Incidental versus non-incidental thyroid carcinoma: Clinical presentation, surgical management and prognosis. / Carcinoma de tiroides incidental versus no incidental: presentación clínica, tratamiento quirúrgico y pronóstico.

BACKGROUND AND OBJECTIVE: Thyroid cancer may be clinically evident as a tumor mass in the neck or as a histopathological incidental finding after thyroid surgery for an apparent benign condition. Our objective was to assess the differences in clinical signs, surgical management, and course between incidental and clinically diagnosed thyroid tumors. METHODS: A retrospective study was conducted on patients operated on for benign or malignant thyroid disease from January 2000 to March 2014. Among the 1415 patients who underwent any thyroid surgery, 264 neoplasms were found, of which 170 were incidental. A comparison was made of incidental versus non-incidental carcinomas. Among incidental carcinomas, cases whose indication for surgery was Graves' disease were compared to those with multinodular goiter. RESULTS: Incidental carcinomas were in earlier stages and required less aggressive surgery. There were no differences in surgical complications between incidental and clinical tumors, but mortality and relapses were markedly higher in non-incidental cancers (4.4% vs 0% and 13.2% vs 4.8% respectively). Carcinomas developing on Graves' disease showed no differences from all other incidental tumors in terms of complications, mortality, or relapse after surgery. CONCLUSIONS: Early stage thyroid cancer has better survival and prognosis after surgical treatment.

Emergency endoscopy for gastrointestinal bleeding after bariatric surgery. Therapeutic algorithm.

OBJECTIVE: Gastrointestinal bleeding (GB) is a potential complication after bariatric surgery and its frequency is around 2-4% according to the literature. The aim of this study is to present our experience with GB after bariatric surgery, its presentation and possible treatment options by means of an algorithm. PATIENTS AND METHOD: From January 2004 to December 2012, we performed 300 consecutive laparoscopic bariatric surgeries. A total of 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of a gastrojejunal anastomosis using a circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. Demographics, clinical presentation, diagnostic evaluation and treatment were reviewed. A total of 20 patients underwent a sleeve gastrectomy. RESULTS: Twenty-seven cases (9%) developed GB. Diagnosis and therapeutic endoscopy was required in 13 patients. The onset of bleeding occurred between the 1(st)-6(th) postop days in 10 patients, and the origin was at the gastrojejunostomy staple-lines, and 3 patients had bleeding from an anastomotic ulcer 15-20 days after surgery. All other patients were managed non-operatively. CONCLUSION: Conservative management of gastrointestinal bleeding is effective in most cases, but endoscopy with therapeutic intent should be considered in patients with severe or recurrent bleeding. Multidisciplinary postoperative follow- up is very important for early detention and treatment of this complication.

Gastrojejunal anastomotic stenosis after laparoscopic gastric bypass. Experience in 280 cases in 8 years.

OBJECTIVE: Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass, but its frequency is about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass. PATIENTS AND METHOD: From January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis is performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation. RESULTS: Twenty cases (7.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and all case were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up has not been detected re-stricture. CONCLUSION: Structure at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.

[Complications and level of satisfaction after dermolipectomy and abdominoplasty post-bariatric surgery]. / Complicaciones y nivel de satisfacción tras la realización de una dermolipectomía y abdominoplastia después de efectuar una cirugía bariátrica.

