Pluvio J. Coronado Martín

Multidisciplinary development of robotic surgery in a University Tertiary Hospital: Organization and outcomes

Background: Da Vinci system (Intuitive Surgical ® ) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation…) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in

Desarrollo multidisciplinario de la cirugía robótica en un hospital universitario de tercer nivel: organización y resultados

Background Da Vinci system (Intuitive Surgical®) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation…) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC.BACKGROUND Da Vinci system (Intuitive Surgical) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation...) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC. MATERIAL AND METHODS Starting from joint management and joint scrub nurses team, General and Digestive Surgery, Urology and Gynaecology Departments were progressively incorporated into the Robotic Surgery Plan, with several procedures increasing in complexity. A number of intra and extra-hospital teaching and information activities were planned to report on the Robotic Surgery Plan. RESULTS Between July 2006 and July 2008, 306 patients were operated on: 169 by General Surgery, 107 by Urology and 30 by Gynaecology teams. The outcomes showed feasibility and a short learning curve. The educational plan included residents and staff interested in robotic technology application. CONCLUSION The structured and gradual incorporation of robotic surgery throughout the PCR-HCSC has made it easier to learn, to share designed infrastructure, to coordinate information activities and multidisciplinary collaboration. This preliminary experience has shown the efficiency of an adequate organization and motivated team.

Thromboprophylaxis in gynecologic cancer surgery: Is extended prophylaxis with low molecular weight heparin justified?

OBJECTIVE Evidence on the optimal duration of thromboprophylaxis with low molecular weight heparin after gynecologic cancer surgery is scarce and the benefits of extended prophylaxis have not been validated specifically in these patients. The aim of this study is to assess the efficacy and safety of postoperative venous thromboembolism (VTE) prophylaxis with enoxaparin 40 mg for 28 days, as recommended by international guidelines, compared to 7 days in patients undergoing surgery for gynecologic cancer. STUDY DESIGN Prospective cohort study compared to a historic cohort of women who underwent surgery for gynecologic cancer in our center between 2004 and 2014. Pre- and postoperative screening with a routine duplex scan was done in the prospective cohort. Comparative analysis of comorbidity, surgical technique and incidence of VTE, as well as prognostic factors of events and mortality. RESULTS N:571 patients (28 days: 207, 7 days: 364). No significant differences were identified between groups in regard to the factors related to VTE in our series. There were no differences in VTE incidence between groups after one month (1.9% vs 1.4%; p = 0.729), 90 days (2.4% vs 2.5%; p > 0.99) or during follow-up (Breslow p = 0.156). No deaths due to VTE at 90 days were recorded. Only one case of asymptomatic DVT was identified in the screening with duplex. The incidence of postoperative bleeding was similar in both groups (0.5% vs 2.2%; p = 0.166). The presence of a history of VTE was the only independent risk factor for VTE after one month (OR 14.31 CI 95% 2.67-76.87; p = 0.002) and 90 days (OR 8.27 CI 95% 1.65-41.45; p = 0.010). No differences were identified regarding age, other comorbidities, type of tumor, stage, surgical approach, reintervention or adjuvant therapy in the multivariate analysis. CONCLUSION Extended prophylaxis for 28 days with enoxaparin did not improve the rates of VTE following gynecologic oncological surgery in our series compared to the 7-day therapy, although neither was this extended duration associated with adverse events or mortality.

Vascular Endothelial Growth Factor (VEGF) Polymorphisms and Serum VEGF Levels in Women With Epithelial Ovarian Cancer, Benign Tumors, and Healthy Ovaries

Objective This study analyzed the relation of 5 single-nucleotide polymorphisms (SNPs) in the VEGF (vascular endothelial growth factor) gene in patients with epithelial ovarian cancer (EOC), compared with patients carrying benign tumors or healthy ovaries. We studied serum VEGF levels and the relation with SNPs and association between VEGF SNPs and haplotypes with progression-free survival (PFS) in patients with cancer. Methods The genotyping of VEGF gene polymorphisms (−2578 C/A, −1154 G/A, −460 T/C, +405 G/C, +936 C/T) was performed in DNA isolated from blood samples of 100 women. The different genotypes were evaluated by quantitative real-time polymerase chain reaction. Vascular endothelial growth factor protein concentration was assessed in serum using solid-phase sandwich enzyme-linked immunosorbent assay. Results We found statistically significant differences in the distribution of VEGF genotypes among the 3 groups of patients: −2578 C/A between those with EOC and healthy ovary (P = 0.04), −460 T/C between those with EOC and healthy ovary (P = 0.03), and −460 T/C between those with benign tumors and healthy ovary (P = 0.02). Vascular endothelial growth factor serum levels were analyzed in patients with EOC. Higher levels were found in patients with clear cell carcinoma compared with those with serous, mucinous, or endometrioid tumors (P < 0.05). No clear association was observed between VEGF SNPs and serum VEGF levels. There was no significant correlation between VEGF SNPs and PFS. In haplotype analysis, CGTCT and CGTGT showed worse prognosis without reaching the statistical significance. CGCGC and AGTGC haplotypes had statistically significant differences among patients with EOC, benign tumors, and healthy ovaries (Ps = 0.046 and 0.041, respectively). Conclusions The distribution of VEGF genotypes was different in patients with EOC, compared with those with benign tumors or women with healthy ovaries. Vascular endothelial growth factor serum levels were higher in patients with clear cell carcinoma. No correlation was found with improved PFS, but CGTCT and CGTGT haplotypes showed worse prognosis.

