[Abdominal re-operations: Prevalence in elective and emergency surgery]. / Reintervenciones abdominales: prevalencia en cirugías electivas y urgencias.

BACKGROUND: The word «re-laparotomy¼ defines the surgical procedure in which the abdominal cavity is re-explored to resolve the complications of the disease or initial surgery. OBJECTIVE: To determine the prevalence of abdominal re-operations in patients undergoing elective and emergency surgery in the General Hospital of Matamoros. MATERIAL AND METHODS: A retrospective, observational, longitudinal study was conducted by reviewing the medical records of patients with a re-operation from January 2014 to January 2015, statistically analysing the variables: Age, sex, type of surgery, complications, and postoperative course. RESULTS: A total of 21 re-operated patients were found, the majority of whom were women (52.38%). The cases were more common in ages between 70 and 79 years old, in both sexes. Almost two-thirds (61.91%) of re-operations were after an emergency surgery. The residual abscess (23.8%) and evisceration (23.8%) were the most frequent indications for re-intervention. There were postoperative complications in 23.8%, with wound dehiscence (60%) being the most frequent. There was an 85.6% survival rate after the re-intervention. CONCLUSIONS: The study showed a low incidence of re-interventions and a low mortality. There is evidence of major occurrence of abdominal re-interventions in advanced ages, in female patients, and emergency surgery.

Cirurgia ortognática: assimetria facial e a limitação do planejamento manual com articulador semi-ajustável Acon (ASA) - correção com planejamento virtual (3D) / Orthognathic surgery: facial asymmetry and the limitation of manual planning with the semi-adjustable Arcon (ASA) articulator ­ correction with virtual (3D) planning

Introdução: os casos de assimetria facial são considerados os de maior complexidade dentro do âmbito da cirurgia Buco-Maxilo-Facial, devido a alteração esquelético-morfológica nos três planos do espaço (Pitch, Yaw e Roll). Estes planos foram trazidos do posicionamento de uma aeronave no espaço para o mundo da cirurgia, mais especificamente ao planejamento virtual, para romper as limitações do planejamento manual e a plataforma de Erickson, usados durante décadas para correção não só de casos simples envolvendo movimentos puros dos ossos, como também assimetrias. Hoje é sabido que o planejamento manual ainda é usado, porém, vem caindo em desuso devido as suas limitações. A cirurgia virtual vem ganhando muito espaço e se superando a cada dia. Objetivo: relatar um caso de cirurgia ortognática em que a paciente era portadora de assimetria facial, planejada de forma manual (tradicional) e os erros encontrados após 04 anos, levando a uma re-operação baseada em planejamento virtual.

Introduction: the cases of facial asymmetry are considered the most complex within the scope of oral and maxillofacial surgery due to skeletal-morphological changes in the three planes of space (Pitch, Yaw and Roll). These plans were brought from the position of an aircraft in space to the world of surgery, specifically the virtual planning to break the limitations of manual planning and Erickson platform, used for decades to fix not only simple cases involving purê bone's movements as well as asymmetries. Today it is known that manual planning is still used, however, it has fallen into disuse because of its limitations. Virtual surgery is gaining a lot of space and surpassing every day. Objective: this article aims to report a case of orthognathic surgery in which the patient had facial asymmetry, planned manually (traditional) and the errors found after 04 years, leading to a virtual planning-based re-operation.

Modelo de pronóstico de reoperación en cirugía abdominal / Prognosis model of reoperation in abdominal surgery

Introducción: En presencia de complicaciones infecciosas intrabdominales postoperatorias, la decisión de reoperar es todavía difícil para el cirujano actuante. Los modelos matemáticos representan una buena ayuda al diagnóstico en estas condiciones. Método: Estudio prospectivo observacional de 300 pacientes post-cirugía abdominal ingresados en la unidad de cuidados intensivos del Hospital Calixto García desde enero de 2008 a enero de 2010. Los pacientes fueron aleatoriamente separados (2:1) en dos grupos; estimación (GE) y validación (GV). En el GE se desarrollaron tres modelos estadísticos para la reoperación, que fueron validados en el GV .Estos modelos incluyeron variables, que en estudios anteriores demostraron su utilidad en el pronóstico, como el índice predictivo de reoperación aguda (ARPI) y la presión intrabdominal (PIA) Resultados: El modelo ARPI-PIA fue el mejor de los tres modelos, según el estadígrafo Hosmer-Lemeshow (calibración C=9,976 p=0.267, discriminación área bajo la curva ROC=0,989 IC 95 por ciento 0,976-1,000). Conclusión: La inclusión de la PIA junto al ARPI en un modelo matemático puede aumentar la certeza del pronóstico de reoperación en presencia de complicaciones infecciosas intrabdominales tras cirugía abdominal. Este modelo puede ser de utilidad en situaciones de recursos diagnósticos limitados.(AU)

