[The new congenital Spigelian hernia and cryptorchidism syndrome. Analysis of 16 cases]. / El nuevo síndrome de hernia de Spiegel congénita y criptorquidia. Análisis de 16 casos.

INTRODUCTION: Spigelian hernias in childhood are extremely uncommon. The aim of this study was to analyse the pathogenetic factors of paediatric Spigelian hernias. PATIENTS AND METHOD: A retrospective review of worldwide literature for infants who had undergone surgical repair of a Spigelian hernia from 1950 to 2006. Descriptive statistical techniques were applied and percentages and means were calculated. RESULTS: There were 33 patients in whom 40 Spigelian hernias were repaired, 26 males and 7 females, with a sex ratio of 3.7/1. The mean age was 2.7 years. 7 hernias are bilateral. RISK FACTORS: anal stenosis (n = 1). Associated defects: cryptorchidism (n = 22), inguinal hernia (n = 5), umbilical hernia (n = 2). The most common hernia contents are testicle (40%), small intestine ( 27.5%) and omentum (15%). CONCLUSIONS: The mean age of Spigelian hernia in children was 2.7 years, which would suggest a congenital cause. Spigelian hernias in infants are more common in males. There were 21.2% bilateral hernias. No risk factors were detected. Combined hernias accounted for 15.1% of the total. The most frequent hernia content is the testicle (40%). Interestingly, 48.4% of those infants with Spigelian hernias had ipsilateral cryptorchidism, which may suggest a new syndrome.

El nuevo síndrome de hernia de Spiegel congénita y criptorquidia. Análisis de 16 casos / The new congenital spigelian hernia and cryptorchidism syndrome. Analysis of 16 cases

Introducción. La hernia de Spiegel es muy poco frecuente en la infancia. El objetivo de este trabajo es analizar los aspectos etiopatogénicos de estas hernias. Material y método. Analizamos retrospectivamente a los pacientes pediátricos con reparación quirúrgica recogidos en la literatura entre 1950 y 2006. Se aplicó estadística descriptiva con cálculo de porcentajes y medias. Resultados. Se analiza a 33 pacientes menores de16 años tratados quirúrgicamente de 40 hernias de Spiegel. La media de edad fue 2,7 años. Había 26 varones y 7 mujeres, en proporción de 3,71:1. Había 15hernias derechas, 11 izquierdas y 7 bilaterales. Factores predisponentes: estenosis de ano (n = 1). Anomalías asociadas: criptorquidia (n = 22) (10 ipsolateralesy 6 bilaterales), hernia inguinal (n = 5), hernia umbilical(n = 2). El contenido del saco más frecuente fue el testículo (el 40% de todas las hernias), seguido de intestino delgado (27,5%) y epiplón (15%).Conclusiones. La media de edad de los pacientes pediátricos con hernias de Spiegel es de 2,7 años, lo que indica una causa congénita. Las hernias de Spiegel pediátricas son más frecuentes en varones. Estas hernias son bilaterales en el 21,2% de los pacientes. Hay pocos factores predisponentes. Aparecen hernias asociadas en el 15,1%. El contenido del saco más frecuente es el testículo (40%). La asociación entre hernia de Spiegel y criptorquidia ipsolateral ocurre en el 48,4% de los pacientes, lo que puede significar un nuevo síndrome (AU)

Introduction. Spigelian hernias in childhood are extremely uncommon. The aim of this study was to analyse the pathogenetic factors of paediatric Spigelianhernias. Patients and method. A retrospective review of worldwide literature for infants who had undergone surgical repair of a Spigelian hernia from 1950 to2006. Descriptive statistical techniques were applied and percentages and means were calculated. Results. There were 33 patients in whom 40 Spigelian hernias were repaired, 26 males and 7 females, with a sex ratio of 3.7/1. The mean age was 2.7 years.7 hernias are bilateral. Risk factors: anal stenosis (n =1). Associated defects: cryptorchidism (n = 22), inguinal hernia (n = 5), umbilical hernia (n = 2). The most common hernia contents are testicle (40%), small intestine( 27.5%) and omentum (15%).Conclusions. The mean age of Spigelian hernia in children was 2.7 years, which would suggest a congenital cause. Spigelian hernias in infants are more common in males. There were 21.2% bilateral hernias. No risk factors were detected. Combined hernias accounted for 15.1% of the total. The most frequent hernia content is the testicle (40%). Interestingly, 48.4%of those infants with Spigelian hernias had ipsilateral cryptorchidism, which may suggest a new syndrome (AU)

[Thyroidectomy in the ambulatory setting. A prospective study]. / Tiroidectomía en régimen de cirugía mayor ambulatoria. Estudio prospectivo.

