Guías de la OMS sobre Seguridad de los Pacientes

La Organización Mundial de la Salud, por medio de la World Alliance for Patient Safety ha publicado unas guías para consensuar la investigación en el area de seguridad de pacientes en cirugía.

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Instrumental Ultrasónico

Ultrasonic and Nonultrasonic Instrumentation: A Systematic Review and Meta-analysis
Brent Matthews; Luba Nalysnyk; Rhonda Estok; Kyle Fahrbach; Deirdre Banel; Heather Linz; Jaime Landman.
Arch Surg. 2008;143(6):592-600.

Objective To compare the efficacy and safety of ultrasonic surgical instrumentation with nonultrasonic traditional surgical techniques in various types of surgery.

Data Sources Electronic searches of MEDLINE, Current Contents, and the Cochrane Library were performed for the period of 1990 to June 1, 2005, using relevant search terms. A manual check of all references in accepted studies was also performed.

Study Selection Only comparative studies (including randomized and nonrandomized control trials) of ultrasonic surgical instrumentation with nonultrasonic instrumentation were accepted. Procedures of interest included the following: colorectal surgery, gynecologic surgery, head and neck surgery, solid organ surgery, vessel harvesting, cholecystectomy, hemorrhoidectomy, mastectomy, and Nissen fundoplication.

Data Extraction Two investigators reviewed each study: the first investigator extracted all relevant data, and consensus of each extraction was performed by a second investigator to verify the data. Data were then entered into a database and quality checked for accuracy.

Data Synthesis Fifty-one primary studies that examined 4902 patients were included in this systematic review, of which 24 were randomized trials and 27 were nonrandomized studies. Comparative meta-analyses for blood loss, surgery time, and hospital length of stay were performed using a random-effects model and stratified by surgery type. Heterogeneity was tested using Q statistics. Statistical significance was defined as P < .05.

Conclusion Meta-analysis of outcomes comparing ultrasonic with conventional nonultrasonic surgical instrumentation demonstrates significant improvement of several perioperative outcomes in procedure-specific settings when ultrasonic instrumentation is used.

Apendicectomía Laparoscópica vs Tradicional

Apendicitis aguda complicada. Abordaje abierto comparado con el laparoscópico
Francisco Gil Piedra, Dieter Morales García, José Manuel Bernal Marco, Javier Llorca Díaz, Paula Marton Bedia y Ángel Naranjo Gómez.
Cir Esp 2008; 83: 309 -12

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Introducción. Aunque el uso de la laparoscopia se ha generalizado en muchas patologías, en el caso de la apendicitis aguda, y sobre todo si es complicada, no ha podido definirse como vía de elección debido al posible aumento de los casos de infección de órgano o espacio. El objetivo es comparar la morbilidad de un grupo de pacientes con apendicitis aguda complicada (gangrenosa o perforada) operados por vía convencional con otro operado por vía laparoscópica.

Pacientes y método. Estudio de cohortes prospectivo constituido por 107 pacientes intervenidos por una apendicitis complicada en un período de 2 años. Se analizaron las medias del tiempo de intervención quirúrgica y del tiempo de ingreso y la morbilidad en forma de infección del sitio quirúrgico e infección de órgano o espacio.

Resultados. En el grupo con apendicitis aguda gangrenosa, la morbilidad fue significativamente menor en el grupo de laparoscopia (p = 0,014). La infección del sitio quirúrgico fue significativamente mayor en el grupo de cirugía abierta (p = 0,041), y no se encontró diferencias en cuanto a la infección de órgano o espacio (p = 0,471). En el grupo de pacientes con apendicitis aguda perforada (p = 0,026), la morbilidad fue significativamente mayor en el grupo de cirugía abierta (p = 0,046). La infección de sitio quirúrgico fue significativamente mayor en este grupo (p = 0,004), y no hubo diferencias significativas en cuanto a la infección de órgano o espacio (p = 0,612).

Conclusiones. Estos resultados indican que la apendicectomía laparoscópica en las apendicitis complicadas es una vía de abordaje segura y ofrece ventajas significativas con respecto a la vía abierta.

Técnica STARR para Prolapso Rectal

Artículo de revisión publicado en Contemporary Surgery. Trata de la resección con sutura mecánica en el tratamiento del prolapso rectal.

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Anestesia Regional vs General en Colecistectomía Laparoscópica Electiva

Spinal vs General Anesthesia for Laparoscopic Cholecystectomy
Interim Analysis of a Controlled Randomized Trial
George Tzovaras; Frank Fafoulakis; Kostantinos Pratsas; Stavroula Georgopoulou; Georgia Stamatiou; Constantine Hatzitheofilou.
Arch Surg. 2008;143(5):497-501.

Objective To compare spinal anesthesia with the gold standard general anesthesia for elective laparoscopic cholecystectomy in healthy patients.

Design Controlled randomized trial.

Setting University hospital.

Patients One hundred patients with symptomatic gallstone disease and American Society of Anesthesiologists status I or II were randomized to have laparoscopic cholecystectomy under spinal (n = 50) or general (n = 50) anesthesia.

Methods Intraoperative parameters, postoperative pain, complications, recovery, and patient satisfaction at follow-up were compared between the 2 groups.
Results All the procedures were completed by the allocated method of anesthesia, as there were no conversions from spinal to general anesthesia. Pain was significantly less at 4 hours (P < .001), 8 hours (P < .001), 12 hours (P < .001), and 24 hours (P = .02) after the procedure for the spinal anesthesia group compared with those who received general anesthesia. There was no difference between the 2 groups regarding complications, hospital stay, recovery, or degree of satisfaction at follow-up.

Conclusions Spinal anesthesia is adequate and safe for laparoscopic cholecystectomy in otherwise healthy patients and offers better postoperative pain control than general anesthesia without limiting recovery.

Daño por Reperfusión tras Hemorragia. Análisis de la Literatura

Reperfusion Injury After Hemorrhage: A Collective Review.
Annals of Surgery. 247(6):929-937, June 2008.
Rushing, G; Britt, L.

Objective: To review current knowledge of hemorrhagic shock and reperfusion injury.

Summary Background Data: Patients with hemorrhagic shock require optimal resuscitation and cessation of ongoing bleeding. Often our resuscitative measures, while necessary, cause a wide range of detrimental physiologic effects. Research continues to answer questions regarding measurable endpoints and optimal fluids used in resuscitation. Elucidation and understanding of the complex metabolic pathways involved in reperfusion injury are areas of intense current investigative effort.

Methods: A literature review was performed using MEDLINE and key words related to experimental and clinical studies concerning shock and reperfusion.
Results: Experimental studies have shown that resuscitation with colloid and crystalloid show no difference in outcomes in critically ill patients. Laboratory studies are showing promising results with immunomodulation of response to injury. However, no clinical trials have shown significance yet.

Conclusions: It is unlikely that a single treatment modality or "magic bullet" will be able to substantially block such a complex regulated process unless performed before feedback mechanisms known to be in place. Ongoing translational research will inevitably have a major impact on patient care.