Evaluación del dolor postoperatorio en cirugía pediátrica

El dolor postoperatorio es una complicación muy frecuente en el postoperatorio del paciente pediátrico. Para prevenirlo, el paciente debe ser analgesiado con eficacia y seguridad. El objetivo del trabajo fue determinar la influencia de la ansiedad presente en el paciente previo a la cirugía con respecto a la sensación dolorosa y a la duración e intensidad de la analgesia perioperatorias. Para ello se realizó un estudio observacional descriptivo prospectivo en niños sometidos a cirugía

Pieloplastia desmembrada Anderson-Hynes mediante mini-laparoscopia : experiencia de 20 años

144 páginas.Trabajo Fin de Máster Universitario en Urología Pediátrica (2017/2018). Directora/Tutora: Anna Bujons Tur. Introducción: La pieloplastia abierta es el patrón oro de tratamiento de la estenosis pieloureteral (EPU) aunque la pieloplastia laparoscópica está ganando popularidad. El objetivo del presente estudio es comparar minilaparoscopia (mLP) de 3mm versus laparoscopia (LP) de 5mm y cirugía abierta para la pieloplastia. Métodos: Estudio retrospectivo de pacientes sometidos a pieloplastia por LP, mLP y cirugía abierta en nuestro centro entre 1997-2017. Analizamos variables demográficas, clínicas, quirúrgicas y radiológicas. Realizamos un estudio de regresión logística multivariante para identificar los factores de riesgo para complicaciones, fuga urinaria y necesidad de reintervención. Resultados: Se realizaron 340 pieloplastias: 197 abiertas, 30 LP y 113 mLP. Factores de riesgo independientes para complicaciones quirúrgicas fueron: LP (vs mLP, OR=3.95;95%CI:1.13-13.8), mayor función renal diferencial (cada punto más incrementa el riesgo un 6%;95%CI:1%-11%), mayor edad (cada año incrementa el riesgo 1.11 veces;95%CI:1.002- 1.225). La cirugía abierta, el diámetro anteroposterior de la pelvis (DAP) renal o el uso de diferentes catéteres transanastomóticos no fueron factores de riesgo. Este modelo tiene 80%VPP, 92.4%VPN. LP (OR=4.65;95%CI:1.08-19.96) y mayor tiempo quirúrgico (OR=1.014;95%CI:1.003-1.025) son factores de riesgo independientes para fuga urinaria. Mayor DAP (OR=0.93;95%CI:0.87-0.99) y el uso de catéter nefroureteral externo (OR=0.09;95%CI:0.01-0.72) son factores protectores independientes para fuga urinaria. No hemos encontrado factores de riesgo independientes para reintervención. Conclusiones: mLP es una técnica segura y efectiva para la realización de pieloplastia en pacientes pediátricos de cualquier edad.Introduction: Open pyeloplasty has been the gold standard treatment for ureteropelvic junction obstruction (PUJO). Since it was first described, the laparoscopic pyeloplasty (LP) has gained popularity. In order to reduce invasiveness, smaller laparoscopic instruments (≤3mm) have been introduced. The aim of our study is to compare 3mm mini-laparoscopy (mLP) and standard 5mm laparoscopy for pyeloplasty. Materials and Methods: Retrospective chart review of patients who underwent pyeloplasty from 1997 to 2017 at our institution was performed. Demographic data, clinical, surgical and radiological variables were assessed. A multivariate logistic regression analysis was performed in order to identify risks for surgical complications, urinary leak and need for redo-surgery. Results: 340 pyeloplasties were performed in this period: 197 open, 30 LP and 113 mLP. The independent risk factors for surgical complications in a multivariate logistic regression model were: LP (vs mLP, OR=3.95;95%CI:1.13-13.8), higher differential renal function (DRF) (each point more increases the risk 6%; 95%CI:1%-11%), higher age (every year increases the risk 1.11 times; 95%CI:1.002- 1.225). Open surgery, pelvis diameter (PD) or the use of different stents were not risk factors. This model has an 80% PPV and a 92.4% NPV. LP (OR=4.65;95%CI:1.08-19.96) and higher surgical time (OR=1.014;95%CI:1.003-1.025) are independent risk factors for urinary leak. Higher PD (OR= 0.93;95%CI: 0.87-0.99) and the use of external stent are independent protective risk factors for urinary leak (OR=0.09;95%CI:0.01-0.72). We have not found independent risk factors for redo-surgery in a multivariate logistic regression model. Conclusion: mLP can be safely and effectively used to perform pyeloplasty in pediatric patients of all ages

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study (vol 46, pg 2021, 2022)

N/

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2

Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study an international prospective cohort study

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care. We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care