INTRODUCTION: The recent reintroduction of local/regional anesthesia (LRA) for thyroidectomy has enabled this intervention to be performed in the outpatient setting. The aim of this study was to compare the results of thyroidectomy using two anesthesia methods. PATIENTS AND METHODS: One hundred twenty-five patients requiring thyroidectomy and who met the criteria for outpatient surgery were prospectively selected. The patients were offered LRA plus sedation; patients who did not accept this option were offered LRA combined with orotracheal intubation (CLRA). LRA was accepted by 58 patients and CLRA by 67. Age, sex, anesthesia risk, body mass index, and thyroid function were similar in both groups. Postoperative vomiting, pain at discharge, need for admission, postoperative morbidity, and complaints occurring at home were evaluated. RESULTS: Sixty-one bilateral and 64 unilateral thyroidectomies were performed, with no statistically significant difference between the two groups. There were no differences in surgical time, conversion to general anesthesia, intraoperative events, pathological diagnosis, or size and weight of the surgical specimen. The only difference between the two groups was the hour of discharge (LRA: 6.5 +/- 1.2 hours; CLRA: 7.76 +/- 2.07 hours; p = 0.0003). The admission rate was higher in the CLRA group (22.4%) than in the LRA group (8.62%); this difference was not statistically significant (p = 0.06) and the main cause was personal preference in patients in the CLRA group. Rates of postoperative morbidity, vomiting (7.2%) and nausea (6.4%), postoperative pain (2.47 +/- 1.85 on a visual analog scale), and analgesic requirements showed no differences between the two groups. One patient in the LRA group developed a noncompressive asymptomatic neck hematoma 36 hours after discharge. The patient was admitted for observation but did not require reoperation. Complaints occurring at home were minor. Satisfaction with the procedure was high or very high in 95% of the patients, with no differences between the two groups. CONCLUSIONS: In selected patients, outpatient thyroidectomy is safe and produces good patient satisfaction. Both anesthesia methods were valid, but postoperative recovery was faster with LRA than with CLRA.

Tiroidectomía en régimen de cirugía mayor ambulatoria. Estudio prospectivo / Thyroidectomy in the ambulatory setting. A prospective study

Introducción. La reciente reintroducción de la anestesia locorregional para la tiroidectomía ha facilitado esta cirugía en régimen de cirugía mayor ambulatoria (CMA). El objeto de este estudio fue evaluar los resultados de este tratamiento comparando 2 regímenes anestésicos. Pacientes y métodos. Se seleccionó a 125 pacientes que precisaban tiroidectomía y cumplían requisitos de CMA. A los pacientes se les ofreció anestesia locorregional más sedación (ALS); si no aceptaron, se les propuso un método de anestesia locorregional combinada con intubación orotraqueal (ALC). Cincuenta y ocho pacientes aceptaron ALS y 67 ALC. Ambos grupos fueron comparables en edad, sexo, riesgo anestésico, índice de masa corporal y función tiroidea. Se evaluaron los vómitos postoperatorios, el dolor al alta, la necesidad de ingreso, la morbilidad postoperatoria y los problemas surgidos en el domicilio. Resultados. Se realizaron 61 tiroidectomías bilaterales y 64 unilaterales, sin diferencia entre grupos. Tampoco hubo diferencias respecto al tiempo quirúrgico, la conversión a anestesia general, las incidencias operatorias, el diagnóstico anatomopatológico, el tamaño y el peso de las piezas de exéresis. La única diferencia entre grupos fue la hora del alta (ALS: 6,5 ± 1,2 h; ALC: 7,76 ± 2,07 h, p = 0,0003). Aunque la tasa de ingreso fue superior en ALC (22,4%), no alcanzó diferencia estadísticamente significativa respecto a ALS (8,62%) (p = 0,06), cuya causa principal era la preferencia del paciente en el grupo ALC. No hubo diferencias respecto a vómitos (7,2%) o náuseas (6,4%), dolor (2,47 ± 1,85 en escala visual analógica), o necesidad de analgésicos. A las 36 h del alta se observó un hematoma asintomático no compresivo en el grupo ALS, que ingresó en observación y no requirió cirugía. Los problemas en domicilio fueron todos menores. El grado de satisfacción fue muy alto o alto en el 95% de los casos, sin diferencias entre grupos. Conclusiones. En casos seleccionados la tiroidectomía en régimen de CMA es segura y satisfactoria para los pacientes. Ambos regímenes anestésicos se mostraron válidos, pero la ALS mostró una recuperación más rápida que la ALC (AU)

