Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study): A Multicentre, Randomised, Open-label, Noninferiority Trial.

OBJECTIVE: Mild AD can be treated safely and effectively on an outpatient basis without antibiotics. SUMMARY OF BACKGROUND DATA: In recent years, it has shown no benefit of antibiotics in the treatment of uncomplicated AD in hospitalized patients. Also, outpatient treatment of uncomplicated AD has been shown to be safe and effective. METHODS: A Prospective, multicentre, open-label, noninferiority, randomized controlled trial, in 15 hospitals of patients consulting the emergency department with symptoms compatible with AD.The Participants were patients with mild AD diagnosed by Computed Tomography meeting the inclusion criteria were randomly assigned to control arm (ATB-Group): classical treatment (875/125 mg/8 h amoxicillin/clavulanic acid apart from anti-inflammatory and symptomatic treatment) or experimental arm (Non-ATB-Group): experimental treatment (antiinflammatory and symptomatic treatment). Clinical controls were performed at 2, 7, 30, and 90 days.The primary endpoint was hospital admission. Secondary endpoints included number of emergency department revisits, pain control and emergency surgery in the different arms. RESULTS: Four hundred and eighty patients meeting the inclusion criteria were randomly assigned to Non-ATB-Group (n = 242) or ATB-Group (n = 238). Hospitalization rates were: ATB-Group 14/238 (5.8%) and Non-ATB-Group 8/242 (3.3%) [mean difference 2.58%, 95% confidence interval (CI) 6.32 to -1.17], confirming noninferiority margin. Revisits: ATB-Group 16/238 (6.7%) and Non-ATB-Group 17/242 (7%) (mean difference -0.3, 95% CI 4.22 to -4.83). Poor pain control at 2 days follow up: ATB-Group 13/230 (5.7%), Non-ATB-Group 5/221 (2.3%) (mean difference 3.39, 95% CI 6.96 to -0.18). CONCLUSIONS: Nonantibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02785549); EU Clinical Trials Register (2016-001596-75).

Early discharge in Mild Acute Pancreatitis. Is it possible? Observational prospective study in a tertiary-level hospital.

BACKGROUND AND AIMS: In acute pancreatitis (AP), first 24 h are crucial as this is the period in which the greatest amount of patients presents an organ failure. This suggests patients with Mild AP (MAP) could be early identified and discharged. This is an observational prospective trial with the aim to demonstrate the safety of early discharge in Mild Acute Pancreatitis (MAP). METHODS: Observational prospective study in a third level single centre. Consecutive patients with AP from March 2012 to March 2014 were collected. INCLUSION CRITERIA: MAP, tolerance to oral intake, control of pain, C Reactive Protein <150 mg/dL and blood ureic nitrogen < 5 mg/dL in two samples. EXCLUSION CRITERIA: pregnant, lack of family support, active comorbidities, temperature and serum bilirubin elevation. Patients with MAP, who met the inclusion criteria, were discharged within the first 48 h. Readmissions within first week and first 30 days were recorded. Adverse effects related to readmissions were also collected. RESULTS: Three hundred and seventeen episodes were collected of whom 250 patients were diagnosed with MAP. From these, 105 were early discharged. Early discharged patients presented a 30-day readmission rate of 15.2% (16 patients out of 105) corresponding to the readmission rates in Acute Pancreatitis published to date. Any patient presented adverse effects related to readmissions. CONCLUSION: Early discharge in accurately selected patients with MAP is feasible, safe and efficient and leads to a decrease in median stay with the ensuing savings per process and with no increase in readmissions or inmorbi-mortality.

Influence of delayed cholecystectomy after acute gallstone pancreatitis on recurrence. Consequences of lack of resources.

INTRODUCTION: Acute pancreatitis is often a relapsing condition, particularly when its triggering factor persists. Our goal is to determine the recurrence rate of acute biliary pancreatitis after an initial episode, and the time to relapse, as well as to identify the risk factors for recurrence. MATERIAL AND METHOD: We included all patients admitted for a first acute gallstone pancreatitis event during four years. Primary endpoints included readmission for recurrence and time to relapse. RESULTS: We included 296 patients admitted on a total of 386 occasions. The incidence of acute biliary pancreatitis in our setting is 17.5/100,000 population/year. In all, 19.6% of pancreatitis were severe (22.6% of severe acute pancreatitis for first episodes versus 3.6% for recurring pancreatitis), with an overall mortality of 4.4%. Overall recurrence rate was 15.5%, with a median time to relapse of 82 days. In total, 14.2% of patients relapsed after an acute pancreatitis event without cholecystectomy or endoscopic retrograde cholangio-pancreatography. Severe acute pancreatitis recur in 7.2% of patients, whereas mild cases do so in 16.3%, this being the only risk factor for recurrence thus far identified. CONCLUSIONS: Patients admitted for pancreatitis should undergo cholecystectomy as soon as possible or be guaranteed priority on the waiting list. Otherwise, endoscopic retrograde cholangio-pancreatography with sphincterotomy may be an alternative to surgery for selected patients.

