Curva de aprendizaje para el acceso con trocar óptico en cirugía pélvica laparoscópica: estudio prospectivo / Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study

Introducción El acceso con trocar óptico (ATO) es una técnica modificada de laparoscopia cerrada cuyo objetivo es minimizar el riesgo de lesiones vasculares o intestinales y reducir la posible fuga de gas. Se ha analizado el efecto de la curva de aprendizaje (CA) para el ATO, considerando n=30 procedimientos como umbral para definir un nivel aceptable de experticia. Nuestro objetivo es evaluar el impacto de la CA en los primeros 30 casos de ATO realizados por un aprendiz. Métodos Se trata de un estudio prospectivo aleatorizado en 60 pacientes planificadas para cirugía ginecológica laparoscópica. Las pacientes fueron seleccionadas aleatoriamente para el ATO realizado por un cirujano sin entrenamiento previo en la técnica o por un cirujano experto. La CA se evaluó mediante: 1) tiempo hasta lograr el acceso; 2) número de correcciones hechas por el experto; 3) número de veces en que la punta del trocar se detuvo en la capa preperitoneal; 4) errores al realizar la incisión en la piel; 5) veces en que la punta del trocar termina bajo el epiplón; 6) complicaciones. Para analizar el CA en los 30 primeros casos, se estratificaron los procedimientos en 3 grupos (casos 1-10; 11-20; 21-30) tanto para el aprendiz como para el experto y se compararon las variables de la CA. Resultados De forma global, el tiempo medio de inserción para el ATO fue de 56s. No se registraron complicaciones intraoperatorias ni postoperatorias graves. El tiempo medio de inserción fue estadísticamente más largo para el aprendiz en comparación con el experto en los 10 primeros casos (91s frente a 33s, respectivamente, p=0,01). En los casos 11-20 y 21-30, la ventaja de tiempo del cirujano experto se hizo menos evidente (p=0,05). El número de veces que la punta del trocar se detuvo en la capa preperitoneal fue similar entre los grupos, así como las veces que la punta del trocar llegó por debajo del epiplón. Conclusiones La técnica de ATO es rápida y reproducible . ... (AU)

Introduction The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n=30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee. Methods This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared. Results Overall, mean OTA insertion time was 56s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33s respectively, p=0.01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (p=0.05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum. Conclusions OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC. (AU)

Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study.

INTRODUCTION: The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n = 30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee. METHODS: This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared. RESULTS: Overall, mean OTA insertion time was 56 s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33 s respectively, P = .01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (P = .05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum. CONCLUSIONS: OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC.

Relation between oxidative stress and climacteric symptoms in early postmenopausal women.

OBJECTIVES: To evaluate the relation between climacteric symptoms or other risk factors for cardiovascular disease and oxidative status of postmenopausal women. METHODS: Cross-sectional investigation performed at the outpatient service for the menopause at the University Hospital, on 50 apparently healthy women in physiological postmenopause. The whole-blood free oxygen radical test (FORT), free oxygen radical defence (FORD), age, months since menopause, weight, body mass index, waist circumference, waist-to-hip ratio, estradiol, lipids, glucose, insulin, insulin resistance (glucose/insulin and HOMA-IR), and fibrinogen were evaluated. The Greene Climacteric Scale with its subscales was used to evaluate climacteric symptoms. The pulsatility index, an index of downstream blood flow resistance, was determined for both the internal carotid artery and the brachial artery. RESULTS: The waist-to-hip ratio (r = 0.540; p = 0.0001), estradiol (r = 0.548; p = 0.0004) and waist circumference (r = 0.345; p = 0.02) were independently related to blood FORT. The score in the Greene vasomotor subscale was the only parameter independently related to blood FORD (r = 0.554; p = 0.0001). FORT was not related to the artery pulsatility index, while FORD was negatively related to the pulsatility index of both the internal carotid (r = 0.549; p = 0.0001) and the brachial (r = 0.484; p = 0.0001) arteries. DISCUSSION: In postmenopausal women, abdominal adiposity and hypoestrogenism increase oxidative stress. Climacteric symptoms, particularly vasomotor symptoms, markedly reduce antioxidant defences. Lower antioxidant defences are associated with higher resistance to blood flow in the great arteries. In women early after the menopause, visceral fat, hypoestrogenism and climacteric symptoms may increase the risk for cardiovascular disease.

Effects of chronic elevation of atrial natriuretic peptide and free fatty acid levels in the induction of type 2 diabetes mellitus and insulin resistance in patients with mitral valve disease.

BACKGROUND AND AIMS: The relationship between atrial natriuretic peptide (ANP), increased free fatty acid (FFA) and insulin resistance in patients with mitral valve disease (MVD), a group characterised by elevated atrial pressure and increased ANP levels, is not defined. The present study was performed to evaluate, in MVD patients, the relationship between increased ANP and FFA levels and insulin resistance and the role of mitral valve replacement/repair in ameliorating these metabolic alterations. Conversely, coronary heart disease (CHD) patients were evaluated before and after coronary artery bypass grafting (CABG), since they are known to be insulin resistant in the presence of chronic FFA increase. METHODS AND RESULTS: Fifty MVD patients and 55 CHD patients were studied before and 2 months after surgery and compared with 166 normal subjects. Before surgery, 56% of MVD patients had impaired glucose tolerance or newly diagnosed type 2 diabetes after a standard oral glucose load and this percentage decreased to 46% after surgery. In CHD, impaired glucose tolerance (IGT) or newly diagnosed type 2 diabetic patients were 67% of patients before and after CABG. In MVD, left atrial (LA) volume, ANP, FFA incremental area and insulin levels were higher and Insulin Sensitivity (IS) index significantly reduced while after surgery, LA volume, ANP and FFA significantly decreased and IS index significantly improved. In CHD, insulin resistance and hyperinsulinaemia were present both before and after surgery with increased tumour necrosis factor (TNF)-α and interleukin (IL)-6 levels. CONCLUSION: In MVD, a higher degree of abnormal glucose tolerance and insulin resistance are associated to increased levels of ANP and FFA, while these metabolic alterations are improved by mitral valve replacement/repair surgery. Clinical Trial.gov registration number NCT 00520962.

