Indication, performance and outcomes of adrenal vein sampling in patients with primary hyperaldosteronism.

Primary hyperaldosteronism (PAH) is an important cause of secondary hypertension (HTN). The study of the same requires a high clinical suspicion in addition to a hormonal study that confirms hormonal hypersecretion. It is important to start the appropriate treatment once the diagnosis is confirmed, and for this is necessary to demonstrate whether the hormonal hypersecretion is unilateral (patients who could be candidates for surgical treatment) or bilateral (patients who are candidates for pharmacological treatment only). At the Hospital del Mar since 2016 there has been a multidisciplinary work team in which Nephrologists, Endocrinologists, Radiologists and Surgeons participate to evaluate cases with suspected hyperaldosteronism and agree on the best diagnostic-therapeutic approach for these patients, including the need for adrenal vein sampling, which is a technique that in recent years has become the gold standard for the study of PAH. In the present study we collect the experience of our centre in performing AVC and its usefulness for the management of these patients.

THERAPY OF ENDOCRINE DISEASE: Central neck dissection: a step forward in the treatment of papillary thyroid cancer.

Since its introduction in the '70s and '80s, CND for papillary cancer is here to stay. Compartment VI should always be explored during surgery for papillary thyroid carcinoma (PTC) for obvious lymph node metastases. These can be easily spotted by an experienced surgeon or, eventually, by frozen section. No doubt, obvious nodal disease in the Delphian, paratracheal and subithsmic areas should be dissected in a comprehensive manner (therapeutic central neck dissection), avoiding the selective removal of suspicious nodes. Available evidence for routine prophylactic CND is not completely satisfactory. Our group's opinion, however, is that it reduces or even eliminates the need for repeat surgery in the central neck, better defines the extent (and stage) of the disease and provides a further argument against routine radioiodine ablation. Thus, PTC is becoming more and more a surgical disease that can be cured by optimized surgery alone in the majority of cases. Prophylactic CND, however, involves a higher risk for the parathyroid function and should be skilfully performed, preferably only on the same side as the primary tumour and preserving the cervical portion of the thymus.

Obesity surgery mortality risk score for the prediction of complications after laparoscopic bariatric surgery.

INTRODUCTION: Morbimortality after bariatric surgery varies according to patient characteristics and associated comorbidities. The aim of this study was to evaluate the usefulness of the Obesity sugery mortality risk score scale (OS-MRS) to predict the risk of postoperative complications after bariatric surgery. METHODS: A retrospective study was performed of a prospective series of patients undergoing bariatric surgery in which the OS-MRS scale was applied preoperatively. Postoperative complications were classified as proposed by Dindo-Clavien. We analyzed the relationship between the categories of OS-MRS scale: A) low risk, B) intermediate risk, and C) high risk and the presence of complications. RESULTS: Between May 2008 and June 2012, 198 patients were included (85 [42.9%] after gastric bypass and 113 [57.1%] after sleeve gastrectomy). Using the OS-MRS scale, 124 patients were classified as class A (62.6%), 70 as class B (35.4%) and 4 as class C (2%). The overall morbidity rate was 12.6% (25 patients). A significant association between OS-MRS scale and rate of complications (7.3, 20 and 50%, respectively, P=.004) was demonstrated. The gastric bypass was associated with a higher complication rate than sleeve gastrectomy (P=.007). In multivariate analysis, OS-MRS scale and surgical technique were the only significant predictive factors. CONCLUSIONS: The OS-MRS scale is a useful tool to predict the risk of complications and can be used as a guide when choosing the type of bariatric surgery.

[Outpatient treatment of uncomplicated acute diverticulitis: Impact on healthcare costs]. / Tratamiento ambulatorio de la diverticulitis aguda no complicada: impacto sobre los costes sanitarios.

BACKGROUND: Outpatient treatment of uncomplicated acute diverticulitis is safe and effective. The aim of this study was to determine the impact of outpatient treatment on the reduction of healthcare costs. PATIENTS AND METHODS: A retrospective cohort study comparing 2 groups was performed. In the outpatient treatment group, patients diagnosed with uncomplicated acute diverticulitis were treated with oral antibiotics at home. In the hospital treatment group, patients met the criteria for outpatient treatment but were admitted to hospital and received intravenous antibiotic therapy. Cost estimates have been made using the hospital cost accounting system based on total costs, the sum of all variable costs (direct costs) plus overhead expenses divided by activity (indirect costs). RESULTS: A total of 136 patients were included, 90 in the outpatient treatment group and 46 in the hospital group. There were no differences in the characteristics of the patients in both groups. There were also no differences in the treatment failure rate in both groups (5.5% vs. 4.3%; P=.7). The total cost per episode was significantly lower in the outpatient treatment group (882 ± 462 vs. 2.376 ± 830 euros; P=.0001). CONCLUSIONS: Outpatient treatment of acute diverticulitis is not only safe and effective but also reduces healthcare costs by more than 60%.

[Multimodal rehabilitation program in elective colorectal surgery: Impact on hospital costs]. / Impacto de un programa de rehabilitación multimodal en cirugía electiva colorrectal sobre los costes hospitalarios.

INTRODUCTION: Multimodal rehabilitation (MMRH) programs in surgery have proven to be beneficial in functional recovery of patients. The aim of this study is to evaluate the impact of a MMRH program on hospital costs. METHOD: A comparative study of 2 consecutive cohorts of patients undergoing elective colorectal surgery has been designed. In the first cohort, we analyzed 134 patients that received conventional perioperative care (control group). The second cohort included 231 patients treated with a multimodal rehabilitation protocol (fast-track group). Compliance with the protocol and functional recovery after fast-track surgery were analyzed. We compared postoperative complications, length of stay and readmission rates in both groups. The cost analysis was performed according to the system «full-costing¼. RESULTS: There were no differences in clinical features, type of surgical excision and surgical approach. No differences in overall morbidity and mortality rates were found. The mean length of hospital stay was 3 days shorter in the fast-track group. There were no differences in the 30-day readmission rates. The total cost per patient was significantly lower in the fast-track group (fast-track: 8.107 ± 4.117 euros vs. control: 9.019 ± 4.667 Euros; P=.02). The main factor contributing to the cost reduction was a decrease in hospitalization unit costs. CONCLUSION: The application of a multimodal rehabilitation protocol after elective colorectal surgery decreases not only the length of hospital stay but also the hospitalization costs without increasing postoperative morbidity or the percentage of readmissions.

Technical hints and potential pitfalls in modified radical neck dissection for thyroid cancer.

Modified radical neck dissection (MRND) is often performed in conjunction with total thyroidectomy for the management of thyroid cancer. Prevention of postoperative sequelae after MRND is closely dependent on the avoidance of technical mistakes that may lead to significant complications and long-term morbidity. A thorough technical discussion with emphasis on potential pitfalls is made of the most relevant steps of MRND using the extrafascial approach: fascial dissection, approach to the accessory nerve, posterior limits, upper internal jugular vein (IJV), transverse cervical vessels, thoracic duct and compartment V dissection. Some anatomical hints are emphasized to help the novice surgeon to develop a refined surgical technique, the key to an uneventful postoperative course.