Background: The decision of re-operating after abdominal surgery is still difficult, especially whenan intra-abdominal infectious complication is present. Mathematical models represent good diagnosis aid. Methods: A prospective observational study was conducted with 300 patients after abdominal surgery consecutively admitted at the intensive care unit of the "CalixtoGarcía Hospital" from January 2008 to January 2010. The patients were randomly separated (2:1) into estimation and validation groups. Three models for re-operation were developed in the estimation group by logistic regression, using some factors that demonstrated their usefulness in previous studies, for example, the acute re-operation predictive index (ARPI) and the intra-abdominal pressure (IAP). Afterwords, the models were validated on the other group. Results: Acute re-operation predictive index-intraabdominal pressure (ARPI-IAP) model was the best of the three models, with an excellent calibration by the Hossmer-Lemeshow goodness-of fit statistic (C=9,976 p=0,267), discrimination (AUC=0,989 95 percent CI 0,976-1,000). Conclusion: The combination of IAP with ARPI in a mathematical model can add accuracy to the prediction of re-operation related to intra-abdominal infectious complications in patients after abdominal surgery. This model is recommended in conditions of limited diagnostic resources. (AU)

Reoperación en cirugía traqueal / Reoperation required in tracheal surgery

Objetivo: describir los resultados obtenidos con el tratamiento quirúrgico en pacientes con recidiva de estenosis isquémica traqueal o subglótica. Métodos: entre junio de 1985 y julio de 2009 fueron operados 28 pacientes por recidiva de estenosis traqueal y laringotraqueal. Dos de ellos se perdieron durante el seguimiento. Las variables estudiadas fueron: procedencia y localización de la lesión, causa de la recidiva, técnica quirúrgica empleada, complicaciones y resultado definitivo. Resultados: diez pacientes fueron intervenidos primariamente por los autores y 16 en otros hospitales. En 12 enfermos la lesión fue traqueal y en 14 subglótica. La principal causa demostrada de recidiva fue la tensión excesiva sobre la línea de sutura. En 15 pacientes no se pudo determinar, la mayoría de estos (14) ocurrió en enfermos remitidos de otros centros. Se realizó resección al 73,1 porciento de los casos (subglótica 11, traqueal 8) y colocación de un tubo en T al resto (tráquea 4, subglotis 3). Las complicaciones comprendieron: granulomas, infección de la herida, dehiscencia parcial de sutura, fístula traqueal y lesión recurrencial bilateral. El resultado fue excelente y satisfactorio en el 96,2 porciento y malo en el 3,8 porciento. Conclusiones: el tratamiento quirúrgico por recidiva de una estenosis traqueal o subglótica, puede producir resultados que garanticen calidad de vida adecuada sin la necesidad de prótesis o traqueostomía(AU)

Objective: to present the results achieved with the surgical treatment in patients with recurrent tracheal and subglottic ischemic stenosis. Methods: twenty eight patients were operated on from recurrent tracheal and laryngeal-tracheal stenosis from June 1985 through July 2009. Two of them were excluded because they were lost during the follow-up. The study variables were origin and location of the lesion, cause of recurrence, surgical technique, complications and final results. Results: Ten patients were operated on by the authors and 16 underwent the same procedure in other hospitals. The tracheal lesion was involved in 12 cases and the subglottic one in 14. The main cause of recurrence was excessive tension on the suture line. It was not possible to define the cause in 15 patients, 14 of whom had been referred from other hospitals. Nineteen patients (73,1 percent) underwent resection (tracheal 8, subglottic 11) and T-tube was placed in other 7 patients (tracheal 4 and subglottic 3). Morbidity comprised granulomas, wound infection, partial suture dehiscence, tracheal fistula and bilateral recurrent nerve lesion. Final results were excellent and satisfactory in 96.2 percent of cases and unsatisfactory in 3.8 percent. Conclusions: Surgical treatment in cases with tracheal or subglottic recurrent stenosis may yield positive results that guarantee adequate quality of life without requiring prosthesis or tracheostomy(AU)

