Predicción de mortalidad en UCI de pacientes con COVID-19: un modelo predictivo supervisado con redes neuronales artificiales (RNA)

Introducción. Se han descrito muchos factores de riesgo de la COVID-19, pero no disponemos de un indicador de mortalidad en UCI para individualizar el pronóstico del paciente y establecer medidas de tratamiento más precoces y eficaces. Las Redes Neuronales Artificiales (RNA) son una forma de análisis multivariante alternativo.Objetivo. Diseñar un indicador mediante RNA para predecir la mortalidad del paciente crítico ingresado en UCI por COVID-19, a partir de las variables presentes en las primeras 24 horas de ingreso en UCI, analizar las variables relacionadas y evaluar su capacidad predictiva.Material y Método. Se ha realizado un estudio observacional, retrospectivo en el que se recogieron las variables presentes en las primeras 24 horas tras el ingreso en el Servicio de Medicina Intensiva del HCU “Lozano Blesa”. Tras realizar un análisis estadístico se ha obtenido una Red MLP, siendo el indicador de mortalidad el valor de la neurona de la capa de salida que predice exitus. El software informático calcula la importancia de las variables (IV) incluidas y asigna cuales de ellas eran altamente predictivas.Resultados. El valor medio del Indicador en el grupo que sobrevivió fue de 0.322 + 0.215, frente a 0.592 + 0.213 en el grupo de falleció; p Conclusiones. Es posible crear un Indicador de Mortalidad del paciente ingresado en UCI por COVID-19 utilizando la metodología del aprendizaje automático de las redes neuronales artificiales. Las variables más importantes relacionadas con su mortalidad son la edad, la ferritina y la LDH. El Indicador propuesto muestra una capacidad predictiva aceptable y podría mejorarse aún más si fuese creado a partir de una base de datos multicéntrica.<br /

Comparison of two radiofrequency-based hemostatic devices: saline-linked bipolar vs. cooled-electrode monopolar

[EN] Purpose To characterize the coagulation zones created by two radiofrequency (RF)-based hemostatic devices: one comprised an internally cooled monopolar electrode and the other comprised externally irrigated bipolar electrodes (saline-linked). Materials and methods RF-induced coagulation zones were created on ex vivo and in vivo porcine models. Computer modeling was used to determine the RF power distribution in the saline-linked device. Results Both external (irrigation) and internal cooling effectively prevented tissue sticking. Under ex vivo conditions in 'painting' application mode, coagulation depth increased with the applied power: 2.8 - 5.6 mm with the 3-mm monopolar electrode, 1.6 - 6.0 mm with the 5-mm monopolar electrode and 0.6 - 3.2 mm with the saline-linked bipolar electrodes. Under in vivo conditions and using spot applications, the 3-mm monopolar electrode created coagulation zones of similar depth to the saline-linked bipolar electrodes (around 3 mm), while the 5-mm monopolar electrode created deeper coagulations (4.5 - 6 mm) with less incidence of popping. The presence of saline around the saline-linked bipolar electrodes meant that a significant percentage of RF power (50 - 80%) was dissipated by heating in the saline layer. Coagulation zones were histologically similar for all the tested devices. Conclusions Both external (irrigation) and internal cooling in hemostatic RF devices effectively prevent tissue sticking and create similar coagulation zones from a histological point of view. Overall, saline-linked bipolar electrodes tend to create shallower coagulations than those created with an internally cooled monopolar electrode.Spanish Ministerio de Ciencia, Innovacion y Universidades MCIN/AEI/10.13039/501100011033 [Grants RTI2018-094357-B-C21 and RTI2018094357-B-C22], "Agencia Nacional de Promocion Cientifica y Tecnologica de Argentina" [PICT-2020-SERIEA-00457], Dr. Irastorza was the recipient of a scholarship from the Programa de Becas Externas Postdoctorales para Jovenes Investigadores del CONICET (Argentina).Moll, X.; Fondevila, D.; García-Arnás, F.; Burdio, F.; Trujillo Guillen, M.; Irastorza, RM.; Berjano, E.... (2022). Comparison of two radiofrequency-based hemostatic devices: saline-linked bipolar vs. cooled-electrode monopolar. International Journal of Hyperthermia. 39(1):1397-1407. https://doi.org/10.1080/02656736.2022.21408401397140739

Cost-Effectiveness of Robotic vs. Laparoscopic Surgery for Different Surgical Procedures: Protocol for a Prospective, Multicentric Study (ROBOCOSTES)

