Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

AIM: The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. METHOD: Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. RESULTS: Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). CONCLUSION: The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Feasibility of quantitative analysis of colonic perfusion using indocyanine green to prevent anastomotic leak in colorectal surgery.

BACKGROUND: The aim of this study was to quantify Fluorescence angiography with indocyanine green (ICG) in colorectal cancer anastomosis, determine influential factors in its temporary intensity and pattern, assessing the ability to predict the AL, and setting the cut-off levels to establish high- or low-risk groups. METHODS: Retrospective analysis of prospectively managed database, including 70 patients who underwent elective surgery for colorectal cancer in which performing a primary anastomosis was in primary plan. In all of them, ICG fluorescence angiography was performed as usual clinical practice with VisionSense™ VS Iridium (Medtronic, Mansfield, MA, USA), in Elevision™ IR Platform (Medtronic, Mansfield, MA, USA). Parameters measured at real time or calculated were T0, Tmax, ∆T, Fmax, %pos, Fpos, and Slope. RESULTS: 70 patients were included, 69 anastomosis were performed and one end colostomy. Arterial hypertension demonstrated higher Fmax, as well as the location of the anastomosis (the nearest to rectum, the most intensity detected). A statistical relationship was found between AL and the lower Fpos and Slope. The decision of changing the subjectively decided point of division did not demonstrate statistical difference on the further development of AL. All parameters were analyzed to detect the cut-off related with AL. Only in case of Fpos lower than 158.3 U and Slope lower than 13.1 U/s p-value were significant. The most valuable diagnostic parameter after risk stratification was the Negative Predictive Value. CONCLUSION: Quantitative analysis of ICG fluorescence in colorectal surgery is safe and feasible to stratify risk of AL. Hypertension and location of anastomosis influence the intensity of fluorescence at the point of section. A change of division place should be considered to avoid AL related to vascular reasons when intensities of fluorescence at the point of section is lower than 169 U or slopes lower than 14.4 U/s.

Prevalence of congenital malformations and deformities of the osteomuscular system in live newborns in Mexico, 2008-2017.

BACKGROUND: From 2009 to 2010 in Mexico. CMDOMS prevalence was 27.4/10,000 births. The first places were congenital deformation of the feet with a prevalence of 8.0 and congenital deformation of the hip with 6.7/10,000 births. OBJECTIVE: To estimate for Mexico the national prevalence of CMDOMS in live births, by state and municipality, as well as to analyze spatial distribution by these same territorial delimitations. METHOD: A database of 20,175,422 newborns (NB) alive from 2008 to 2017 was integrated. Percentages and prevalence were calculated at the national level, federal entities and municipalities, with confidence intervals at 95%. Maps were made and prevalence was stratified. RESULTS: The congenital malformation prevalence rate was 77.8/10,000 NB. CMDOMS were in first place with 40.8% and a prevalence of 31.8/10,000 NB. Prevalence by federal entity presented a range of 8.0-75.8/10,000 NB, were stratified by states and municipalities for presentation on maps. CONCLUSION: In Mexico for the years 2008-2017 an increase in CMDOMS prevalence was observed globally and in particular of some specific causes.

ANTECEDENTES: En México, de 2009 a 2010, la prevalencia de las malformaciones y deformidades congénitas del sistema osteomuscular (MDCSOM) fue de 27.4 por 10,000 nacimientos. Los primeros lugares los ocuparon la deformación congénita de los pies, con una prevalencia de 8.0, y la deformación congénita de la cadera, con 6.7 por 10,000 nacimientos. OBJETIVO: Estimar para México la prevalencia nacional de MDCSOM en nacidos vivos (NV), por entidad federativa y municipio, y analizar su distribución espacial por esas mismas delimitaciones territoriales. MÉTODO: Se integró una base de datos de 20,175,422 NV en 2008-2017. Se calcularon porcentajes y prevalencias por ámbito nacional, entidades federativas y municipios, con intervalos de confianza al 95%. Se elaboraron mapas y se estratificaron las prevalencias. RESULTADOS: La tasa de prevalencia de malformaciones congénitas fue de 77.8 por 10,000 NV. Se ubicaron en el primer lugar las MDCSOM, con un 40.8% y una prevalencia de 31.8 por 10,000 NV. Las prevalencias por entidad federativa presentaron un rango de 8.0 a 75.8 por 10,000 NV; se estratificaron por estados y municipios para su presentación en mapas. CONCLUSIÓN: En México, para los años 2008-2017, se observa un incremento en las prevalencias de las MDCSOM en forma global y en particular por algunas causas específicas.