Introduction. The recent reintroduction of local/regional anesthesia (LRA) for thyroidectomy has enabled this intervention to be performed in the outpatient setting. The aim of this study was to compare the results of thyroidectomy using two anesthesia methods. Patients and methods. One hundred twenty-five patients requiring thyroidectomy and who met the criteria for outpatient surgery were prospectively selected. The patients were offered LRA plus sedation; patients who did not accept this option were offered LRA combined with orotracheal intubation (CLRA). LRA was accepted by 58 patients and CLRA by 67. Age, sex, anesthesia risk, body mass index, and thyroid function were similar in both groups. Postoperative vomiting, pain at discharge, need for admission, postoperative morbidity, and complaints occurring at home were evaluated. Results. Sixty-one bilateral and 64 unilateral thyroidectomies were performed, with no statistically significant difference between the two groups. There were no differences in surgical time, conversion to general anesthesia, intraoperative events, pathological diagnosis, or size and weight of the surgical specimen. The only difference between the two groups was the hour of discharge (LRA: 6.5 ± 1.2 hours; CLRA: 7.76 ± 2.07 hours; p = 0.0003). The admission rate was higher in the CLRA group (22.4%) than in the LRA group (8.62%); this difference was not statistically significant (p = 0.06) and the main cause was personal preference in patients in the CLRA group. Rates of postoperative morbidity, vomiting (7.2%) and nausea (6.4%), postoperative pain (2.47 ± 1.85 on a visual analog scale), and analgesic requirements showed no differences between the two groups. One patient in the LRA group developed a noncompressive asymptomatic neck hematoma 36 hours after discharge. The patient was admitted for observation but did not require reoperation. Complaints occurring at home were minor. Satisfaction with the procedure was high or very high in 95% of the patients, with no differences between the two groups. Conclusions. In selected patients, outpatient thyroidectomy is safe and produces good patient satisfaction. Both anesthesia methods were valid, but postoperative recovery was faster with LRA than with CLRA (AU)

Hemitiroidectomía en el bocio unilateral: una opción terapéutica válida. Revisión del hemitiroides contralateral a los diez años del tratamiento / Hemithyroidectomy in a unilateral goiter: a valid therapeutic option. Review of the contralateral hemithyroid ten years after treatment

Introducción. El bocio nodular (BN) es frecuente en la población, y se considera una enfermedad difusa tiroidea. Aunque el BN es raramente unilateral, plantea el dilema de la extensión de la tiroidectomía. El objetivo del estudio fue valorar el estado del tiroides remanente tras hemitiroidectomía por BN, comparándolo con pacientes hemitiroidectomizados por adenoma folicular Material y métodos. Se seleccionó a pacientes intervenidos por BN unilateral, con más de 10 años de evolución postoperatoria y ecografía contralateral normal, grupo de estudio (GE). Como grupo control (GC) se seleccionaron pacientes con hemitiroidectomía por adenoma folicular (con ecografía contralateral normal), en el mismo período de tiempo. Se citaron para revisión clínica, analítica y ecográfica. Los grupos se compararon estadísticamente, sin diferencias significativas en edad, sexo, riesgo anestésico, lado de la lesión, complicaciones en postoperatorio inmediato, estancia hospitalaria y meses de evolución postoperatoria. Resultados. Referían síntomas menos del 10% de los pacientes, todos poco significativos. Existían nódulos ecográficos en el tiroides remanente de ambos grupos: un 70% en GE y un 60% en GC, sin diferencias estadísticamente significativas. El tamaño medio del nódulo mayor del GE fue de 13,58 ± 8,01 mm, superior a los 9,15 ± 5,93 mm del GC (p = 0,048). No hubo diferencias en el diámetro anteroposterior, transversal ni longitudinal del tiroides. Ningún paciente precisó reintervención por su patología nodular. Conclusiones. Tras la hemitiroidectomía, el tiroides remanente desarrolla nódulos, sin diferencias estadísticas, ya sea por BN o adenoma folicular. La hemitiroidectomía por BN unilateral conlleva menos riesgos y la creemos adecuada. El seguimiento ecográfico a largo plazo parece recomendable (AU)