Prospective registry of severe polytrauma. Analysis of 1200 patients.

INTRODUCTION: Polytrauma continues to be one of the main causes of death in the population between 10-40 years of age, and causes severe discapability in surviving patients. The aim of this study is to perform an analysis of the quality of care of the polytrauma patient using an epidemiological study. METHOD: Prospective registry of all polytrauma patients treated at our hospital over 16 years of age, admitted to the critical care area or dead before admission. RESULTS: From March 2006 to August 2014, we registered 1200 polytrauma patients. The majority were men (75%) with a median age of 45. The mean ISS was 20,9±15,8 and the most common mechanism of injury was blunt trauma (94% cases), The global mortality rate was 9.8% (117 cases), and neurological death was the most frequent cause (45.3%), followed by hypovolemic shock (29,1%). In 17 cases (14,5% of deaths) mortality was considered evitable or potentially evitable, A total of 327 patients (27.3%) needed emergency surgery and 106 patients (8,8%) needed emergency treatment using interventional radiology. 18,5% of patients (222) presented an inadverted injury, with a total of 318 inadverted injuries. CONCLUSION: Trauma care at our centre is adequate. A prospective registry of the global care of polytrauma patients is necessary to evaluate the quality of care and improve results.

Development and pilot study of an essential set of indicators for general surgery services. / Desarrollo y estudio piloto de un conjunto esencial de indicadores para los servicios de cirugía general.

INTRODUCTION: At present there is a lack of appropriate quality measures for benchmarking in general surgery units of Spanish National Health System. The aim of this study is to present the selection, development and pilot-testing of an initial set of surgical quality indicators for this purpose. METHODS: A modified Delphi was performed with experts from the Spanish Surgeons Association in order to prioritize previously selected indicators. Then, a pilot study was carried out in a public hospital encompassing qualitative analysis of feasibility for prioritized indicators and an additional qualitative and quantitative three-rater reliability assessment for medical record-based indicators. Observed inter-rater agreement, prevalence adjusted and bias adjusted kappa and non-adjusted kappa were performed, using a systematic random sample (n=30) for each of these indicators. RESULTS: Twelve out of 13 proposed indicators were feasible: 5 medical record-based indicators and 7 indicators based on administrative databases. From medical record-based indicators, 3 were reliable (observed agreement >95%, adjusted kappa index >0.6 or non-adjusted kappa index >0.6 for composites and its components) and 2 needed further refinement. CONCLUSIONS: Currently, medical record-based indicators could be used for comparison purposes, whilst further research must be done for validation and risk-adjustment of outcome indicators from administrative databases. Compliance results in the adequacy of informed consent, diagnosis-to-treatment delay in colorectal cancer, and antibiotic prophylaxis show room for improvement in the pilot-tested hospital.

Surgical electronic logbook: A step forward.

INTRODUCTION: The surgical electronic logbook (surgical e-logbook) aims to: simplify registration of the training activities of surgical residents, and to obtain reliable and detailed reports about these activities for resident evaluation. METHODS: The surgical e-logbook is a unique and shared database. Residents prospectively record their activities in 3 areas: surgical, scientific and teaching. We can access activity reports that are constantly updated. RESULTS: Study period using the surgical e-logbook: Between June 2011 and May 2013. Number of surgeries reported: 4,255. Number of surgical procedures reported: 11,907. Number of surgeries per resident per year reported: 250. Number of surgical procedures per resident per year reported: 700. Surgical activity as a primary surgeon during the first year of residency is primarily in emergency surgery (68,01%) and by laparotomy (97,73%), while during the fifth year of residency 51,27% is performed in elective surgery and laparoscopy is used in 23,10% of cases. During this period, residents participated in a total of 11 scientific publications, 75 conference presentations and 69 continuing education activities. CONCLUSIONS: The surgical e-logbook is a useful tool that simplifies the recording and analysis of data about surgical and scientific activities of the residents. It is a step forward in the evaluation of the training of surgical residents, however, is only an intermediate step towards the development of a larger Spanish registry.

