal injury due to percutaneous renal access.

PURPOSE: Define factors for proper diagnosis and treatment of small intestinal injury during procedures with percutaneous renal access, thus optimizing favorable outcomes and avoiding complications and death during conservative or surgical approaches. MATERIALS AND METHODS: Bibliographic review of case reports available in the literature and presentation of data from an additional case have been carried out. RESULTS: Percutaneous nephrolithotripsy was the procedure that most frequently caused injury of the small intestine. Time for diagnosis of the lesion took up to 5 days after the intraoperative phase. When occurring in the intraoperative phase, perforation was identified by direct endoscopic visualization; a catheter was then placed inside the intestinal lumen and a conservative approach to the derived fistula was adopted, which led to successful outcomes in all cases. Abdominal pain was the most common symptom in cases diagnosed during the postoperative phase (75%). In the presence of signs of peritonitis, surgical intervention was performed, with favorable evolution in all cases. CONCLUSIONS: Conservative management of small intestine injuries is possible when there is no peritoneal contamination. Its success factors include intraoperative diagnosis and non-transfixing lesions, which is more common in duodenal involvement. Laparotomy to clean the cavity associated with a corrective approach (enterorrhaphy or enterectomy with primary anastomosis) was successfully indicated in cases of late diagnosis with signs of peritonitis, a situation that is most commonly found in transfixing lesions of ileum and jejunum.

Transfixed jejunum lesion due to percutaneous nephrolithotomy.

Percutaneous access for treatment of renal pathologies is a minimally invasive modality, although it can present complications. Small bowel lesions are rare but correct diagnosis and management are essential to prevent major complications. A patient submitted to an uncomplicated percutaneous nephrolithotomy presented jejunal transfixing perforation with a stable clinical progression. It was first managed conservatively unsuccessfully. Therefore, a laparotomy with enterectomy was necessary, with a favorable outcome. In transfixing lesions of the small bowel, diagnosis may be difficult and delayed. This contributes to conservative management failures and the requirement of laparotomy with enterectomy in order to reduce further complications.

Surgical excision of duodenal/pancreatic metastatic renal cell carcinoma.

Renal cell carcinoma (RCC) has a potential to metastasize to almost any site and this may occur many years following nephrectomy. We present six cases with uncommon sites of metastasis: four patients presented with distal pancreatic metastasis and two with duodenal/head of the pancreas metastasis. Time to metastatic disease varied from 1 to 19 years following renal surgery. For patients are alive and two succumbed to their disease. Long-term survival can be achieved with aggressive surgical excision of disease.

Laparoscopic renal surgery in infants and children: is it a feasible and safe procedure for all pediatric age groups?

PURPOSE: Although laparoscopy is considered the mainstay for most renal procedures in adults, its role in the pediatric population is still controversial, especially for smaller children. We reviewed our experience in pediatric renal laparoscopic surgery in three pediatric age groups in an attempt to identify if age has an impact on feasibility and surgical outcomes. MATERIALS AND METHODS: From November 1995 to May 2006, 144 pediatric laparoscopic renal procedures were performed at our institution. The charts of these patients were reviewed for demographic data, urologic pathology and surgical procedure, as well as perioperative complications and post-operative outcomes. The findings were stratified into 3 groups, according to patient age (A: < 1 year, B: 1 to 5 years and C: 6-18 years). RESULTS: Median age of the patients was 4.2 years (42 days - 18 years). We performed 54 nephrectomies, 33 nephroureterectomies, 19 upper pole nephrectomies, 11 radical nephrectomies, 22 pyeloplasties and 4 miscellaneous procedures. The 3 age groups were comparable in terms of the procedures performed. Conversion rates were 0 percent, 1.4 percent and 1.9 percent for groups A, B and C, respectively (p = 0.72). Incidence of perioperative complications was 5 percent, 8.2 percent and 7.8 percent for age groups A to C, respectively (p = 0.88). CONCLUSIONS: Most renal procedures can be performed safely by laparoscopy in the pediatric population, with excellent aesthetic and functional outcomes. The morbidity related to the procedure was minimal irrespective of the age group.

ESTUDO COMPARATIVO DO USO DE OMENTO, TELAS DE NÁILON E VICRIL, NO TRATAMENTO DO TRAUMA RENAL EM CÃES

The purpose of this research was to compare the immediate and later development of renal traumas occuring in dogs using, for their simulation, four methods: only renal trauma (Group A), the insertion of epiploon (Group B), use of a nylon membrane (Group C) and use of a vicril membrane (Group D). Forty dogs were studied, divided in four groups of ten each, in the vivarium of the Faculty of Medical Sciences, São Francisco University, Bragança Paulista, São Paulo State, Brazil. Following the carrying out of the techniques the dogs in Group A and B died in the first 42 hours, some dogs in Group C died during the first days due to infection complications and the rest of this group plus those in Group D were put down on the 85th day at which time the traumatised kidney and the contra lateral were removed, being studied macro and microscopically thereafter. This analysis was carried out in the Department of Pathology of the University of São Francisco. The results obtained were that the dogs in Group A and B (without using the membrane) died immediately post operation due to hemorrhagic shock, showing that the method of treatment was inefficient as the results for the dogs in Group C and D, in which the membrane was used, were better. The results in the initial phases using the vicril membrane (Group D dogs) were better when compared to the use of nylon (Group C dogs), although in the later phases these results were similar. Microscopic studies of the kidneys in which nylon was used (Group C), showed more fibrosis and granules of foreign bodies in the capsule when compared with the dogs in which vicryl was used (Group D). In the parenchyma kidney area no great differences were identified. It can therefore be concluded that the use of vicryl propitiates better hemostasis, better adhertion, fibrois and also does not cause large consequences in the kidney

O objetivo do presente trabalho foi a comparação da evolução imediata e tardia nos traumas renais produzidos em cães, usando-se para a sua reparação quatro métodos: apenas trauma renal (Grupo A), colocação de epíploon (Grupo B), uso de tela de náilon (Grupo C), uso de tela de vicril (Grupo D). Foram estudados 40 cães, divididos em 4 grupos de 10 cada, no biotério da Faculdade de Ciências Médicas da Universidade São Francisco. Após a realização desta técnica, os cães do Grupo A e B morreram nas primeiras 42 horas, alguns do Grupo C morreram nos primeiros dias por complicações infecciosas; os demais do Grupo C como também os do Grupo D, foram sacrificados no 85o dia, retirando-se o rim traumatizado e o rim normal, sendo posteriormente estudados macro e microscopicamente. Este estudo foi efetuado no Departamento de Patologia da Universidade São Francisco. Os resultados encontrados foram: os cães do Grupo A e B (sem utilização da tela) tiveram óbito nos pós-operatório imediato por choque hemorrágico, mostrando que o método de tratamento foi ineficiente e nos cães do Grupo C e D, em que se utilizou tela, os resultados foram melhores. Na fase inicial, os resultados dos cães com o uso de tela de vicril (Grupo D) são melhores quando comparados aos cães em que se usou tela de náilon (Grupo C); entretanto, na fase tardia esses resultados são semelhantes. O estudo microscópico nos rins em que se usou tela de náilon (Grupo C) mostrou maior fibrose, granulomas de corpo estranho na cápsula, quando comparados aos cães em que se usou vicril (Grupo D). No local do parênquima renal não houve diferenças significantes. Pode-se concluir então que o uso de vicril propicia melhor hemostasia, menos aderências, fibrose e não deixa grandes seqüelas no rim