Introduction. Nodular goiter (NG) is frequent among the general population and is considered a diffuse disease. Although NGs are rarely unilateral, they pose a dilemma in terms of the extent of the thyroidectomy. The aim of the present study was to evaluate the remaining thyroid in patients with NG compared with those with follicular adenoma who underwent hemithyroidectomy. Patients and methods. Patients who underwent surgery for unilateral NG with over 10 years of postoperative follow-up and normal findings on ultrasonography of the contralateral thyroid lobe were selected to form the study group (SG). Patients with follicular adenoma (with normal contralateral ultrasonography) who underwent hemithyroidectomy during the same period were selected to form the control group (CG). The selected patients underwent clinical, laboratory and ultrasound examinations. Both groups were compared statistically. No significant differences were found in age, gender, anesthetic risk, side, postoperative complications, length of hospital stay, or postoperative outcome. Results. Less than 10% of the patients reported symptoms, and all symptoms were of little significance. Ultrasonographic nodules were found in the remaining thyroid lobe in 70% of patients in the SG and in 60% of those in the CG, with no statistically significant differences. The mean size of the largest nodule was 13.58 ± 8.01 in the SG and 9.15 ± 5.93 in the GC (p = 0.048). No differences were found in the anterior-posterior, transverse or longitudinal diameters of the remaining lobe. None of the patients underwent reintervention for nodular disease. Conclusions. After hemithyroidectomy, both groups of patients developed nodules in the remaining thyroid lobe, with no statistically significant differences. Hemithyroidectomy due to unilateral NG involves less risk to the patient and therefore we consider it to be a valid option. Long-term ultrasonographic follow-up seems advisable (AU)

[Hemithyroidectomy in a unilateral goiter: a valid therapeutic option. Review of the contralateral hemithyroid ten years after treatment]. / Hemitiroidectomía en el bocio unilateral: una opción terapéutica válida. Revisión del hemitiroides contralateral a los diez años del tratamiento.

INTRODUCTION: Nodular goiter (NG) is frequent among the general population and is considered a diffuse disease. Although NGs are rarely unilateral, they pose a dilemma in terms of the extent of the thyroidectomy. The aim of the present study was to evaluate the remaining thyroid in patients with NG compared with those with follicular adenoma who underwent hemithyroidectomy. PATIENTS AND METHODS: Patients who underwent surgery for unilateral NG with over 10 years of postoperative follow-up and normal findings on ultrasonography of the contralateral thyroid lobe were selected to form the study group (SG). Patients with follicular adenoma (with normal contralateral ultrasonography) who underwent hemithyroidectomy during the same period were selected to form the control group (CG). The selected patients underwent clinical, laboratory and ultrasound examinations. Both groups were compared statistically. No significant differences were found in age, gender, anesthetic risk, side, postoperative complications, length of hospital stay, or postoperative outcome. RESULTS: Less than 10% of the patients reported symptoms, and all symptoms were of little significance. Ultrasonographic nodules were found in the remaining thyroid lobe in 70% of patients in the SG and in 60% of those in the CG, with no statistically significant differences. The mean size of the largest nodule was 13.58 +/- 8.01 in the SG and 9.15 +/- 5.93 in the GC (p = 0.048). No differences were found in the anterior-posterior, transverse or longitudinal diameters of the remaining lobe. None of the patients underwent reintervention for nodular disease. CONCLUSIONS: After hemithyroidectomy, both groups of patients developed nodules in the remaining thyroid lobe, with no statistically significant differences. Hemithyroidectomy due to unilateral NG involves less risk to the patient and therefore we consider it to be a valid option. Long-term ultrasonographic follow-up seems advisable.