[Validation of abdominal wound dehiscence's risk model]. / Validación de un modelo de riesgo de evisceración.

INTRODUCTION: The aim of this study is to determine the usefulness of the risk model developed by van Ramshorst et al., and a modification of the same, to predict the abdominal wound dehiscence's risk in patients who underwent midline laparotomy incisions. MATERIALS AND METHODS: Observational longitudinal retrospective study. SAMPLE: Patients who underwent midline laparotomy incisions in the General and Digestive Surgery Department of the Sabadell's Hospital-Parc Taulí's Health and University Corporation-Barcelona, between January 1, 2010 and June 30, 2010. Dependent variable: Abdominal wound dehiscence. INDEPENDENT VARIABLES: Global risk score, preoperative risk score (postoperative variables were excluded), global and preoperative probabilities of developing abdominal wound dehiscence. SAMPLE: 176 patients. Patients with abdominal wound dehiscence: 15 (8.5%). The global risk score of abdominal wound dehiscence group (mean: 4.97; IC 95%: 4.15-5.79) was better than the global risk score of No abdominal wound dehiscence group (mean: 3.41; IC 95%: 3.20-3.62). This difference is statistically significant (P<.001). The preoperative risk score of abdominal wound dehiscence group (mean: 3.27; IC 95%: 2.69-3.84) was better than the preoperative risk score of No abdominal wound dehiscence group (mean: 2.77; IC 95%: 2.64-2.89), also a statistically significant difference (P<.05). The global risk score (area under the ROC curve: 0.79) has better accuracy than the preoperative risk score (area under the ROC curve: 0.64). CONCLUSION: The risk model developed by van Ramshorst et al. to predict the abdominal wound dehiscence's risk in the preoperative phase has a limited usefulness. Additional refinements in the preoperative risk score are needed to improve its accuracy.

Barrett's esophagus and esophageal cancer after sleeve gastrectomy. Myth or reality?

Sleeve gastrectomy has become the most performed bariatric surgery technique in the world. This bariatric technique has been related to the appearance of gastroesophageal reflux and recently with de novo Barrett's esophagus. It is not clear that this leads to an increased incidence of esophageal adenocarcinoma. In this review we analyze the current scientific literature to try to answer the true incidence of Barrett's esophagus and adenocarcinoma after sleeve gastrectomy, and whether these data should make us change the indications for this technique.

Alterations in tissue oxygen saturation measured by near-infrared spectroscopy in trauma patients after initial resuscitation are associated with occult shock.

PURPOSE: Persistent occult hypoperfusion after initial resuscitation is strongly associated with increased morbidity and mortality after severe trauma. The objective of this study was to analyze regional tissue oxygenation, along with other global markers, as potential detectors of occult shock in otherwise hemodynamically stable trauma patients. METHODS: Trauma patients undergoing active resuscitation were evaluated 8 h after hospital admission with the measurement of several global and local hemodynamic/metabolic parameters. Apparently hemodynamically stable (AHD) patients, defined as having SBP ≥ 90 mmHg, HR < 100 bpm and no vasopressor support, were followed for 48 h, and finally classified according to the need for further treatment for persistent bleeding (defined as requiring additional red blood cell transfusion), initiation of vasopressors and/or bleeding control with surgery and/or angioembolization. Patients were labeled as "Occult shock" (OS) if they required any intervention or "Truly hemodynamically stable" (THD) if they did not. Regional tissue oxygenation (rSO2) was measured non-invasively by near-infrared spectroscopy (NIRS) on the forearm. A vascular occlusion test was performed, allowing a 3-min deoxygenation period and a reoxygenation period following occlusion release. Minimal rSO2 (rSO2min), Delta-down (rSO2-rSO2min), maximal rSO2 following cuff-release (rSO2max), and Delta-up (rSO2max-rSO2min) were computed. The NIRS response to the occlusion test was also measured in a control group of healthy volunteers. RESULTS: Sixty-six consecutive trauma patients were included. After 8 h, 17 patients were classified as AHD, of whom five were finally considered to have OS and 12 THD. No hemodynamic, metabolic or coagulopathic differences were observed between the two groups, while NIRS-derived parameters showed statistically significant differences in Delta-down, rSO2min, and Delta-up. CONCLUSIONS: After 8 h of care, NIRS evaluation with an occlusion test is helpful for identifying occult shock in apparently hemodynamically stable patients. LEVEL OF EVIDENCE: IV, descriptive observational study. TRIAL REGISTRATION: ClinicalTrials.gov Registration Number: NCT02772653.