Cost-effectiveness; Laparoscopic surgery; Multicenter studiesRendibilitat; Cirurgia laparoscòpica; Estudis multicèntricsRentabilidad; Cirugía laparoscópica; Estudios multicéntricosBackground: The studies which address the impact of costs of robotic vs. laparoscopic approach on quality of life (cost-effectiveness studies) are scares in general surgery. Methods: The Spanish national study on cost-effectiveness differences among robotic and laparoscopic surgery (ROBOCOSTES) is designed as a prospective, multicentre, national, observational study. The aim is to determine in which procedures robotic surgery is more cost-effective than laparoscopic surgery. Several surgical operations and patient populations will be evaluated (distal pancreatectomy, gastrectomy, sleeve gastrectomy, inguinal hernioplasty, rectal resection for cancer, Heller cardiomiotomy and Nissen procedure). Discussion: The results of this study will demonstrate which treatment (laparoscopic or robotic) and in which population is more cost-effective. This study will also assess the impact of previous surgical experience on main outcomes.Project PI20/00008, funded by Instituto de Salud Carlos III (ISCIII) and co-funded by the European Union

Single instrument for hemostatic control in laparoscopic partial nephrectomy in a porcine model without renal vascular clamping

This is a copy of an article published in the Journal of Endourology ©2011 copyright Mary Ann Liebert, Inc.; Journal of Endourology is available online at: http://www.liebertpub.com/end[EN] Materials and Methods: We performed a comparative experimental study between a new radiofrequency (RF)-assisted device consisting of a handheld instrument that simultaneously conducts coagulation and cutting tasks without hilar clamping vs a standard technique with hilar clamping. A porcine model was used (10 animals per group) with survival of 17 days. Results: The estimated blood loss with the new device was significantly lower than with the standard technique (15.5 +/- 23.7 vs 79.4 +/- 76.3 mL). Although transection time was longer with the new device (10.7 +/- 13.7 vs 2.1 +/- 1.2 min), the total operative time was significantly shorter (35.3 +/- 13.7 vs 60.2 +/- 10.5 min). Evidence of localized urinary extravasation (urinoma) was identical in both groups (five cases). The group subjected to the new device, however, showed a significantly higher number of cases of leakage after conducting the methylene-blue test: eight (80%) cases vs only one (11%) with the standard technique. Necrosis depth was significantly greater with the new device (6.6 +/- 0.9 vs <1 mm). Conclusions: The experimental results suggest that the proposed RF-assisted device provides adequate hemostatic control during transection of the renal parenchyma without additional instruments or surgical maneuvers and could therefore be a valuable adjunct for LPN without vascular clamping. The device was unsuccessful in effectively sealing the collecting system.This work received financial support from the Spanish "Plan Nacional de I + D + I del Ministerio de Ciencia e Innovacion," Grant No. TEC2008-01369/TEC. The translation of this paper was funded by the Universidad Politecnica de Valencia, Valencia, Spain.Subira Rios, J.; Sanchez Zalabardo, JM.; Burdio, F.; Berjano, E.; Moros, M.; Gonzalez, A.; Navarro, A.... (2011). Single instrument for hemostatic control in laparoscopic partial nephrectomy in a porcine model without renal vascular clamping. Journal of Endourology and Part B, Videourology. 25(6):1005-1011. https://doi.org/10.1089/end.2010.0557S1005101125

Microwave versus radiofrequency ablation for the treatment of liver malignancies: a randomized controlled phase 2 trial

[EN] Microwave (MWA) and radiofrequency ablation (RFA) are main ablative techniques for hepatocellular carcinoma (HCC) and colorectal liver metastasis (MT). This randomized phase 2 clinical trial compares the effectiveness of MWA and RFA as well as morphology of corresponding ablation zones. HCC and MT patients with 1.5-4 cm tumors, suitable for ablation, were randomized into MWA or RFA Groups. The primary endpoint was short-to-long diameter ratio of ablation zone (SLR). Primary technical success (TS) and a cumulative local tumor progression (LTP) after a median 2-year follow-up were compared. Between June 2015 and April 2020, 82 patients were randomly assigned (41 patients per group). For the per-protocol analysis, five patients were excluded. MWA created larger ablation zones than RFA (p = 0.036) although without differences in SLR (0.5 for both groups, p = 0.229). The TS was achieved in 98% (46/47) and 90% (45/50) (p = 0.108), and LTP was observed in 21% (10/47) vs. 12% (6/50) (OR 1.9 [95% CI 0.66-5.3], p = 0.238) of tumors in MWA vs. RFA Group, respectively. Major complications were found in 5 cases (11%) vs. 2 cases (4%), without statistical significance. MWA and RFA show similar SLR, effectiveness and safety in liver tumors between 1.5 and 4 cm.This work was supported by a grant for medical research from Spanish Government (FIS-PI12/00799) and by the Spanish Ministerio de Ciencia, Innovacion y Universidades under "Programa Estatal de I+D+i Orientada a los Retos de la Sociedad", Grant RTI2018-094357-B-C21.Radosevic, A.; Quesada, R.; Serlavos, C.; Sánchez, J.; Zugazaga, A.; Sierra, A.; Coll, S.... (2022). Microwave versus radiofrequency ablation for the treatment of liver malignancies: a randomized controlled phase 2 trial. Scientific Reports. 12(1):1-10. https://doi.org/10.1038/s41598-021-03802-xS11012