Influencia de la superespecialización en cirugía endocrina en los resultados de la tiroidectomía en un servicio de cirugía general / Influence of superspecialization in endocrine surgery on outcomes of thyroidectomy in a general surgery department

Introducción. El objetivo de este trabajo fue estudiar la influencia de la superespecialización en los diferentes estándares de la cirugía tiroidea, antes y después de la creación de una unidad de cirugía endocrina. Pacientes y métodos. Estudio retrospectivo comparativo de 2 períodos de 7 años: antes de la creación de la unidad se intervinieron 340 tiroidectomías (G1) y después 583 (G2). Se valoran edad, sexo, riesgo anestésico, cirujano, función tiroidea, datos anatomopatológicos, extensión intratorácica, tipo de tiroidectomía, utilización de drenajes, complicaciones y estancia postoperatoria. Resultados. La edad fue superior en el G2 (G1: 44,7 ± 15 años, G2: 48,09 ± 16,3 años; p < 0,001). No hubo diferencia (p = NS) en el sexo, riesgo ASA, función tiroidea ni enfermedad benigna o no, pero se remitió a más pacientes con bocio nodular en el segundo pe-ríodo (p = 0,009) y hubo más bocios intratorácicos (p = 0,0004). Los MIR realizaron más tiroidectomías con el G2 (p < 0,001). Se realizaron más tiroidectomías bilaterales (G1: 155, G2: 315; p = 0,016) y, dentro de éstas, más tiroidectomías totales (p < 0,001). La tasa de drenajes cervicales (G1: 75,29%; G2: 12,18%) mostró diferencia estadística (p < 0,001). No hubo diferencias en el global de complicaciones postoperatorias. Pese a procederes más agresivos en el G2 la hipocalcemia asintomática fue similar (p = NS), al igual que la sintomática (p = NS) o hipocalcemia permanente (G1: 1,17%; G2: 0,68%; p = NS). La tasa de paresia recurrencial fue similar referida a pacientes (p = NS) o nervios (p = NS). La tasa de parálisis permanente no fue distinta referida a pacientes (p = 0,083) pero sí referida a nervios (G1: 1,44%; G2: 0,33%; p = 0,04). Falleció un paciente del G2 (p = NS). Hubo diferencias significativas en la estancia hospitalaria (p < 0,001) a favor del G2, al igual que pacientes con estancia de 1 día o menos (p < 0,001) e intervenidos en régimen de cirugía mayor ambulatoria (0 frente a 71; p < 0,001). Conclusiones. Una unidad de cirugía endocrina permite una gestión más eficiente de la tiroidectomía. La tasa de tiroidectomías totales es mayor, las complicaciones definitivas son menores, y permite una mejor docencia a los MIR, un menor consumo de recursos y el desarrollo de programas de cirugía mayor ambulatoria para la tiroidectomía (AU)

Introduction. The aim of this study was to analyze the influence of superspecialization in endocrine surgery on the standard of thyroidectomy, both before and after the creation of an endocrine surgery unit. Patients and methods. We performed a retrospective, comparative study of two 7-year periods. Three hundred forty thyroidectomies (G1) were performed before the instauration of the unit, and 583 were carried out afterwards (G2). The variables of age, gender, anesthesia risk, surgeon expertise (staff vs. resident), thyroid function, pathological features, intrathoracic growth, extent of the procedure (unilateral or bilateral), neck drainage, morbidity and mortality and length of hospital stay were compared. Results. Age was older in G2 (G1: 44.7 ± 15 years old, G2: 48.09 ± 16.3 years old; p < 0.001). There were no differences (p NS) between the two groups in gender, anesthesia risk, thyroid function or rate of benign/malignant disease, but there was a greater frequency of nodular (p = 0.009) and intrathoracic goiters (p = 0.0004) in the second period. Residents operated on more patients in G2 (p < 0.001). Bilateral thyroidectomy was more frequent in G2 (G1: 155, G2: 315; p = 0.016) as was the rate of total thyroidectomy vs. subtotal or near total thyroidectomy (p < 0.001). Neck drainage also showed statistically significant differences (G1: 75.29%, G2: 12.18%; p < 0.001). No differences were found in overall postoperative complications. Although the procedures used were more aggressive in G2, similar rates of transient asymptomatic hypocalcemia (p NS) and transient symptomatic (p NS) and permanent hypocalcemia were found (G1: 1.17%, G2: 0.68%, p NS). The rate of transitory recurrent laryngeal nerve paralysis was similar with regard to patients (p NS) or nerves at risk (p NS). Permanent inferior laryngeal nerve paralysis was no different regarding patients (p = 0.083) but statistically significant differences were found with regard to nerves at risk (G1: 1.44%, G2: 0.33%; p = 0.04). One patient in G2 died (p NS). Length of hospital stay was shorter in G2 (p < 0.001) and more patients in this group stayed in hospital for only one day (p < 0.001) or were operated on in the outpatient setting (0 versus 71; p < 0.001). Conclusions. An endocrine surgical unit allows more efficient management of thyroidectomy. It increases the rate of total thyroidectomy, reduces definitive complications and improves training of resident surgeons. In addition, it reduces resource use and allows the development of programs of outpatient thyroid surgery (AU)