OriginalDesarrollo multidisciplinario de la cirugía robótica en un hospital universitario de tercer nivel: organización y resultadosMultidisciplinary development of robotic surgery in a University Tertiary Hospital: Organization and outcomes

Background Da Vinci system (Intuitive Surgical®) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation…) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC.BACKGROUND Da Vinci system (Intuitive Surgical) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation...) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC. MATERIAL AND METHODS Starting from joint management and joint scrub nurses team, General and Digestive Surgery, Urology and Gynaecology Departments were progressively incorporated into the Robotic Surgery Plan, with several procedures increasing in complexity. A number of intra and extra-hospital teaching and information activities were planned to report on the Robotic Surgery Plan. RESULTS Between July 2006 and July 2008, 306 patients were operated on: 169 by General Surgery, 107 by Urology and 30 by Gynaecology teams. The outcomes showed feasibility and a short learning curve. The educational plan included residents and staff interested in robotic technology application. CONCLUSION The structured and gradual incorporation of robotic surgery throughout the PCR-HCSC has made it easier to learn, to share designed infrastructure, to coordinate information activities and multidisciplinary collaboration. This preliminary experience has shown the efficiency of an adequate organization and motivated team.

Teratoma inmaduro de ovario en la gestación

Resumen La incidencia de masas anexiales en la gestacion es de 1 por 1.000 embarazos; de ellos, el 3% son malignos. La mayoria de estas masas son asintomaticas y el diagnostico se realiza frecuentemente mediante un hallazgo casual en la ecografia obstetrica; lo mas comun es que sea en el segundo trimestre. El manejo de los tumores ovaricos depende de su naturaleza y clinica. En los casos en que se sospeche malignidad es necesaria una cirugia de estadificacion e incluso asociar quimioterapia. En estos casos, debe intentarse conservar la fertilidad. Presentamos 2 casos de teratomas inmaduros de ovario en gestantes.

Mortalidad perinatal en el Hospital Clínico San Carlos de Madrid

Objetivo: Comparar las tasas de mortalidad perinatal del Hospital Clinico San Carlos entre los periodos 1995-1999 y 2000-2004. Material y metodos: Estudio retrospectivo de la mortalidad perinatal del quinquenio 2000-2004, empleando la clasificacion internacional de la Federacion Internacional de Ginecologia y Obstetricia. Se recopilo un total de 157 casos y se estudiaron la mortalidad segun el tipo de parto, asi como los resultados de los estudios anatomopatologicos post mortem realizados. Resultados: La mortalidad perinatal ampliada (MPNA) fue de 10,68/1.000 nacidos y la mortalidad perinatal estandar (MPNE) de 4,82�, sobre un total de 14.261 partos, con 14.508 recien nacidos de 500 g o mas de peso. Las tasas de MPNA y MPNE corregidas fueron de 10,2 y 4,34/1.000 nacidos, respectivamente. Conclusiones: La mortalidad perinatal ha disminuido de forma drastica, de 13,6� nacidos en el periodo 1995-1999 a un 10,68� en el periodo estudiado. Los mejores resultados se obtuvieron en el ano 2002 (6,63� nacidos vivos).

Evaluación de la seguridad y la eficacia de la endometrectomía histeroscópica en la menometrorragia

Resumen Objetivo Analizar la eficacia y la seguridad de la endometrectomia histeroscopica en pacientes con hemorragia uterina disfuncional. Material y metodos Estudio retrospectivo de 119 pacientes con menometrorragias. Se evaluo la histologia prequirurgica y posquirurgica, las complicaciones inmediatas y tardias, la recidiva de la sintomatologia y la necesidad de reintervencion. Resultados La edad media de las pacientes fue de 45 anos (rango, 25-72). Tras una mediana de seguimiento de 14 meses (rango, 9-54), el 92,8% de las mujeres mejoro de su metropatia. En el 30,9% persistio la amenorrea; en el 26,3%, la hipomenorrea; y en el 35,4%, la eumenorrea. Las complicaciones globales fueron del 5,9% (7 casos), 6 casos a corto plazo (3 perforaciones y 3 hemorragias intraoperatorias) y un caso de hematometra a largo plazo. Un 7,2% (8 casos) mantuvo menometrorragias tras la ablacion. El fallo del tratamiento se asocio con la reseccion incompleta del endometrio y la presencia de complicaciones intraoperatorias. La tasa de respuesta se redujo con el tiempo: el 96% a los 6meses y el 87% a los 3 anos. Se realizo un 7,3% (8 casos) de reintervenciones, 3 de ellas histerectomias. Conclusiones La ablacion/reseccion endometrial o endometrectomia histeroscopica es un tratamiento seguro y efectivo en el manejo quirurgico de la menometrorragia.