[Evaluation of a clinical pathway of the inguinal hernia repair in a general surgery service]. / Evaluación de la vía clínica de la cirugía de la hernia inguinal en un servicio de cirugía general.

OBJECTIVE: The objective of this work is to assess the level of implementation of an inguinal hernia clinical pathway and its impact on the patient satisfaction. MATERIAL AND METHOD: An inguinal hernia repair clinical pathway was introduced in our service in January 2008. We studied all patients included in the clinical pathway since its introduction. The evaluation variables included: level of implementation, indicators of effectiveness in clinical care, and indicators of satisfaction based on a questionnaire. RESULTS: During the first year of introducing the clinical pathway we operated on 582 patients for hernia repair. We excluded 85 cases (14.6%) from the study, due to not fulfilling the inclusion criteria. The study was finally conducted with 497 patients, 49 (9.8%) women and 448 (90.2%) men. The mean age of these patients was 56.6 (21-88) years old. A right hernia repair was performed on 273 cases (54.3%) and 224 (45.7% on the left hernia. In 473 (95.2%) it was a primary hernia and a recurrence in 24 (4.8%). In 441(88.7%) it was a unilateral hernia and 56 (11.3%) a bilateral hernia. The mean length of hospital stay was 1.1 (1-119) days. The level of compliance with length of hospital stay was 96.8%. The level of compliance with surgical prevention was 87.7%. Level of document management by the nursing staff was 86.5% and for doctors it was 80,7%. Overall morbidity was 6%. The informed consent was correctly executed in 97,8% of the cases and 98.6% of patients were given a final report on the day of leaving hospital. A total of 369 satisfaction questionnaires were collected, which was a response rate of 74.2%. Almost all (96%) patients were satisfied with the received information, 87.6% said their pain was managed correctly, and 81% found stay appropriate, and 95% said their hospital stay was between acceptable and good. The level of satisfaction with the care received was 97.5%, and 97.4% of the patients studied would recommend the hospital to a friend or family. CONCLUSION: The introduction of a clinical pathway for inguinal hernia repair has led to a good integration, the services involved in the same. Patients have expressed a high level of satisfaction with the service received, but there are aspects that we must improve: in the information and communication with the patient, the action protocols, evaluation criteria, the VC ¿clinical pathway? Registers, and the satisfaction survey model.

[Gastric bypass in the surgical treatment of the morbid obesity and super obesity: comparative study]. / Bypass gástrico en el tratamiento de la obesidad mórbida y la superobesidad: estudio comparativo.

INTRODUCTION: Gastric Bypass (GB) constitutes the surgical treatment of election of morbid obesity (BMI < 50) at the present time, however doubts exist about its effectiveness in super obesity patients (BMI > 50). OBJECTIVE: The purpose of this work is one of to analyze the results of loss of weight of the first 52 open GB of our series, and to compare the losses of weight in morbid obesity (MO) and super obesity (SO), to determine if the superobese patient looses enough weight with this technique or if it would be more indicated another technique more malabsorptive, like some authors recommend. MATERIALS AND METHOD: Retrospective study of the first 52 patients operated of open GB pathway. The weight loss of 32 patients' with MO are compared with the weight loss of 20 patients with super obesity after five year follow-up. The parameters analyzed are: age, sex, height, initial weight, current weight, initial BMI, current BMI, % BMI lost, % overweight lost, incidence of incisional hernia, acceptable oral tolerance and metabolic alterations. The malabsorptive procedure associated in patients with super obesity was a 200 cm Roux-en-Y and a patients with BMI between 40 and 50 was a 150 cm Roux-en-Y. The results are compared by means of the X2 and Mann Whitney statistical test. RESULTS: The age, the sex and the stature are homogeneous in the two groups. In the group of MO the initial weight was of 121.5 kg; initial BMI, 45; current BMI; 28.9, the median loss of weight in 5 years was of 48 kg; the percentage loss of the excess of BMI is of 80% and the percentage loss of the excess of weight is of 74.6%. In the group of SO the initial weight was of 142.,7 kg; initial BMI, 54.9; current BMI, 34.,9; the median loss of weight in 5 years was of 54 kg; the percentage loss of the excess of BMI was of 65,3% and the percentage loss of the excess of weight was of 63.2%. The analysis of the results ponders shows that it exists statistically significant differences (P < 0.05) among the two groups, however the rate of success, according to the classic parameter of loss of more than 50% of the excess of weight, was superior to 90% in both groups. The results of the study about the presence of incisional postoperative hernia, alimentary tolerance and metabolic alterations, indicate that it doesn't exist differences statistically significant between both groups. CONCLUSIONS: GB is an effective surgical technique in patients with morbid obesity and with super obesity, provided that in these patients is realized a procedure more malabsorptive. There are not differences between both groups, in morbidity, improvement in the associate disease, alimentary tolerance and necessity of nutritional supplements.

