[Laparoscopic cholecystectomy in a patient with situs inversus totalis]. / Colecistectomía laparoscópica en una paciente con situs inversus totalis.

OBJECTIVE: To report a case with situs inversus totalis (SIT) and chronic cholelithiasis solved by laparoscopic surgery, outlining the utility of minimal invasive surgery and specific considerations in patients with anatomic variations. CASE REPORT: A case of a 46 year-old female who presented with a six-month history of abdominal colic pain at the left hypochondrium, accompanied with nausea and vomiting, is presented. On examination she had epigastric tenderness. Blood tests, including liver function tests, were normal. Electrocardiogram showed right axis deviation and right ventricular hypertrophy, in keeping with dextrocardia. Chest-X-Ray confirmed the diagnosis of dextrocardia. An ultrasound scan of the upper abdomen identified the gallbladder containing stones in the left upper quadrant. A CT scan visualized the spleen and the gastric camera in the right upper quadrant. Barium gastrointestinal transit, barium enema and abdominal-X-Ray were used as complementary diagnostic studies. A magnetic resonance cholangiography was not performed because the patient suffered from claustrophobia. Cholecystectomy and transcystic cholangiography were performed by laparoscopic route, taking care to set-up the operating theatre in the mirror image of the normal set-up for cholecystectomy. The patient completed a successful procedure without complications and was discharged 48 hours after the procedure. Histological exam diagnosed a chronic lithiasic cholecystitis. CONCLUSIONS: Laparoscopic cholecystectomy is an adequate surgical procedure for patients with total situs inversus and cholelithiasis, having a high security range. Detailed clinical examination is important for the diagnosis of previously unknown anatomic variations. Transcystic cholangiography is mandatory when a magnetic resonance cholangiography can not be performed. Furthermore, perhaps in this situation a left-handed surgeon is better prepared than a right-handed one to comfortably carry out the procedure.

[High prevalence of undernutrition in Spanish elders admitted to a general hospital and associated factors]. / Alta prevalencia de la desnuttrición en ancianos Españoles ingresados en un hospital general y factores asociados.

The objective of the study was to evaluate the nutritional status of the hospitalised elderly patients using the Mini Nutritional Assessment (MNA) and nutritional classic parameters, to estimate the prevalence of undernutrition among them and to value the correlation of undernutrition with epidemiological characteristics of the sample for determine the highest risk's group among the malnourished patients. A cross sectional survey was done among a sample of 200 elderly patients admitted to the USP San Carlos Hospital (Murcia, Spain) during a period of 3 months. Patients answered a questionnaire including demographic data and the MNA clinical tool. Lymphocyte concentration and albumin and transferrin serum levels were also collected. Statistical analyses were performed with the Student t and chi 2 tests. For the MNA, the Spearman's coefficient was employed. Mean age of the 200 patients was 80.72 SD 7.43 years. Mean weight was 63.41 SD 19.57 kg and mean height was 160.93 SD 8.36 cm, with a mean Body Mass Index of 24.27 SD 7.31. The serum values of albumin and transferrin and total lymphocytes in blood were 3.09 SD 0.5 g/l, 1.69 SD 0.37 mg/dl and 1412 mm3 respectively. Average score of the MNA was 15.9 SD 6.21 and, according to this scale, 50% (n=100) of the patients were malnourished. Correlation analyses resulted in significant association (p < 0.001) between values of undernutrition in the MNA and measurements under normality of the biochemical and immunological parameters. The patients who presents chronic diseases, advanced physical or mental deterioration and minor self-sufficiency are either malnourished or at high risk of being. The individualized nutritional evaluation must be performed routinely when the patient is admitted to the hospital for detect and treat early signs of malnutrition.

[Quality assessment and improvement in the indication and management of parenteral nutrition in a general surgery unit]. / Evaluación y mejora de la calidad en la indicación y el manejo de la nutrición parenteral en un servicio de cirugía general.

OBJECTIVE: To analyze the degree of compliance with a variety of internationally accepted standards defined for Total Parenteral Nutrition (TPN) quality control in our Surgery Department. PATIENTS AND METHOD: Prospective study of patients treated with TPN over two years in the department of surgery of a university teaching hospital (n = 72). Assessment of quality was performed by measurements of compliance using 19 criteria. The criteria were divided into three groups according to characteristics of TPN standardisation: this must be "appropriate" to the nutritional requirements of the patient, "safe" in order to prevent complications and "accurate" in its daily programming. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria over six months, paying particular attention to those criteria which had the highest percentage of errors in the study carried out using a Pareto analysis. During a third period of six months the information on all 19 criteria was gathered again and the improvement with regard to the standard values and to the compliance in the first period (using the value of z) was evaluated. RESULTS: The compliance with seven criteria was significantly below standard values: all those of the "appropriate" group, except the criteria "type of diet" and "composition of the diet", and the criteria "absence of complications" of the "safe" group, which was also the one with the highest number of grouped non-compliances. In the second period all the below standard criteria improved with compared to the first period. The criteria "time of fasting", "concordance" and "duration" were significantly improved. The criteria "time of fasting", "duration" and "latency" reached the standard. The rest of criteria that reached their standard in the first evaluation maintained the same results. CONCLUSIONS: Corrective measures introduced were effective since all the below standard criteria improved, including metabolic complications. Notwithstanding, it is necessary to continue in this line to improve the criteria still below standard.