Demand for obstetric care and density of health resources for childbearing age Mexican women.

INTRODUCTION: In Mexico, there is an increase recorded in the number of C-sections, as well as inequity and inequality in the distribution of resources for obstetric care. OBJECTIVE: To identify the states and municipalities in Mexico that concentrate the demand for obstetric care and the C-section rates and their relationship with health resources and women of childbearing age (WCBA). METHOD: Births of the 2008-2017 period were recorded, grouped into five municipal strata, as well as 2017 health resources and WCBA. RESULTS: The 2008-2017 national rate of C-sections was 45.3/100 births; 95 and 97 % of births and C-sections were concentrated in the "very high" stratum, where 80 % or more of health resources were used, with overuse standing out. The density of health resources assigned to WCBAs reflected inequity and inequality. CONCLUSIONS: The high concentration of obstetric demand and health resources supply could entail a higher recurrence of C-sections. Policies for C-section reduction should consider proper organization and administration of health resources.

INTRODUCCIÓN: México registra aumento de las cesáreas e inequidad y desigualdad en la distribución de recursos para la atención obstétrica. OBJETIVO: Identificar las entidades y municipios en México que concentran la demanda de atención obstétrica y tasas de cesáreas y su relación con los recursos en salud y mujeres en edad fértil (MEF). MÉTODO: Se registraron los nacimientos del periodo 2008-2017, agrupados en cinco estratos municipales, y los recursos en salud y MEF de 2017. RESULTADOS: La tasa nacional de cesáreas 2008-2017 fue de 45.3/100 nacimientos; 95 y 97 % de los nacimientos y cesáreas se concentraron en el estrato "muy alto", en el cual se utilizó 80 % o más de los recursos en salud y destacó la sobreutilización. La densidad de recursos en salud destinados a las MEF reflejó inequidad y desigualdad. CONCLUSIONES: La alta concentración de la demanda obstétrica y oferta de los recursos en salud pudiera conllevar mayor recurrencia a la cesárea. En las políticas de reducción de cesáreas es necesario considerar la organización y administración adecuadas de los recursos en salud.

Demanda de atención obstétrica y densidad de recursos en salud para mujeres mexicanas en edad fértil / Demand for obstetric care and density of health resources for childbearing age Mexican women

Resumen Introducción: México registra aumento de las cesáreas e inequidad y desigualdad en la distribución de recursos para la atención obstétrica. Objetivo: Identificar las entidades y municipios en México que concentran la demanda de atención obstétrica y tasas de cesáreas y su relación con los recursos en salud y mujeres en edad fértil (MEF). Método: Se registraron los nacimientos del periodo 2008-2017, agrupados en cinco estratos municipales, y los recursos en salud y MEF de 2017. Resultados: La tasa nacional de cesáreas 2008-2017 fue de 45.3/100 nacimientos; 95 y 97 % de los nacimientos y cesáreas se concentraron en el estrato “muy alto” (470 municipios), en el cual se utilizó 80 % o más de los recursos en salud y destacó la sobreutilización. La densidad de recursos en salud destinados a las MEF reflejó inequidad y desigualdad. Conclusiones: La alta concentración de la demanda obstétrica y oferta de los recursos en salud pudiera conllevar mayor recurrencia a la cesárea. En las políticas de reducción de cesáreas es necesario considerar la organización y administración adecuadas de los recursos en salud.

Abstract Introduction: In Mexico, there is an increase in the number of C-sections, as well as inequity and inequality in the distribution of resources for obstetric care. Objective: To identify the states and municipalities in Mexico that concentrate the demand for obstetric care and the C-section rates and their relationship with health resources and women of childbearing age (WCBA). Method: Births of the 2008-2017 period were recorded, grouped into five municipal strata, as well as 2017 health resources and WCBA. Results: The 2008-2017 national rate of C-sections was 45.3/100 births; 95 and 97 % of births and C-sections were concentrated in the “very high” stratum, where 80 % or more of health resources were used, with overuse standing out. The density of health resources assigned to WCBAs reflected inequity and inequality Conclusions: The high concentration of obstetric demand and health resources supply could entail a higher recurrence of C-sections. Policies for C-section reduction should consider proper organization and administration of health resources.

Analysis of frequency, type of complications and economic costs of outlying patients in general and digestive surgery. / Análisis de la frecuencia, tipos de complicación y costes económicos en los pacientes ectópicos de cirugía general y digestiva.