[Influence of superspecialization in endocrine surgery on outcomes of thyroidectomy in a general surgery department]. / Influencia de la superespecialización en cirugía endocrina en los resultados de la tiroidectomía en un servicio de cirugía general.

INTRODUCTION: The aim of this study was to analyze the influence of superspecialization in endocrine surgery on the standard of thyroidectomy, both before and after the creation of an endocrine surgery unit. PATIENTS AND METHODS: We performed a retrospective, comparative study of two 7-year periods. Three hundred forty thyroidectomies (G1) were performed before the instauration of the unit, and 583 were carried out afterwards (G2). The variables of age, gender, anesthesia risk, surgeon expertise (staff vs. resident), thyroid function, pathological features, intrathoracic growth, extent of the procedure (unilateral or bilateral), neck drainage, morbidity and mortality and length of hospital stay were compared. RESULTS: Age was older in G2 (G1: 44.7 +/- 15 years old, G2: 48.09 +/- 16.3 years old; p < 0.001). There were no differences (p NS) between the two groups in gender, anesthesia risk, thyroid function or rate of benign/malignant disease, but there was a greater frequency of nodular (p = 0.009) and intrathoracic goiters (p = 0.0004) in the second period. Residents operated on more patients in G2 (p < 0.001). Bilateral thyroidectomy was more frequent in G2 (G1: 155, G2: 315; p = 0.016) as was the rate of total thyroidectomy vs. subtotal or near total thyroidectomy (p < 0.001). Neck drainage also showed statistically significant differences (G1: 75.29%, G2: 12.18%; p < 0.001). No differences were found in overall postoperative complications. Although the procedures used were more aggressive in G2, similar rates of transient asymptomatic hypocalcemia (p NS) and transient symptomatic (p NS) and permanent hypocalcemia were found (G1: 1.17%, G2: 0.68%, p NS). The rate of transitory recurrent laryngeal nerve paralysis was similar with regard to patients (p NS) or nerves at risk (p NS). Permanent inferior laryngeal nerve paralysis was no different regarding patients (p = 0.083) but statistically significant differences were found with regard to nerves at risk (G1: 1.44%, G2: 0.33%; p = 0.04). One patient in G2 died (p NS). Length of hospital stay was shorter in G2 (p < 0.001) and more patients in this group stayed in hospital for only one day (p < 0.001) or were operated on in the outpatient setting (0 versus 71; p < 0.001). CONCLUSIONS: An endocrine surgical unit allows more efficient management of thyroidectomy. It increases the rate of total thyroidectomy, reduces definitive complications and improves training of resident surgeons. In addition, it reduces resource use and allows the development of programs of outpatient thyroid surgery.

Paratiroidectomía ambulatoria bajo anestesia local tras exploración cervical bilateral en el hiperparatiroidismo primario. Estudio prospectivo / Outpatient parathyroidectomy under local anesthesia after bilateral cervical examination in primary hyperparathyroidism. A prospective study

