[Results of the implementation of a protocol for outpatient management of the paediatric patient with tuberculosis]. / Resultados de la implantación de un protocolo para el manejo ambulatorio del paciente pediátrico con enfermedad tuberculosa.

OBJECTIVE: To assess the results of the implementation of a protocol for the outpatient management of paediatric patients with tuberculosis, and to compare it with the previous approach. MATERIAL AND METHODS: All patients younger than 14 years of age diagnosed with tuberculosis in Cantabria between 2005 and 2014 were included in the study. The pre-implementation period included patients admitted for gastric aspirate collection and to start treatment until 2010 (Pre-group). The post-implementation period was from 2010 onwards, using a protocol established for the outpatient management of these patients, with admission only being for clinical or social reasons, post-implantation period (Post-group). RESULTS: A total of 82 patients were studied: 29 from the Pre-group and 53 from Post-group. The median age was 61 months (IQR 32.5-97.75). All patients in the Pre-group were systematically admitted, compared to 26.4% of the Post-group (P<.001). The mean hospital stay was higher (7.27±7.1 days) in the Pre-group than in Post-group (3.4±11.46 days) (P<.0001). Only in 6.9% of patients from Pre-group were the 3 microbiological samples recommended for diagnosis following the international guidelines were provided, whereas they were provided by 73.58% patients from Post-group (P<.001). Of the cultures performed, 26.6% were positive for Mycobacterium tuberculosis, 37.5% of the Pre-group and 21.6% of the Post-group (P=.121). No significant differences were observed between the groups in other parameters related to treatment such as, therapeutic adherence, treatment not adjusted to the guidelines, treatment withdrawal or relapse.. DISCUSSION: Although guidelines recommend three microbiological samples for culture, no superior microbiological isolation was detected despite the increased number of samples collected. The management in hospital clinics of patients with suspected tuberculosis with stable clinical situation show similar or better clinical and microbiological results to the previous management, with lower hospital admission rate and with the subsequent cost savings.

Obesity surgery results depending on technique performed: long-term outcome.

BACKGROUND: Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. METHODS: This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). RESULTS: One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. CONCLUSIONS: The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75-225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m(2)), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.

Incidence of incisional hernia following vertical banded gastroplasty.

BACKGROUND: Our aim was to determine which patient-related factors influence the incidence of incisional hernia after vertical banded gastroplasty for morbid obesity. METHODS: We reviewed the medical records of 80 morbidly obese patients operated on between 1986 and 1993. All the operations were performed by only one surgeon, and the midline laparotomy was closed by means of continuous polyglactin 910 suture. Statistical analysis was performed using the Fisher exact test, and significance was assigned for values of P<0.05. RESULTS: Incidence of incisional hernia in: obese 24%, superobese 51% ( P=0.0165), men 40%, women 34% ( P=0.7671), age<50 33%, age>50 50% ( P=0.3137), nondiabetics 31%, diabetics 66% ( P=0.0610), no wound infection 34%, wound infection 37% ( P>0.9999), no anemia 31%, anemia 50% ( P=0.1675), no vomiting 39%, vomiting 32% ( P=0.6350). CONCLUSION: The only patient-related factor that significantly influences the incidence of incisional hernia in morbidly obese patients is body mass index.

Transanal full-thickness excision of rectal tumours: should the defect be sutured? a randomized controlled trial.

PURPOSE: It is generally recommended that the defect, after full thickness total wall excision of a tumour located in the extraperitoneal part of the rectum, should be sutured. There is a lack of controlled studies however, supporting this approach. The aim of this study was to compare the results obtained in patients after peranal local excision of rectal tumours whose defect were sutured with those that were not. METHODS: 44 patients were prospectively randomized to group A: The defect is closed; Group B: Defect left un-sutured. Pre-operative test were digital examination, proctoscopy and endorectal ultrasound. Local full-thickness excision was performed mainly with the Transanal Endoscopic Microsurgery (TEM) equipment, but for cases near the anal verge a Parks' retractor was used. Data recorded were operation time, blood loss, hospital stay and early and late complications. The first postoperative assessment was planned at 1 month and then every three months until 18 months of follow-up. Result for 40 patients (21 from group A; 19 from group B) were analysed. There were no differences between groups regarding age, sex, location of the tumour and specimen's size. RESULTS: The intra-operative loss of blood was 22 ml for group A and 39 ml for B, the difference was not significant. The mean operation time was slighter longer for group A (93 min) than for group B (77 min) but not statistically significant. For both group the mean hospital stay was of 4[2-7] days. No differences in early or late complications could be demonstrated. CONCLUSION: The present study suggests that there is no difference between these two practices in terms of intra-operative results and outcome.

Is endosonography useful to select patients for endoscopic treatment of rectal cancer?

AIM: in recent years there have been remarkable advances in the treatment of rectal cancer, stimulated by a general tendency towards conservative treatment, and aided by the development of diagnostic tools that allow the surgeon to select the most suitable tumors for treatment. In some cases, conservative local excision by transanal endoscopic microsurgery (TEM) may be appropriate. We analyzed the value of transrectal endosonography for the preoperative staging of rectal cancer previous to TEM. METHODS: data were collected prospectively from a consecutive series of patients with rectal cancer who underwent TEM between January 1994 and December 1997. RESULTS: the accuracy of rectal endosonography in predicting rectal wall invasion was 72.7%. 18.2% of the tumors were overstaged and 9. 1% were understaged. CONCLUSION: transrectal endosonography is a useful technique for the selection of patients for TEM but is amenable to further improvement.