INTRODUCTION: The shortage of available beds and the increase in Emergency Department pressure can cause some patients to be admitted in wards with available beds assigned to other services (outlying patients). The aim of this study is to assess the frequency, types of complications and costs of outlying patients. METHODS: Using a retrospective cohort model, we analysed the 2015 general and digestive surgery records (source: Minimum Basic Data Set and economic database). After selecting all outlying patients, we compared the complications, length of stay, costs and consequences of complications against a randomized sample of non-outlying patients with the same DRG and date of episode for every outlying patient, obtaining one non-outlying patient for each selected outlying patient. Thirteen outlying patients with no non-outlying patient pair were excluded from the study. RESULTS: From a total of 2,915 patients, 363 (12.45%) were outlying patients. A total of 350 outlying patients were analysed versus 350 non-outlying patients. There were no significant differences in complications (9.4 vs. 8.3%), length of stay (4.33 vs. 4.65 days) or costs (€3,034.12 vs. €3,223.27). Outlying patients men presented a significantly higher risk of complications compared to women (RR=2.10). Outlying patients presented complications after 2.5 or more days. CONCLUSIONS: When outlying admissions become necessary, the selection of patients with less complex pathologies does not increase complications or their consequences (ICU admissions, readmissions, reoperations or mortality), hospital stays or costs. Only in cases of prolonged outlying stays of more than 2.5 days, or in males, may more complications appear. Therefore, male outliers should be avoided in general, and patients should be transferred to the proper ward if a length of stay beyond 2.5 days is foreseen.

Estudio de variabilidad geográfica de las hospitalizaciones potencialmente evitables en México durante tres quinquenios.

INTRODUCCIÓN: Las enfermedades que motivan hospitalización potencialmente evitable tienen la característica de ser sensibles a la prevención, diagnóstico y control ambulatorio en atención primaria a la salud. OBJETIVOS: Identificar la tendencia nacional de la hospitalización potencialmente evitable entre 2001 y 2015 y analizar el patrón geográfico a nivel municipal y priorizar municipios. MÉTODO: Se usaron los egresos hospitalarios de la Secretaría de Salud. Se calcularon tasas de prevalencia nacionales y razones municipales, estandarizadas por edad y sexo. Se emplearon estadísticos de variabilidad para analizar y elaborar mapas. RESULTADOS: De los egresos hospitalarios, 10.39, 9.81 y 9.26 % se clasificaron como hospitalizaciones potencialmente evitables para cada periodo quinquenal. La tasa nacional se incrementó en el lapso estudiado: de 36.27 a 47.24 por 10 000 habitantes. La diabetes mellitus, las gastroenteritis y otras enfermedades de las vías respiratorias inferiores fueron las causas de mayor frecuencia. Los patrones geográficos en los tres periodos fueron semejantes. Se identificaron 487 municipios prioritarios, 174 con alto uso y 313 con sobreuso hospitalario, que concentraron 35.83 % de las hospitalizaciones evitables, 8.58 y 27.25 %, respectivamente. CONCLUSIONES: En México existe amplia variabilidad geográfica de la hospitalización potencialmente evitable con un patrón casi inmutable. INTRODUCTION: Diseases that motivate potentially preventable hospitalization (PH) have the characteristic of being sensitive to prevention, diagnosis and control on an outpatient basis in primary care. OBJECTIVES: To identify the national trend of potentially avoidable hospitalization between 2001 and 2015; to analyze its geographical pattern at the municipal level and prioritize municipalities. METHOD: Hospital discharge records from the Ministry of Health were used. National prevalence rates and municipal PH ratios, standardized by age and gender, were calculated. Variability statistics were used to analyze and generate maps. RESULTS: Among all hospital discharges, 10.39%, 9.81% and 9.26% were classified as PH for each period. The national PH rate did increase in the studied period: from 36.27 to 47.24 per 10,000 population. Diabetes mellitus, gastroenteritis and other diseases of the lower respiratory tract were the most common causes. Geographic patterns of PH were similar for the three periods. A total of 487 priority municipalities were identified, 174 with hospital high use and 313 with overuse, 35.83 % were avoidable hospitalizations, 8.58% and 27.25%, respectively. CONCLUSIONS: In Mexico there is wide geographical variability in PH, with an almost unchanging geographical pattern.

Prevention of parastomal hernia with a preperitoneal polypropelene mesh.