Learning Curves of Minimally Invasive Distal Pancreatectomy in Experienced Pancreatic Centers

IMPORTANCE Understanding the learning curve of a new complex surgical technique helps to reduce potential patient harm. Current series on the learning curve of minimally invasive distal pancreatectomy (MIDP) are mostly small, single-center series, thus providing limited data.OBJECTIVE To evaluate the length of pooled learning curves of MIDP in experienced centers.DESIGN, SETTING, AND PARTICIPANTS This international, multicenter, retrospective cohort study included MIDP procedures performed from January 1, 2006, through June 30, 2019, in 26 European centers from 8 countries that each performed more than 15 distal pancreatectomies annually, with an overall experience exceeding 50 MIDP procedures. Consecutive patients who underwent elective laparoscopic or robotic distal pancreatectomy for all indications were included. Data were analyzed between September 1, 2021, and May 1, 2022.EXPOSURES The learning curve for MIDP was estimated by pooling data from all centers.MAIN OUTCOMES AND MEASURES The learning curvewas assessed for the primary textbook outcome (TBO), which is a composite measure that reflects optimal outcome, and for surgical mastery. Generalized additive models and a 2-piece linear model with a break point were used to estimate the learning curve length of MIDP. Case mix-expected probabilities were plotted and compared with observed outcomes to assess the association of changing case mix with outcomes. The learning curve also was assessed for the secondary outcomes of operation time, intraoperative blood loss, conversion to open rate, and postoperative pancreatic fistula grade B/C.RESULTS From a total of 2610 MIDP procedures, the learning curve analysis was conducted on 2041 procedures (mean [SD] patient age, 58 [15.3] years; among 2040 with reported sex, 1249 were female [61.2%] and 791 male [38.8%]). The 2-piece model showed an increase and eventually a break point for TBO at 85 procedures (95% CI, 13-157 procedures), with a plateau TBO rate at 70%. The learning-associated loss of TBO rate was estimated at 3.3%. For conversion, a break point was estimated at 40 procedures (95% CI, 11-68 procedures); for operation time, at 56 procedures (95% CI, 35-77 procedures); and for intraoperative blood loss, at 71 procedures (95% CI, 28-114 procedures). For postoperative pancreatic fistula, no break point could be estimated.CONCLUSION AND RELEVANCE In experienced international centers, the learning curve length of MIDP for TBO was considerable with 85 procedures. These findings suggest that although learning curves for conversion, operation time, and intraoperative blood loss are completed earlier, extensive experience may be needed to master the learning curve of MIDP

Preliminary evaluation of the safety and efficacy of glucose solution infusion through the hepatic artery on irreversible electroporation focusing.

[EN] Due to electrical features of the tissue, such as impedance, which have a significant impact on irreversible electroporation (IRE) function, the administration of glucose solution 5% (GS5%) through the hepatic artery would focus IRE on scattered liver tumors. By creating a differential impedance between healthy and tumor tissue. This study aimed to determine the effects of the GS5% protocol on healthy liver tissue and its safety. 21 male Athymic nude rats Hsd: RH-Foxn1mu were used in the study. Animals were split into two groups. In group 1, a continuous infusion through the gastroduodenal artery of GS5% was performed to measure the impedance with a dose of 0.008 mL/g for 16 min. In group 2, the animals were divided into two subgroups for infusions of GS5%. Group 2.1, at 0.008 mL/g for 16 min. Group 2.2 at 0.03 mL/g for 4 min. Blood samples were collected after anesthesia has been induced. The second sample, after catheterization of the artery, and the third after the GS5% infusion. All the animals were sacrificed to collect histological samples. The survival rate during the experiment was 100%. A considerable impact on the impedance of the tissue was noticed, on average up to 4.31 times more than the baseline, and no side effects were observed after GS5% infusion. In conclusion, impedance alteration by Glucose solution infusion may focus IRE on tumor tissue and decrease IRE¿s effects on healthy tissue.This research was supported by the Spanish government (Ministry of Economy and Competitiveness) under Grants RTI2018-094357-B-C21, RTI2018-094357-B-C22 and Carlos III Health Institute under Grant PI17/0048 and also PI21/00440 from the same institution.Sarreshtehdari, A.; Burdio, F.; López-Alonso, B.; Lucia, O.; Burdio, JM.; Villamonte, M.; Andaluz, A.... (2023). Preliminary evaluation of the safety and efficacy of glucose solution infusion through the hepatic artery on irreversible electroporation focusing. Scientific Reports. 13(1):1-9. https://doi.org/10.1038/s41598-023-33487-31913