[Measurement of lactic acid in multiple injury patients and its usefulness as a predictor of multiorgan failure and mortality]. / Medición del ácido láctico en pacientes politraumatizados y su utilidad como factor predictor de mortalidad y fallo multiorgánico.

INTRODUCTION: The use of lactic acid as marker of occult hyperfusion and its relationship with multiorgan failure (MOF) and/or mortality is a subject of debate. MATERIAL AND METHOD: A prospective study was conducted on multiple injury patients over 16 years of age in critical care areas. The lactic acid was measured at the beginning and at 24 hours of the trauma and associating it with the patient morbidity and mortality. RESULTS: A total of 342 patients, with a mean injury severity score of 24.1, were included. The patients who survived had an initial, and 24 hours after the trauma, lactic acid of 27.8 mg/dl and 17.9 mg/dl, respectively, (normal values less than 22 mg/dl), increasing to 36.5mg/dl and 40.2mg/dl, respectively, in those who died. There were no differences between the initial lactic acid in patients with and without MOF, being increased at 24 hours in those who had MOF (17.8 vs 26.7). The patients with a lactic acid that got worse or remained abnormal at 24 hours had a higher mortality than those in which it remained the same or improved (25% - 17.1% vs 6.3% - 0.8%), with the percentage of patients with MOF also increasing (40.6% - 32.8% vs 14.9% - 11.1%). In haemodynamically stable patients, there was also a higher mortality when the lactic acid got worse or remained abnormal in the first 24 hours (23.8% - 19.2% vs 8.8% - 0%), as well as a higher percentage of MOF (38.1% - 26.9% vs 10.9% - 7.6%). CONCLUSIONS: The lactic acid results in the first 24 hours of the multiple injury patient are associated with mortality and MOF, even when the patient is haemodynamically stable.

Is percutaneous cholecystostomy safe and effective in acute cholecystitis? Analysis of adverse effects associated with the technique.

INTRODUCTION: The main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure. MATERIAL AND METHOD: Observational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy. RESULTS: Of 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%). CONCLUSION: We consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment.

Consequencies of therapeutic decision-making based on FAST results in trauma patients with pelvic fracture.

INTRODUCTION: FAST is essential to decide whether trauma patients need laparotomy, but it has a notable decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture. METHODS: Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who died. The FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables. RESULTS: Over the 13-year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs 14%, P < .05). Patients with positive FAST died more than negative FAST (43% vs 26%); and 4 out of 10 hemodynamically unstable patients who underwent non-therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis. CONCLUSION: FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduced notably by applying preperitoneal packing.

Is percutaneous cholecystostomy safe and effective in acute cholecystitis? Analysis of adverse effects associated with the technique. / ¿Es segura y eficaz la colecistostomía percutánea en la colecistitis aguda? Análisis de los efectos adversos asociados a la técnica.

INTRODUCTION: The main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure. MATERIAL AND METHOD: Observational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy. RESULTS: Of 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%). CONCLUSION: We consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment.

Aprendizaje basado en la simulación: valoración de los objetivos docentes en un programa de abdomen agudo y oclusión intestinal en cirugía general / Simulation-based learning: assessment of the teaching objectives in a program of acute abdomen and intestinal occlusion in general surgery, in medicine degree students