Colovesical fistula complicating diverticular disease: one-stage resection.

Colonic diverticular disease is common in developed countries, and its prevalence increases with age. Most affected individuals remain asymptomatic throughout their lives, and relatively few patients require surgical intervention for obstructive or inflammatory complications. Colovesical fistula is the most common type (65%) of fistula associated with colonic diverticular disease. Primary resection of sigmoid colon with colorectal anastomosis performed as a one-stage procedure is its definitive treatment and can be performed safely--as simple closure, using an omental flap, or through resection and closure of bladder defect--in 90% of the patients. We report our experience with four patients suffering from colovesical fistula who were treated with primary resection of sigmoid colon and colorectal anastomosis performed as a one-step procedure. In our experience, diverting colostomy or Hartmann intervention is not recommended because of the lack of fistula definitive resolution and the possibility of additional complications.

[Bochdalek's hernia in an adult with stomach volvulus and extrapulmonary sequestration]. / Hernia de Bochdalek del adulto con volvulación gástrica y secuestro extrapulmonar.

We report a case of Bochdalek's hernia with volvulus of the stomach and extrapulmonary sequestration in an adult. A 27-year-old woman presented acute respiratory failure, pain in the left side of the chest and recurrent vomiting of sudden onset. Upon examination there was pain in the left hypochondrium that was not tolerated in decubitus position. A chest film showed an "arch" at the base on the left side and an upper gastrointestinal series revealed volvulus of the stomach. After a left thoracotomy, the stomach, spleen and greater omentum were found displaced into the thoracic cavity. After the viscera were confined to the abdomen, the hernia was repaired and the pulmonary sequestration was removed. Two years later, the patient was asymptomatic and a chest film was normal.

[Bronchoesophageal fistula and broncholithiasis]. / Fístula broncoesofágica y broncolitiasis.

Bronchoesophageal fistulas (BEF) in an adult, whether acquired or congenital, are uncommon but bronchoesophageal perforation secondary to broncholithiasis caused by calcified mediastinal adenopathy and leading to the formation of a fistulous tract is extremely rare. We present a case of acquired BEF in a 57-years-old women who presented cough with expectoration of broncholiths, hemoptysis and cough after swallowing liquid or solid hemoptysis and cough after swallowing liquid or solid foods. The chest film and computed tomographic scan showed calcified mediastinal adenopathy. Endoscopic examination of the esophagus revealed no mucosal abnormality. A bronchial esophageal fistula was identified at the level of the 1/3 midesophagus just below the carina in the esophagogram. The bronchoscopy showed a polypoid area located in the medial side of the right main bronchus. There was no evidence of neoplasm. The patient underwent excision of fistula and interposition of pleural bundle after completing a right posterolateral thoracotomy. The postoperative course was uneventful and the patient has been doing well on follow-up.

[Horner's syndrome associated with a solitary bone plasmacytoma of the first rib]. / Síndrome de Horner asociado a plasmocitoma óseo solitario del primer arco costal.

A case of solitary plasmacytoma originated in the left first rib in a 45-year-male is presented. The initial symptomatology was a Horner's syndrome. A chest X-ray, gammagraphy, TAC and arteriography showed a tumor shadow in the left chest wall; no evidence of plasmacytoma after clinical study found use where. The treatment was surgical excision and postsurgical radiotherapy. The histological investigation revealed a plasmacytoma of the rib. The patient have been followed for two years. The patient is asymptomatic, without evidence of local recurrence and systemic spread of the disease two years after treatment.

[Mediastinal bronchogenic cyst in the carina of an asymptomatic patient]. / Quiste broncogénico mediastínico en carina de paciente asintomático.

A patient of 30 year-old male with a bronchogenic cyst in the mediastinum detected as an incidental finding on a routine chest X-ray is presented. Laboratory examinations did not reveal any significant abnormalities. Chest X-ray and TAC revealed the mass lesion with smooth margen, low density and homogeneous at the middle mediastinum. Treatment consisted in the resection of the cyst by left thoracic approach. Histologically, the lesion was typical a bronchogenic cyst.

[Cyst in the second branchial cleft: review of 3 cases]. / Quiste del segundo arco branquial: a propósito de tres casos.

Three cases of cysts arising from the second branchial cleft are described. They were completely removed. Histopathological examination revealed that cysts were lined with columnar (respiratory type) epithelium. The authors take this opportunity to review the underlying pathogenic mechanism, the clinical manifestations and therapeutic procedures.

[Isolated mesenteric fibromatosis]. / Fibromatosis mesentérica aislada.

A case of isolated mesenteric fibromatosis in a forty one years-old male is reported. The patient was symptom-free and no associated disease was detected. In the course of an appendectomy, a tumor was found in the mesentery of the small bowel (jejunum). Surgical excision was performed and the patient is free of recurrence thirteen months later.