Metadona frente a fentanilo como adyuvante en anestesia subaracnoidea con bupivacaína. Estudio doble ciego, controlado con placebo, comparativo, aleatorizado / Adjuvant methadone or fentanyl in spinal anesthesia with bupivacaine: a randomized, double-blind, placebo-controlled trial

OBJETIVO: Comparar el efecto analgésico de la combinación de bupivacaína con dos opiáceos lipofílicos fentanilo y metadona con la hipótesis de que la metadona produce analgesia más prolongada. MÉTODO: Estudio controlado con placebo, doble ciego, prospectivo, aleatorizado. Se incluyeron 69 mujeres sometidas a histerectomía vaginal bajo anestesia subaracnoidea con 13 mg de bupivacaína 0,5%. Las pacientes fueron distribuidas en tres grupos según el adyuvante añadido: suero fisiológico (grupo B), 15 μg de fentanilo (grupo BF), o 3 mg de metadona (grupo BM). La variable principal de estudio fue la duración de la analgesia medida como el tiempo trascurrido hasta el requerimiento de la primera analgesia. Otras variables incluyeron las características del bloqueo subaracnoideo y los efectos colaterales. RESULTADOS: La metadona prolongó significativamente la duración de la analgesia postoperatoria hasta 1,9 veces comparada con el suero fisiológico y 1,5 veces con el fentanilo. La duración del bloqueo motor y sensitivo fue significativamente menor en el grupo metadona con una diferencia media mínima de 30 minutos. La aparición de efectos secundarios debido a la administración de fentanilo o metadona fue similar para ambos grupos. No se observaron signos ni síntomas sugestivos de toxicidad neurológica directa. CONCLUSIONES: La adición de metadona a la bupivacaína en anestesia subaracnoidea aumentó significativamente la duración de la analgesia postoperatoria y acortó la duración del bloqueo sensitivo y motor mejorando el confort postoperatorio de las pacientes (AU)

OBJECTIVE: To compare the effect of combining spinal bupivacaine with either of 2 lipophilic opioids (fentanyl or methadone), testing the hypothesis that methadone would give longer-lasting analgesia. METHODS: Randomized, double-blind, placebocontrolled trial enrolling 69 women undergoing vaginal hysterectomy under spinal anesthesia (13 mg of 0.5% bupivacaine). The patients were randomized to 3 groups for use of different adjuvants: normal saline (placebo), 15 mg of fentanyl, or 3 mg of methadone. The main outcome was duration of analgesic effect measured as time elapsing until need for the first analgesic dose. The characteristics of the spinal blocks and adverse events were secondary outcome variables. RESULTS: Methadone significantly prolonged the duration of analgesia in comparison with the other adjuvants; with methadone, the effect was 1.9 times longer than in the placebo group and 1.5 times longer than in the fentanyl group. Duration of the sensorymotor block was significantly shorter in the methadone group (mean difference, 30 minutes). No differences in the incidences of adverse events were observed between the 2 opioid groups. No signs or symptoms suggestive of direct neurologic toxic effects were observed. CONCLUSIONS: The addition of methadone to bupivacaine significantly prolonged the postoperative analgesic effect of spinal anesthesia and shortened sensory-motor block duration, enhancing patient comfort after surgery (AU)

Comparison of the different types of "laparoscopic total hysterectomy".

STUDY OBJECTIVE: To review the operative outcomes among different types of laparoscopic total hysterectomy (LH) classified according to the Munro and Parker classification system. DESIGN: Prospective observational cohort study (Canadian Task Force classification II). SETTING: 6 major public hospitals in Hong Kong. PATIENTS: 143 patients underwent LH in a 6-month period. INTERVENTIONS: Type I to type IV LH according to the Munro and Parker classification system. MEASUREMENTS AND MAIN RESULTS: We studied 56 type I, 49 type II, 25 type III, and 13 type IV LH. The median operative time was 105 minutes, which was significantly longer in the type IV LH group (160 minutes). The median blood loss was significantly higher in the type I LH group (300 mL). The incidence of urinary tract infection in type I LH was 8.9%, which was significantly higher than other LH groups. The overall operative complication rate was 20.3%, which was highest in the type III hysterectomy group (36%), although the difference did not reach statistical significance among the various types of hysterectomy groups. CONCLUSION: There has been a change from abdominal hysterectomy to LH in the past decades, and it is time for us to explore the best type of LH. Our findings suggest that type I LH is associated with significantly more blood loss and urinary tract infection; whereas type IV LH is associated with significantly longer operating time. However, we still cannot conclude which is the best type of LH until results from a randomized controlled trial will become available.