Introducción y objetivo: Analizar el logro de los objetivos docentes desarrollados durante el escenario de los casos de simulación a través de la valoración del profesor, los participantes observadores y quien realiza la propia simulación. Sujetos y métodos: Estudio observacional, prospectivo, descriptivo y unicéntrico, realizado con estudiantes de tercer curso de Medicina de la Universitat Autònoma de Barcelona. Se evalúan los objetivos docentes para cada caso clínico simulado por parte de los estudiantes que realizan la simulación, los observadores y el profesor. La evaluación numérica sigue una escala de tipo escala visual analógica y la categórica los clasifica en conseguidos, parcialmente conseguidos y no conseguidos. El estado nervioso y la comodidad de los alumnos también se evalúan numéricamente. Resultados: Se ha registrado la valoración de los objetivos de 929 participantes. La evaluación de los objetivos tiene un valor medio superior a 7 para cada uno de ellos. Existe una diferencia de 1,5-2 puntos en la valoración media entre el primer caso y el último, y no hay ningún alumno que no consiga los objetivos en el último caso. Se describe un estado de nervios alrededor de 4,5 y de comodidad alrededor de 7, sin diferencias entre los distintos evaluadores. Conclusiones: El logro de los objetivos se consigue de forma notable. Entre el primer caso y el último existe una significativa diferencia en el grado de obtención de los objetivos. No hay una relación entre el estado emocional de los participantes y la consecución de los objetivos.(AU)

Introduction and aim: To analyze the achievement of the educational objectives developed during the scenario of the simulation cases through the assessment of the teacher, the observer participants and the person who performs the simulation itself. Subjects and methods: Observational, prospective, descriptive and single-center study, carried out with 3rd year Medicine students at the Universitat Autònoma de Barcelona. The teaching objectives for each simulated clinical case are evaluated by the students who carry out the simulation, the observers and the teacher. The numerical evaluation follows a VAS-type scale and the categorical one classifies them as achieved, partially achieved and not achieved. The nervous state and comfort of the students are also evaluated numerically. Results: The evaluation of the objectives of 929 participants has been registered. The evaluation of the objectives has an average value greater than 7 for each one of them. There is a difference of 1.5-2 points in the average assessment between the first case and the last, with no student not achieving the objectives in the last case. A state of nerves around 4.5 and comfort around 7 is described, with no differences between the different evaluators. Conclusions: The achievement of the objectives is achieved in a remarkable way. Between the first case and the last, there is a significant difference in the degree of achievement of the objectives. There is no relationship between the emotional state of the participants and the achievement of the objectives.(AU)

The use of the Shock Index as a predictor of active bleeding in trauma patients. / Aplicación del Shock Index como predictor de hemorragia en el paciente politraumático.

INTRODUCTION: Vital signs indicate the presence of bleeding only after large amounts of blood have been lost, with high morbidity and mortality. The Shock Index (SI) is a hemorrhage indicator with a cut-off point for the risk of bleeding at 0.9. The aim of this study is to assess whether a cut-off of≥0.8 is more sensitive for detecting occult bleeding, providing for early initiation of therapeutic maneuvers. METHODS: SI analytical validation study of severe trauma patients older than 16 years of age. Vital signs were recorded, and scales for predicting bleeding included: SI, Assessment of Blood Consumption score, and Pulse Rate Over Pressure score. The relationship between the SI and 5 markers for bleeding was analyzed: need for massive transfusion, angiographic embolization, surgical bleeding control, death due to hypovolemic shock, and the overall predictor «active bleeding¼ (defined as the presence of at least one of the 4 markers above). RESULTS: Data from 1.402 trauma patients were collected prospectively over a period of 10 years. The mean Injury Severity Score was 20.9 (SD 15.8). The mortality rate was 10%. The mean SI was 0.73 (SD 0.29). «Active bleeding¼ was present in 18.7% of patients. The SI area under the ROC curve for «active bleeding¼ was 0.749. CONCLUSIONS: An SI cut-off point≥0.8 is more sensitive than≥0.9 and allows for earlier initiation of resuscitation maneuvers in patients with occult active bleeding.

¿Es segura y eficaz la colecistostomía percutánea en la colecistitis aguda? Análisis de los efectos adversos asociados a la técnica / Is percutaneous cholecystostomy safe and effective in acute cholecystitis? Analysis of adverse effects associated with the technique