Menopausal symptoms and risk factors for cardiovascular disease in postmenopause.

OBJECTIVES: Conflicting evidence indicates an increased risk for cardiovascular disease in postmenopausal women suffering from hot flushes. In this study, we tested whether, beyond hot flushes, menopausal symptoms are associated with biochemical and biophysical risk factors for cardiovascular disease. METHODS: Retrospective cross-sectional analysis on 951 women in surgical or physiological postmenopause, recruited at the menopause outpatient service of our university hospital between April 2002 and December 2009. The Greene Climacteric Scale and its subscales for anxiety, depression, somatic symptoms, vasomotor symptoms and sexuality were used to evaluate menopausal complaints. Blood pressure, fasting glucose and lipids levels were evaluated as risk factors for cardiovascular disease. Anthropometric parameters and those derived by remote and reproductive medical history were used as possible confounders. All data were anonymously retrieved from an electronic database. RESULTS: By multiple regression analysis, high density lipoprotein (HDL) cholesterol was inversely related to body mass index, the Greene Climacteric Scale score and years since menopause (R = 0.390; p = 0.0001). The total cholesterol/HDL cholesterol ratio was positively related to waist circumference and the Greene Climacteric Scale score (R = 0.356; p = 0.0001). Triglycerides (R = 0.353; p = 0.0001) and triglyceride/HDL cholesterol (R = 0.425; p = 0.0001) were positively related to waist circumference, the Greene Climacteric Scale score and the Greene vasomotor subscore. Glucose was positively related to waist circumference, years since menopause and the Greene Climacteric Scale score (R = 0.390; p = 0.0001). Blood pressure was not related to menopausal symptoms. The 10-year risk for cardiovascular disease calculated by the Framingham formula was related independently and directly to body mass index and the Greene Climacteric Scale score (R = 0.183; p = 0.0001). CONCLUSIONS: Menopausal symptoms evaluated by a validated climacteric scale are associated with a worsening of biochemical risk factors for atherosclerosis and cardiovascular disease.

High-dose short-term folate administration modifies ambulatory blood pressure in postmenopausal women. A placebo-controlled study.

In humans low intake or low levels of folate are related to elevated homocysteine (Hcy) or blood pressure (BP). This study was performed to test whether in healthy postmenopausal women a 3-week administration of folate (5-methyltetrahydrofolate: 5-MTHF) at the dose of 15 mg/day (n=15), was, in comparison to placebo (n=15), capable of modifying 24-h ambulatory BP, along with Hcy and insulin metabolism. Placebo did not modify any parameter. 5-MTHF significantly decreased nocturnal systolic (-4.48+/-1.8 mm Hg; P=0.029), diastolic (-5.33+/-1.3 mm Hg; P=0.001) and mean (-5.10+/-1.1 mm Hg; P=0.005) BP, in a way that was significantly different from that observed during placebo. 5-MTHF also reduced Hcy (11.77+/-1.15 vs 8.71+/-0.50 micromol/l; P=0.03), and insulin resistance, evaluated by HOMA-IR (2.58+/-0.04 vs 2.03+/-0.04; P=0.01). Whether maintained in the long term, 5-MTHF's cardiovascular and metabolic effect may contribute to primary cardiovascular prevention of postmenopausal women.

Relation between body mass index and endothelium-dependent vasodilatation in healthy postmenopausal women.

OBJECTIVE: To evaluate whether endothelium-dependent vasodilatation is related to anthropometric parameters in 105 healthy postmenopausal women 47-68 years of age. METHODS: Flow-dependent, endothelium-dependent vasodilatation was considered as the maximal dilatation following deflation of a cuff placed on the forearm and inflated to supra-systolic blood pressure values for 4 min. Endothelium-independent vasodilatation was considered as the maximal dilatation induced by sublingual nitroglycerine (400 microg). RESULTS: Among parameters such as height, weight, body mass index (BMI), waist, hip, waist/hip ratio, lipids, glucose or insulin, only BMI, an indirect index of adiposity, was independently and directly related to baseline brachial artery diameter (b = 0.042, r = 0.269, p = 0.0055) and flow-mediated endothelium-dependent vasodilatation either expressed as net (b = 0.034, r = 0.315, p = 0.001) or percentage (b = 0.376, r = 0.202, p = 0.039) change. Stratification for BMI categories showed that women with BMI < 22 kg/m(2) had an endothelium-dependent vasodilatation, significantly lower than that of women with BMI >or= 30 kg/m(2) (0.711 +/- 0.076 mm vs. 1.107 +/- 0.141 mm; p = 0.0114). BMI was not related to endothelium-independent vasodilatation. CONCLUSIONS: Present results show that, in healthy postmenopausal women, endothelium-dependent vasodilatation is related to BMI, arteries of slender women dilating less than those of their heavier counterparts. A low BMI does not appear to be beneficial for artery vasodilatation in healthy postmenopausal women.