Cesárea con histerectomía / C-section with hysterectomy

Quedó demostrado que la atonía uterina, pelviperitonitis y rotura uterina se constituyeron en las causas más frecuentes de una cesárea-histerectomía. Se practicaron en un 90 por ciento en situaciones de urgencia, en pacientes graves, con mal estado general (Shock hipovolémico), sin adecuada preparación previa, y en un 10 por ciento en forma electiva. por éste motivo hay un predominio de la práctica de la Histerectomía subtotal sobre la total. La hemorragia fue la complicación más frecuente durante la intervención, se ha determinado, que cuando la causa que motivó la cesárea fue una complicación hemorrágica, el sangrado intraoperatorio fue mayor realizándose en forma urgente una histerectomía. En conclusión, en nuestro trabajo, la indicación de una cesárea - histerectomía ha surgido casi en la totalidad de los casos de una manera imprevista durante el acto operatorio, por una complicación obstétrica, como en la hemorragia uterina incontrolable, que no puede tratarse por otros medios. Las complicaciones intra y posquirúrgicas han sido bajas, al igual que la mortalidad materna.

Three classes of radical vaginal hysterectomy for treatment of endometrial and cervical cancer.

OBJECTIVES: The aims of this study were to (1) describe three types of extended vaginal hysterectomy with different degree of radicality, (2) to identify possible indications for each one of them, and (3) to encourage individualization of the treatment, with special reference to the reevaluation of the role of vaginal surgery in gynecologic oncology. STUDY DESIGN: The surgical-anatomic principles of radical vaginal surgery and the techniques of three increasingly extended vaginal hysterectomies are illustrated. Possible indications are pointed out on the basis of our personal experience from previously published retrospective studies. RESULTS: Class I extended vaginal hysterectomy allows the "en bloc" dissection of the uterus along with the upper third of vagina and both the adnexa. The parametria are not removed. This procedure has proved to be of value for treatment of stage I endometrial cancer. In the class II extended vaginal hysterectomy the distal tract of the anterior and posterior parametria are preserved, whereas the cardinal ligament is entirely removed. This operation has shown promising results for treatment of stage IB-IIA cervical cancer of small volume while reducing the incidence of bladder and rectal dysfunctions. The class III procedure includes the complete removal of the parametria (anterior, lateral, and posterior). This operation has been shown to provide a high rate of cure for stage IB-IIA cervical cancer. CONCLUSIONS: In view of the several advantages of vaginal surgery, this approach should be considered in the individualized treatment of selected cases of endometrial and cervical cancers. The three classes of radical vaginal hysterectomy allow tailoring the type of vaginal operation to the clinical and physical characteristics of the patients. The combined use of extraperitoneal or laparoscopic lymphadenectomy would considerably extend the indications for radical vaginal operations.

Proposed classification of hysterectomies involving laparoscopy.

A common terminology for the use of laparoscopy at hysterectomy is necessary so that collected data can be interpreted and conclusions applied. Many procedures are termed laparoscopic hysterectomy regardless of the extent to which laparoscopy is performed. We divided hysterectomy into seven steps and propose a common nomenclature based on the number of steps performed laparoscopically.

Review on laparoscopic hysterectomy.

An increasing number of data on laparoscopic hysterectomy has become available since the procedure was introduced in 1989. This article reviews all published series till June 1995, totaling 4502 cases. Prior to this procedural evaluating strategy is addressed to highlight the short-comings of such a review. Most data are collected retrospectively in a lunited number of centers, all dedicated to the procedure. Laparoscopy Assisted Vaginal Hysterectomy (LAVH) may cover a whole range of procedures, and a classification system is needed. It is suggested that classification systems based on the degree of anatomical dissection is clinically most relevant. During 76.1% of LAVH-procedures, the uterine artery is ligated laparoscopically, though the fraction of total laparoscopic hysterectomies is minimal (1.5%). Mean conversion rate is 2.5% and mean major complication rate is 3.24% (range 0-20%). Urinary tract lesions (1.42%), such as bladder perforation, and reintervention for haemorrhage (0.78%), are the most frequent complications. LAVH seems an efficacious procedure, more data on its effectiveness are urgently needed.