Introducción. La exploración cervical bilateral es el estándar en la cirugía del hiperparatiroidismo primario. La exploración unilateral parece válida, pero precisa pruebas que encarecen el proceso. Nuestro objetivo fue evaluar la factibilidad de la exploración cervical bilateral bajo anestesia local en régimen de cirugía mayor ambulatoria. Pacientes y método. Se diseñó un protocolo prospectivo con los clásicos criterios de la cirugía mayor ambulatoria. El cirujano realizó la anestesia por bloqueo bilateral de las raíces de C2-C3 del plexo cervical profundo y la incisión. En el postoperatorio, la ingesta se inició al cabo de 1,5 o 2 h, a las 3 o 4 h se levantó al paciente y, después, se recomendó que deambulara. El objetivo fue darlo de alta a las 6 u 8 h de la intervención. Resultados. El protocolo fue aplicable al 75,86 por ciento de los pacientes y aceptado por 35 de ellos (aceptabilidad del 79,54 por ciento). Se halló un adenoma único en 32 pacientes, un adenoma doble en uno, una hiperplasia en otro y en un paciente no se halló el adenoma en el cuello. Hubo 4 casos de adenomas ectópicos. En 5 pacientes se practicó una hemitiroidectomía concomitante. La duración de la intervención fue de 80,77 ñ 27,84 min. Surgieron complicaciones en 4 pacientes (11,4 por ciento), todas leves, 2 de ellas paresias recurrenciales transitorias. Todos los pacientes se recuperaron con rapidez. Sólo 9 pacientes (25,71 por ciento) precisaron analgésicos. Ingresaron una noche 6 pacientes (17,14 por ciento), 3 de los 4 que presentaron complicaciones, 2 más por vómitos y uno por preferencia personal. En los restantes, el alta se produjo a las 6,19 ñ 0,99 h postoperatorias. El dolor al alta fue de 1,83 ñ 2,2 en la escala visual analógica. Hubo incidencias en el domicilio, poco significativas, en 12 pacientes; las más frecuentes fueron la cefalea y el dolor cervical. El grado de satisfacción fue muy alto o alto en el 94,28 por ciento de los pacientes. El 100 por ciento de los pacientes tenía una calcemia normal. Conclusiones. La exploración cervical bilateral es factible bajo anestesia local en régimen de cirugía mayor ambulatoria, con una alta satisfacción del paciente. La recuperación postoperatoria es rápida, permite realizar una tiroidectomía concomitante, disminuye el consumo de analgésicos y ahorra pruebas pre o intraoperatorias (AU)

Uso de drenajes en cirugía tiroidea y paratiroidea / Use of drains in thyroid and parathyroid surgery

El uso de drenaje posquirúrgico en las tiroidectomías y paratiroidectomías sigue creando controversias. Una revisión de CIRUGÍA ESPAÑOLA muestra que sólo se cita el drenaje (se deje o no) en el 11 por ciento de las publicaciones sobre tiroides y paratiroides. De las discusiones en nuestros congresos parece adivinarse que la mayoría de los cirujanos lo usa sistemáticamente. Se lleva a cabo un análisis de 25 publicaciones: sólo 2 recomiendan el drenaje sistemático. De esta revisión se deduce que: a) el uso de drenajes no evita o previene la hemorragia; b) el tratamiento de la hemorragia no es más rápido por usar drenajes; c) cuando hay una hemorragia postoperatoria, el drenaje es obstruido por los coágulos; d) la forma de prevenir hematomas es prestar una atención escrupulosa a la hemostasia; e) el drenaje no evita las colecciones cervicales; f) el drenaje alarga la estancia hospitalaria; g) es causa de molestias para los pacientes; h) la tasa de infección no es mayor sin drenaje, e i) el drenaje no ofrece beneficios o es innecesario en la cirugía no complicada. Según nuestra experiencia, el drenaje puede obviarse en el 90 por ciento de las tiroidectomías y en el 100 por ciento de paratiroidectomías por hiperparatiroidismo primario. Parece aconsejable cambiar nuestra práctica en este sentido (AU)

Retrosternal goiters: safety of surgical treatment.

Retrosternal goiters still pose a problem to expert endocrine surgeons. Whether surgery should be the treatment of choice or not remains controversial because of hypothetical increased morbidity rates associated with the surgical approach. Eighty-three patients were retrospectively reviewed for anesthetic risk, fibrobronchoscopic guidance for intubation, surgical technique, mortality and morbidity rates, and pathological findings. We found 6.09% of American Society of Anesthesiologists (ASA) I, 41.46% of ASA II, 40.24% of ASA III, and 12.19% of ASA IV risk. Twelve patients (14.45%) required fibrobronchoscopic guidance for intubation. Only one patient required a sternotomy. No mortality occurred. Seven patients (8.43%) had major complications, but there were no instances of permanent recurrent laryngeal palsy or hypocalcemia. Pathological examination revealed 9.63% incidence of malignancy. Surgery should be the treatment of choice for retrosternal goiters because there is a significant incidence of malignancy and an acceptable morbidity rate.