Influence of approach on outcome in radiofrequency ablation of liver tumors

In this article some recent data concerning the approach on radiofrequency ablation (RFA) of liver tumors are reviewed. Specifically, several critical statements between surgical and percutaneous approach are raised and discussed: (1) Open approach may lead to a higher complication rate; (2) Temporary occlusion of hepatic inflow during surgical approach may lead to a higher rate of ablation of the liver tumors; (3) Surgical approach may permit better targeting of the tumor to be ablated. (4) Surgical approach may discover additional liver tumors. Finally, several conclusions and recommendations are also addressed

Cost-Effectiveness of Robotic vs. Laparoscopic Surgery for Different Surgical Procedures Protocol for a Prospective, Multicentric Study (ROBOCOSTES)

Background: The studies which address the impact of costs of robotic vs. laparoscopic approach on quality of life (cost-effectiveness studies) are scares in general surgery. Methods: The Spanish national study on cost-effectiveness differences among robotic and laparoscopic surgery (ROBOCOSTES) is designed as a prospective, multicentre, national, observational study. The aim is to determine in which procedures robotic surgery is more cost-effective than laparoscopic surgery. Several surgical operations and patient populations will be evaluated (distal pancreatectomy, gastrectomy, sleeve gastrectomy, inguinal hernioplasty, rectal resection for cancer, Heller cardiomiotomy and Nissen procedure). Discussion: The results of this study will demonstrate which treatment (laparoscopic or robotic) and in which population is more cost-effective. This study will also assess the impact of previous surgical experience on main outcomes

CT mapping of saline distribution after infusion of saline into the liver in an ex vivo animal model. How much tissue is actually infused in an image-guided procedure?

[EN] Purpose: To track the saline during infusion with a 15 G needle into healthy pig livers at high and low infusion rates for 300 s. Methods: In each experiment, the needle was inserted into a single lobe of the liver to a depth of at least 2 cm following its longer axis. Two sets of experiments were defined: 1) low infusion rate of 0.1 mL/min (n = 6) and 2) high infusion rate of 1 mL/min (n = 6). Cine CT scans were carried out and three transverse planes were defined around the infusion point (IP), which corresponds with needle tip. Two assessments were performed: 1) a dynamic plane study focused on the time progress of the saline distribution on a single plane, which provided the Mean Percentage of Grayscale Intensity (MPG!): and 2) a volumetric study focused on the three dimensional distribution of the saline around IP at the end of the experiment, which provided the High Intensity Volume Ratio (HIVR). Results: The saline solution was conspicuous around the IP and shortly after heterogeneously inside the vessels. At the high infusion rate, the saline became conspicuous not only much sooner (evident at 20 s) but farther away (mean value of MPGI over 2%, up to 17 mm from the IP) and at a much higher intensity (mean value of MPGI over 10% up to 4 mm from the IP). The lower the radial distance to the IP, the greater the difference in HIVR between both groups. Conclusions: The high infusion rate leads to a faster, wider and a more marked presence of saline than the low rate. The rapid drainage into the hepatic veins may explain the heterogeneous distribution. (C) 2012 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.This work received financial support from the Spanish "Plan Nacional de I+D+I del Ministerio de Ciencia e Innovacion" Grant No. TEC2008-01369/TEC. The translation of this paper was funded by the Universidad Politecnica de Valencia, Spain.Burdio, F.; Berjano, E.; Milian, O.; Grande, L.; Poves, I.; Silva, C.; De La Fuente, MD.... (2013). CT mapping of saline distribution after infusion of saline into the liver in an ex vivo animal model. How much tissue is actually infused in an image-guided procedure?. Physica Medica. 29(2):188-195. https://doi.org/10.1016/j.ejmp.2012.03.001S18819529