IntroducciónEl objetivo principal de nuestro estudio es valorar la seguridad y la eficacia de la colecistostomía percutánea para el tratamiento de la colecistitis aguda determinando la incidencia de efectos adversos que presentan los pacientes sometidos a este procedimiento.Material y métodoEstudio observacional con inclusión consecutiva de todos los pacientes con diagnóstico de colecistitis aguda durante 10 años. La variable principal estudiada ha sido la morbilidad (efectos adversos) recogida de forma prospectiva. Seguimiento mínimo de un año de los pacientes sometidos a colecistostomía percutánea.ResultadosDe 1.223 pacientes ingresados por colecistitis aguda, 66 pacientes han precisado colecistostomía percutánea. El 21% de estos han presentado algún efecto adverso, con un total de 22 efectos adversos. Tan solo 5 de estos efectos, presentados por 5 pacientes (7,6%), han podido ser atribuidos al propio drenaje vesicular. La mortalidad asociada a la técnica es del 1,5%. Tras la colecistostomía un tercio de los pacientes (22 pacientes) han sido sometidos a colecistectomía. Se ha realizado intervención quirúrgica urgente por fracaso del tratamiento percutáneo en 2 pacientes, y diferida en otros 2 pacientes por recidiva del proceso inflamatorio. El resto de los pacientes colecistectomizados han sido intervenidos de forma programada pudiéndose llevar a cabo el procedimiento de forma laparoscópica en 16 pacientes (72,7%) ConclusiónConsideramos la colecistostomía percutánea como técnica segura y eficaz por relacionarse con una baja incidencia de morbimortalidad, debiéndose considerar como alternativa puente o definitiva en aquellos pacientes no tributarios de colecistectomía urgente tras fracaso del tratamiento conservador con antibiótico (AU)

IntroductionThe main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure.Material and methodObservational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy.ResultsOf 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%).ConclusionWe consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment (AU)

Gastrointestinal stromal tumors: experience in 49 patients.

INTRODUCTION: Gastrointestinal stromal tumours (GIST) are mesenchymal tumours of the digestive tract originated in the interstitial cells of Cajal. They express the tyrosine kinase c-kit (CD117) activity receptor. Mutations in this receptor cause neoplastic development. Curative treatment continues to be radical resection of the tumour and is resistant to commonly employed chemotherapy regimens. Imatinib mesilate is a drug that inhibits c-kit activity expressed by GIST and its activity in these tumours has been demonstrated. MATERIAL AND METHODS: Retrospective study of all cases of leiomyoma, leiomyosarcoma, schwannoma, and stromal or mesenchymal tumors from 1989 to July 2004. C-kit and CD34 proteins were detected at immunohistochemical study in addition to the usual markers for mesenchymal tumours. RESULTS: 49 GISTs were diagnosed, 26 males and 23 females (mean age 64.1). Symptoms were digestive tract bleeding (n = 13), abdominal pain (n = 13), intestinal occlusion (n = 4) and others. The lesion was located in small bowel (n = 22), stomach (n = 19), rectum (n = 3), peritoneum (n = 2), esophagus (n = 1), omentum (n = 1), and retroperitoneum (n = 1). Forty-three of the 49 patients underwent surgery; radical resection was performed in 37 (75.5%) and palliative surgery in the other six (16.2%). Two of the patients that did not undergo surgery received chemotherapy. At the time of study, 28 (57.14%) patients remained alive, 23 (46.9%) of whom were disease- free and five (10.2%) were not. Nineteen (38.7%) patients died. CONCLUSIONS: The results of our series are similar to the others published. Before the year 2001, surgery was the only successful option for the GIST. Surgical resection continues being the best treatment to definitively cure this disease. Imatinib is used to treat not only resectable tumours, but even to allow the possibility to make a subsequent rescue surgery. On the other hand, Imatinib is used in the treatment of the metastatic disease.

Consecuencias de la toma de decisiones terapéuticas con base en el resultado del FAST en pacientes politraumáticos con fractura pélvica / Consequencies of therapeutic decision-making based on FAST results in trauma patients with pelvic fracture

Introducción: La exactitud del FAST disminuye notablemente en los pacientes politraumáticos con fractura pélvica. El objetivo es analizar las consecuencias de tomar decisiones terapéuticas basadas en el resultado del FAST en los pacientes politraumáticos con fractura de pelvis. Métodos: Estudio descriptivo de pacientes con politraumatismos mayores de 16 años que han ingresado en el área de críticos o que han fallecido previamente, con fractura pélvica. El resultado del FAST ha sido comparado con un valor realmente positivo o negativo según el resultado de la laparotomía o de la tomografía computarizada.Resultados: En 13 años, se ha incluido a 263 pacientes politraumáticos con fractura pélvica (ISS medio de 31; mortalidad 19%). El FAST tenía una sensibilidad del 65,2%, una especificidad del 69%, una tasa de falsos negativos del 34,8% y una tasa de falsos positivos del 30,9%. Los pacientes hemodinámicamente inestables tenían el doble de mortalidad que los pacientes estables (27% vs. 14%, p <0,05). Los pacientes con un FAST positivo tenían mayor mortalidad que los pacientes con FAST negativo (43% vs. 26%); 4 de 10 pacientes hemodinámicamente inestables con un FAST falsamente positivo que se sometieron a laparotomía exploradora innecesaria murieron por shock hipovolémico. La mortalidad se redujo del 60 al 20% asociando un packing preperitoneal. Conclusiones: La reducida eficacia del FAST en pacientes con fractura de pelvis nos obliga a cuestionarnos las consecuencias de la toma de decisiones terapéuticas con base en sus resultados. Los pacientes con FAST falsamente positivo tienen una mortalidad mayor, que se puede reducir aplicando un packing preperitoneal. (AU)

