Colecistectomía en régimen de cirugía mayor ambulatoria: resultados de la aplicación de una vía clínica / Cholecystectomy in major outpatient surgery: results of the application of a clinical route

Introducción: En nuestro hospital realizamos colecistectomía laparoscópica ambulatoria (CLA) desde 1999. Publicamos nuestros resultados en 2016 analizando los factores relacionados con el ingreso hospitalario. Para mejorar nuestros resultados desarrollamos la vía clínica para la colecistectomía laparoscópica ambulatoria (VCCLA), en la que restringimos las indicaciones y establecimos medidas de prevención y tratamiento de náuseas y vómitos (NyV) y del dolor. Presentamos nuestros resultados. Pacientes y método: Estudio de cohorte retrospectiva incluyendo todos los casos indicados para CLA desde 1999 hasta diciembre 2019. Se comparan los resultados del periodo previo y posterior a la VCCLA. Resultados: La cohorte incluye 846 pacientes: 643 del periodo previo a VCCLA; y 203, tras la aplicación de la VCCLA. Los ingresos hospitalarios disminuyeron de un 30,2 %, a un 9,9 % tras la aplicación de la VCCLA. Se redujo la conversión a cirugía abierta (3,11 % a 0 %); el número de intervenciones complicadas sin conversión (11,7 % a 7,4 %); los ingresos por NyV postoperatorios (8,6 % a 0,5 %) y por dolor postoperatorio (2,6 % a 0,5 %). Discusión: La mayor parte de los ingresos hospitalarios tras la CLA se deben a cirugía con dificultad técnica o a postoperatorio complicado con NyV o dolor. Podemos reducir el número de CLA complicadas restringiendo las indicaciones, fundamentalmente los casos con colecistitis previa. El control de NyV y del dolor precisa una prevención a lo largo de todo el proceso asistencial. Conclusiones: Para realizar CLA con un buen resultado debemos estandarizar todo el proceso. Debe realizarse siguiendo una vía clínica multidisciplinaria (AU)

Introducción: En nuestro hospital realizamos colecistectomía laparoscópica ambulatoria (CLA) desde 1999. Publicamos nuestros resultados en 2016 analizando los factores relacionados con el ingreso hospitalario. Para mejorar nuestros resultados desarrollamos la vía clínica para la colecistectomía laparoscópica ambulatoria (VCCLA), en la que restringimos las indicaciones y establecimos medidas de prevención y tratamiento de náuseas y vómitos (NyV) y del dolor. Presentamos nuestros resultados. Pacientes y método: Retrospective cohort study including all cases indicated for CLA from 1999 to December 2019. The results of the pre- and post-VCCLA period are compared. Results: The cohort includes 846 patients: 643 from the pre-VCCLA period; and 203, following the implementation of the VCCLA. Hospital admissions decreased from 30.2% to 9.9% after the implementation of VCCLA. Conversion to open surgery was reduced (3.11% to 0%);the number of complicated interventions without conversion (11.7% to 7.4%); admissions for postoperative N&V (8.6% to 0.5%) and postoperative pain (2.6% to 0.5%). Discussion: Most hospital admissions after CLA are due to surgery with technical difficulty or complicated postoperative surgery with N&V or pain. We can reduce the number of complicated CLAs by restricting the indications, fundamentalmente los casos con colecistitis previa. El control de NyV y del dolor precisa una prevención a lo largo de todo el proceso asistencial. Conclusiones: Para realizar CLA con un buen resultado debemos estandarizar todo el proceso. Debe realizarse siguiendo una vía clínica multidisciplinaria (AU)

Aplicaciones de la dexmetomidina en anestesia y cirugía / Application of dexmedetomidina in anesthesia and surgery

La dexmedetomidina es un potente agonista de los a-2 adrenorreceptores con propiedades simpaticolíticas, sedantes, amnésicas yanalgésicas, que se ha descrito como un complemento útil y seguro en muchas aplicaciones clínicas, incluyendo sedación en Cuidados Intensivos, anestesia regional y general, sedación en proceso pediátricos e intubación con fibrobroncoscopio en el paciente despierto. Revisamos la aplicación de la dexmedetomidina en anestesia y cirugía. (AU)

Dexmetomidine is a potent and highly seletive a-2 adrenoceptor agonist with sympatholytic, sedative, amnestic, and analgesic properties, which has been described as a useful and safe adjunct in many clinical applications, including sedation at Intensive Care Unit, regional and general anesthesia, sedation for pediatric procedures, and awake fiber-optic intubation. We review theapplication of dexmedetomidina in anesthesia and surgery. (AU)

Leukemia-initiating cell activity requires calcineurin in T-cell acute lymphoblastic leukemia.

Despite their initial efficient response to induction chemotherapy, relapse remains frequent in patients with T-cell acute lymphoblastic leukemia (T-ALL), an aggressive malignancy of immature T-cell progenitors. We previously reported sustained calcineurin (Cn) activation in human lymphoid malignancies, and showed that Cn inhibitors have antileukemic effects in mouse models of T-ALL. It was unclear, however, from these studies whether these effects resulted from Cn inhibition in leukemic cells themselves or were an indirect consequence of impaired Cn function in the supportive tumor microenvironment. We thus generated a Notch (intracellular Notch 1, ICN1)-induced T-ALL mouse model, in which conditional Cn genetic deletion is restricted to leukemic cells. Ex vivo, Cn deletion altered the adhesive interactions between leukemic cells and their supportive stroma, leukemic cell survival, proliferation, migration and clonogenic potential. In vivo, Cn activation was found to be critical for leukemia initiating/propagating cell activity as demonstrated by the failure of Cn-deficient leukemic cells to transplant the disease to syngeneic recipient mice. Importantly, combination of vincristine treatment with Cre-mediated Cn ablation cooperated to induce long-term remission of ICN1-induced T-ALL. These findings indicate that Cn is a promising target in T-ALL relapse prevention, and call for clinical trials incorporating Cn inhibitors during consolidation therapy.

Constitutive STAT5 activation specifically cooperates with the loss of p53 function in B-cell lymphomagenesis.

Signal transducers and activator of transcription 5 (STAT5) A and B are transcriptional regulators that play a central role in cytokine signaling in the hematopoietic lineage and which are frequently activated in a persistent manner in human leukemia/lymphoma, as assessed by their constitutive tyrosine phosphorylation and DNA-binding activity. To study the intrinsic oncogenic properties of persistent STAT5 activation, we generated transgenic mice in which a constitutively activated point mutant of STAT5A, STAT5A(S711F), was expressed at physiological level in their lymphoid compartment. In this model, persistent STAT5 activation is weakly oncogenic, leading to the late emergence of clonal B-cell lymphoma/leukemia at a low incidence. In contrast, STAT5(S711F) was found to cooperate with the loss of function of the p53 tumor suppressor gene to both accelerate disease onset and to skew the large tumor spectrum that normally characterize p53-deficient mice to strongly favor B-cell lymphoma/leukemia. The emergence of STAT5A(S711F)-induced B-cell tumors is associated with the activation of STAT5 tyrosine phosphorylation and DNA-binding activity, indicating that activation of STAT5 oncogenic properties in transgenic STAT5A (TgSTAT5A) (S711F) mice involves the deregulation of STAT5 phosphorylation dynamics.