OBJECTIVE: To show our results with the use of a polypropylene mesh at the stoma site, as prophylaxis of parastomal hernias in patients with rectal cancer when a terminal colostomy is performed. METHODS: From January 2010 until March 2014, 45 consecutive patients with rectal cancer, underwent surgical treatment with the need of a terminal colostomy. A prophylactic mesh was placed in a sublay position at the stoma site in all cases. We analyze Demographics, technical issues and effectiveness of the procedure, as well as subsequent complications. RESULTS: A prophylactic mesh was placed in 45 patients, 35 male and 10 females, mean age of 66.2 (47-88) and Body Mass Index 29.19 (20.4-40.6). A total of 7 middle rectal carcinoma, 36 low rectal carcinoma, one rectal melanoma and one squamous cell anal carcinoma were electively treated with identical protocol. Abdominoperineal resection was performed in 38 patients, and low anterior resection with terminal colostomy in 7. An open approach was elected in 39 patients and laparoscopy in 6, with 2 conversions to open surgery. Medium follow up was 22 months (2.1-53). Overall, 3 parastomal hernias (6.66%) were found, one of which was a radiological finding with no clinical significance. No complications related to the mesh or the colostomy were found. CONCLUSIONS: The use of a prophylactic polypropylene mesh placed in a sublay position at the stoma site is a safe and feasible technique. It lowers the incidence of parastomal hernias with no increased morbidity.

[Percentage of births and fertility rates in adolescents in Mexico (2008-2012): stratification and priorization of municipalities with high risk]. / Porcentaje de nacimientos y tasas de fecundidad en adolescentes de México (2008-2012): estratificación y priorización de municipios con alto riesgo.

BACKGROUND: Mexico in 2008 was designed as the first place of adolescent pregnancy at the Organization for Economic Cooperation and Development, with specific fertility rate (SFR) for 15-1 9years of age of 64.2/1,000 woman at the same age. OBJECTIVE: Estimate of percentage births and SFR in adolescent population at national, state and municipal level in Mexico in 2008-2012 at the total group of adolescents 10 to 1 9 years old and by subgroups of 10-14 and 15 tol 9 years old, identifying the priority municipalities with adolescence pregnancies. MATERIAL AND METHOD: Data bases of certificates of live birth and fetal death with gestational age of 22-45 weeks were joined in 2008-2012. RESULTS: A data base of 1 0'585,032 births in 2008-2012 was obtained, 98.9% were live births and 1.1% was stillbirths. The SFR nationwide for the period 2008-2012 were of the order of 3.l for the group of 10-1 4years, 75.3 for 15-19, 39.6 for the total group of 10-19 years and 66.1 for 20 to 49 years per 1000 women for the same age. CONCLUSION: In the last decade it has increased teen pregnancy as well as the percentage of births and the fertility rate in this age group, worrying situation for the high risk of biological, psychological and social damage that pregnancy early.

Prevalencia del síndrome de Down en México utilizando los certificados de nacimiento vivo y de muerte fetal durante el periodo 2008-2011 / Prevalence of Down syndrome using certificates of live births and fetal deaths in México 2008-2011

Introducción: El síndrome de Down (SD) o trisomía 21 es la causa genética más frecuente de retraso mental. Clínicamente presenta una serie de características bien definidas. Se ha asociado la edad materna avanzada con la presencia de SD. Métodos: Se conjuntaron las bases de datos de los certificados de nacimientos vivos y de muerte fetal. Se seleccionaron los códigos con base en la Clasificación Internacional de Enfermedades décima revisión (CIE-10) del capítulo XVII: <

Background: Down syndrome (DS) or trisomy 21 is the most common genetic cause of mental retardation with the clinical presentation of a series of well-defined characteristics. Advanced maternal age has been associated with DS. Methods: The databases of all the certificates of live births and fetal deaths in Mexico were combined. Codes based on the International Classification of Diseases 10th Revision (ICD-10) in Chapter XVII "Congenital malformations, deformations and chromosomal abnormalities" were selected. Results: A database of 8,250,375 births during the period 2008-2011 was constructed: 99.2% were live births with 0.8% of fetal deaths and 3,076 cases diagnosed with DS. Conclusions: The importance of this report is to initiate an epidemiological surveillance of newborn cases of DS nationwide and by state using census information systems available in the country since 2008. An increased risk has been observed for having a child with DS since the mother is ≥ 35 years, as has been reported in other studies.

[Prevalence of Down syndrome using certificates of live births and fetal deaths in México 2008-2011]. / Prevalencia del síndrome de Down en México utilizando los certificados de nacimiento vivo y de muerte fetal durante el periodo 2008-2011.