Introduction: FAST is essential to decide if trauma patients need laparotomy, but has a notably decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture. Methods: Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who were fallecimiento. FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables. Results: Over the 13–year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs. 14%, p <0.05). Patients with positive FAST died more than negative FAST (43% vs. 26%); and 4 of 10 hemodynamically unstable patients who underwent non therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis. Conclusion: FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduce notably applying a preperitoneal packing. (AU)

Aplicación del Shock Index como predictor de hemorragia en el paciente politraumático / The use of the Shock Index as a predictor of active bleeding in trauma patients

INTRODUCCIÓN: Las constantes vitales detectan la presencia de hemorragia al perder grandes cantidades de sangre, lo que comporta una gran morbimortalidad. El Shock Index (SI) es un parámetro que detecta el sangrado con puntos de corte de 0,9. El objetivo de este estudio es valorar si un punto de corte de ≥ 0,8 es más sensible para detectar sangrado oculto, permitiendo iniciar maniobras terapéuticas más precoces. MÉTODOS: Estudio analítico de validación del SI que incluye pacientes politraumatizados graves mayores de 16 años. Se registran constantes vitales y escalas predictivas de sangrado: SI, Assessment of Blood Consumption score y Pulse Rate Over Pressure score. Se analiza la relación del SI con 5 marcadores predictivos de sangrado: necesidad de transfusión masiva, embolización angiográfica, control del sangrado quirúrgico, muerte por shock hipovolémico y "sangrado activo" (presencia de al menos uno de los 4 marcadores anteriores en un paciente). RESULTADOS: Recogida prospectiva de datos de 1.402 pacientes politraumatizados durante 10 años. El Injury Severity Score medio fue de 20,9 (DE 15,8). Hubo una mortalidad del 10%. El SI medio fue de 0,73 (DE 0,29). En total presentaron "sangrado activo" el 18,7% de la serie. El SI medio en los pacientes con "sangrado activo" fue de 0,87, mientras que las constantes vitales estaban dentro de la normalidad. El área bajo la curva ROC del SI para el "sangrado activo" fue de 0,749. CONCLUSIONES: El SI con un punto de corte ≥ 0,8 es más sensible que aquel con el punto de corte ≥ 0,9 y permite iniciar maniobras de reanimación más precoces en los pacientes con sangrado oculto

INTRODUCTION: Vital signs indicate the presence of bleeding only after large amounts of blood have been lost, with high morbidity and mortality. The Shock Index (SI) is a hemorrhage indicator with a cut-off point for the risk of bleeding at 0.9. The aim of this study is to assess whether a cut-off of ≥ 0.8 is more sensitive for detecting occult bleeding, providing for early initiation of therapeutic maneuvers. METHODS: SI analytical validation study of severe trauma patients older than 16 years of age. Vital signs were recorded, and scales for predicting bleeding included: SI, Assessment of Blood Consumption score, and Pulse Rate Over Pressure score. The relationship between the SI and 5 markers for bleeding was analyzed: need for massive transfusion, angiographic embolization, surgical bleeding control, death due to hypovolemic shock, and the overall predictor "active bleeding" (defined as the presence of at least one of the 4 markers above). RESULTS: Data from 1.402 trauma patients were collected prospectively over a period of 10 years. The mean Injury Severity Score was 20.9 (SD 15.8). The mortality rate was 10%. The mean SI was 0.73 (SD 0.29). "Active bleeding" was present in 18.7% of patients. The SI area under the ROC curve for "active bleeding" was 0.749. CONCLUSIONS: An SI cut-off point ≥ 0.8 is more sensitive than ≥ 0.9 and allows for earlier initiation of resuscitation maneuvers in patients with occult active bleeding