Estudo de acurácia em cirurgia assistida por navegação na revisão cirúrgica de deformidade vertebral / Estudio de la precisión en cirugía asistida por navegación en la reoperación de deformidad espinal / Study of the accuracy of navigation-assisted surgery in the surgical revision of spinal deformity

OBJETIVO: Avaliar as vantagens da cirurgia com navegação na revisão cirúrgica de deformidades vertebrais, verificando a acurácia deste método. MÉTODO: Foram revisados cincos pacientes com deformidades vertebrais que tiveram intercorrências na primeira cirurgia. Esses pacientes foram submetidos a um estudo de tomografia computadorizada (TC) com cortes de 2mm da coluna vertebral antes da segunda cirurgia. Nos cinco pacientes submetidos a reabordagem cirúrgica procedeu-se a instrumentação posterior com auxílio da navegação. Foram 84 parafusos pediculares implantados, sendo que 33 destes parafusos foram assistidos por computação. A navegação foi empregada nos níveis da deformidade vertebral onde a anatomia apresentava-se alterada inviabilizando o correto uso dos parâmetros anatômicos para inserção de parafusos pediculares. Nos demais níveis onde era possível a correta identificação desses parâmetros anatômicos foi utilizada a técnica padrão. A TC pós-operatória foi realizada para aferição do posicionamento dos parafusos pediculares. Avaliamos os resultados obtidos no posicionamento com e sem o uso da navegação. O tempo de fluoroscopia e o tempo da cirurgia também foram comparados com o padrão ouro da literatura. RESULTADOS: Dos 33 parafusos implantados com navegação observou-se uma acurácia de 94 por cento, com uma taxa de violação pedicular de 6 por cento. CONCLUSÕES: O uso da navegação é importante nas revisões cirúrgicas das deformidades vertebrais com anatomia alterada, influenciando no bom resultado final da cirurgia.

OBJECTIVE: To evaluate the benefits of computer-assisted spine surgery in re-operations due to vertebral deformities, and verify method accuracy. METHOD: A total of five patients with vertebral deformities who had complications during prior surgery were re-operated. These patients underwent a specific Computer Tomography scan with 2mm cuts of the spine before the second surgery. In the five patients who underwent re-operation, posterior instrumentation with the aid of computer-assisted spine surgery was performed. 84 pedicle screws were implanted, and in 33 of these computer-assisted surgeries were used. The computer-assisted surgery was used at the levels of spinal deformity where anatomy was altered making correct use of anatomical parameters for insertion of pedicle screws impossible. In the remaining levels, standard technique was used where the correct identification of anatomical parameters was possible. Post-operative computed tomography was performed to measure the placement of pedicle screws. We evaluated the results in positioning with and without the use of navigation. The fluoroscopy and surgery time were also compared with the gold standard of literature. RESULTS: Of the 33 screws implanted with navigation, 94 percent accuracy was observed; with a pedicle violation rate of 6 percent.The use of navigation is an important tool for surgical revision of the vertebral deformities with altered anatomy, influencing surgery result.

OBJETIVO: Evaluar las ventajas de la cirugía con navegación en reoperación por deformidades vertebrales, verificando la precisión de este método. MÉTODO: Fueron revisados cinco pacientes con deformidades vertebrales que tuvieron complicaciones en la primera cirugía. Esos pacientes fueron sometidos a un estudio de tomografía computada (TC) con cortes de 2 mm de la columna vertebral antes de la segunda cirugía. En los 5 pacientes sometidos al reabordaje quirúrgico se procedió a instrumentación posterior con auxilio de la navegación. Fueron 84 tornillos pediculares implantados, siendo que 33 de éstos fueron asistidos por computación. La navegación fue empleada en los niveles de la deformidad vertebral en donde la anatomía se presentaba alterada impidiendo el uso correcto de los parámetros anatómicos para inserción de tornillos pediculares. En los demás niveles en donde era posible la correcta identificación de esos parámetros anatómicos se utilizó la técnica estándar. La TC postoperatoria fue realizada para medición del posicionamiento de los tornillos pediculares. Evaluamos los resultados obtenidos en el posicionamiento con y sin el uso de la navegación. El tiempo de fluoroscopía y el tiempo de la cirugía también fueron comparados con la regla áurea de la literatura. RESULTADOS: De los 33 tornillos implantados con navegación se observó una precisión de 94 por ciento, con una tasa de violación pedicular del 6 por ciento. CONCLUSIONES: El uso de la navegación es importante en la reoperación de las deformidades vertebrales con anatomía alterada, influenciando en el buen resultado de la cirugía.