BACKGROUND: Down syndrome (DS) or trisomy 21 is the most common genetic cause of mental retardation with the clinical presentation of a series of well-defined characteristics. Advanced maternal age has been associated with DS. METHODS: The databases of all the certificates of live births and fetal deaths in Mexico were combined. Codes based on the International Classification of Diseases 10th Revision (ICD-10) in Chapter XVII "Congenital malformations, deformations and chromosomal abnormalities" were selected. RESULTS: A database of 8,250,375 births during the period 2008-2011 was constructed: 99.2% were live births with 0.8% of fetal deaths and 3,076 cases diagnosed with DS. CONCLUSIONS: The importance of this report is to initiate an epidemiological surveillance of newborn cases of DS nationwide and by state using census information systems available in the country since 2008. An increased risk has been observed for having a child with DS since the mother is ≥ 35 years, as has been reported in other studies.

Prevalencia de malformaciones congénitas registradas en el certificado de nacimiento y de muerte fetal: México, 2009-2010 / Prevalence of congenital malformations recorded on the birth certificate and fetal death, Mexico, 2009 to 2010

Introducción. Las malformaciones congénitas son causas importantes de mortalidad infantil, enfermedad crónica y discapacidad en muchos países. La frecuencia esperada es de 2 a 3% en nacidos vivos y de 15 a 20% en muertes fetales. En México, en 2010, la mortalidad infantil ocupó el segundo lugar, con una tasa de 336.3/100,000 nacimientos. El objetivo de este trabajo fue estimar la prevalencia de malformaciones congénitas en México al nacimiento y las principales causas registradas en los certificados de nacimiento y muerte fetal para el período 2009-2010. Métodos. Se conjuntaron las bases de datos del certificado de nacimiento de nacido vivos y del de muerte fetal. Resultados. La población total fue de 4'123,531 registros, 99.3% nacidos vivos y 0.7% muertes fetales. Se registró un total de 30,491 casos de malformaciones congénitas en 91.7% nacidos vivos y 8.3% muertes fetales. La prevalencia fue de 73.9/10,000 nacimientos. Conclusiones. La tasa de prevalencia fue más baja que la esperada. Se requieren programas de validación y capacitación para fortalecer estos sistemas de registro.

Background. Congenital malformations are a main cause of infant death, chronic illness and disability in several countries. The expected frequency is ~2-3% in live newborns and ~15-20% in stillbirths. In 2010 in Mexico, infant mortality ranked in second place with a rate of 336.3/100,000 births. In order to estimate prevalence and main causes of congenital malformations in live births and stillbirths, national base registries of newborns and stillbirths were evaluated for 2009-2010. Methods. Databases of neonatal live births and fetal deaths were combined. Results. From a total population of 4,123,531 certificates, 99.3% were live born and there were 0.7% fetal deaths. Congenital malformations were registered in 30,491 cases, 91.7% of live newborns and 8.3% of fetal deaths with a prevalence rate of congenital malformations of 73.9/10,000. Conclusions. The reported prevalence was lower than expected. It is necessary to enforce registry systems through system validation and training of personnel.

[Importance of the quality of the discharge report in the management of a surgical clinical unit]. / Importancia de la calidad del informe de alta en la gestión de una unidad clínica quirúrgica.

BACKGROUND: The discharge report is a basic document at the end of a care process, and is a key element in the coding process, since its correct wording, reliability and completeness are factors used to determine the hospital production. MATERIAL AND METHODS: From a hypothesis based on the analysis of the consistency between the discharge report and data collected from the routine clinical notes during admission, we should be able to re-code all those mis-coded, thus placing them in a more appropriate diagnosis-related group (DRG). A total of 24 patient outliers were analysed for the correct filling in of the type and reason for admission, personal history, medication, anamnesis, primary and secondary diagnosis, sugical procedure, outcome, number of diagnostic and procedures cited, concordance between discharge report and history and recoding of the DRG. RESULTS: From a total of 24 episodes, 6 had precise and valid reports, 4 were valid but not precise enough, 9 were insufficient, and 5 were clearly invalid. The recoded DRG after the documentation review was not significantly different, according to the Wilcoxon test, being changed in only 5 cases (P = .680). CONCLUSION: Quality in discharge reports depends on an adequate minimum data set (MDS) in concordance with the source documentation during admission. Discordance can change the DRG, despite it not being significantly different in our series. Self-audit of discharge reports allows quality improvements to be developed along with a reduction in information mistakes.