BACKGROUND: Body contouring surgery is in high demand following the increase in bariatric surgery. But these types of procedures are associated with high complication rates that cause long hospital stays and have a negative effect on patient satisfaction. The purpose of this study is to identify predictors of complications in order to optimize outcomes in these patients and find a relationship between complication rate and satisfaction. MATERIAL AND METHODS: Out of a group of 175 post-bariatric patients, 72 patients underwent body contouring surgery following massive weight loss from 2003-2008. They were reviewed retrospectively for demographic data, pre- and postoperative weight status, co-morbidities and complications and reoperation rate. Patient satisfaction was evaluated. RESULTS: a) COMPLICATIONS: The overall complication rate was 45.8%. The most frequent were seromas (23.6%); infection (13.9%), bleeding (11.1%), hematoma (6.9%) (needing transfusions [6.9%]), skin necrosis (6.9%) and umbilical necrosis (4.2%). A total of 8 patients required reoperation (11.1%). b) Satisfaction rating: 1) very satisfied: 51.4%, 2) satisfied: 31.9%, 3) dissatisfied: 8.3%, 4) very dissatisfied: 8.3%. c) The presence of complications was significantly associated with patients' satisfaction, reoperation rate and longer hospital stays (P<.001). CONCLUSIONS: Post operative complications were frequent. No predictors could be found to prevent these complications and optimize patient selection and appropriate timing of surgery. Patients with complications had a significantly higher reoperation rate, longer hospital stay and more dissatisfaction. The patients' satisfaction was negatively influenced by complication occurrence and not by the aesthetic results.

Unnoticed small bowel perforation as a complication of lumbar discectomy.

BACKGROUND CONTEXT: Surgery for disc herniation is one of the most common traumas and neurosurgical procedures. Although discectomy has low morbidity, serious intra-abdominal complications can affect retroperitoneal structures, such as the large vessels, small intestine, and ureters. CASE REPORT: A 36-year-old woman in uncontrollable pain presented with left sciatic neuralgia in the L5 region. Magnetic resonance imaging revealed an extruded left paracentral hernia at L5-S1. With the patient in the decubitus prone position, trauma surgeons specializing in spine surgery performed an L5-S1 flavectomy and a simple discectomy. Intraoperative complications were not observed. About 4 hours after surgery, the patient reported sharp abdominal pain and had persistent hypotension. Emergency abdominal computed tomography showed hemoperitoneum in the pouch of Douglas and left parietocolic space. Laparoscopic exploration confirmed hemoperitoneum without visible cause, a seton perforation of the small intestine, and a few adhesions in the right iliac fossa that were consequences of previous appendectomy. A laparotomy was then performed. A lesion was discovered in the mesentery of the rectosigmoid junction coinciding with the S5-L1 space. A segmental bowel resection and mechanical side-to-side anastomosis, with drainage, were done. The patient recovered satisfactorily despite a surgical wound infection. DISCUSSION: Although bowel perforation after discectomy rarely occurs, spine surgeons must try to prevent them by being more cautious during surgery. General surgeons must be highly suspicious of the presence of an intra-abdominal complication when there are signs and symptoms of a postoperative acute abdomen.

Evaluation and monitoring of the clinical pathway for thyroidectomy.

The aim of this study is to present the evaluation and monitoring of a clinical pathway for thyroidectomy 1 year after its implementation and after 4 years' follow up. We compare the results of an evaluation and monitoring indicators series before and after the establishment of the clinical pathway for thyroidectomy in the Surgery Department of Morales Meseguer Hospital, a general university hospital in Murcia, Spain. Implementation of the clinical pathway led to a reduction in length of hospital stay for all the surgery patients (4.8 +/- 2.1 and 3.6 +/- 1.9 days before and after pathway implementation, respectively; P < 0.001). Implementation of the clinical pathway led to a reduction in cost in all the operated patients (3357 +/- 966 and 2695 +/- 970 US$ before and after implementing the clinical pathway, respectively; P < 0.001). Evolution of the mean hospital cost according to year of study shows a reduction from 2000 (3400 +/- 1056 US$) to 2004 (2404 +/- 666 US$) with a slight increase during 2005 (2721 +/- 1335 US$) (P < 0.001). Implementation of the clinical pathway for thyroidectomy has successfully reduced clinical variation and therefore the length of hospital stay and mean cost of the process. In subsequent years, no such major improvements have been made with regard to hospital stay, although they are still clearly better than those before pathway implementation.

[Evaluation of a clinical pathway for laparoscopic cholecystectomy]. / Evaluación de la vía clínica de la colecistectomía laparoscópica.

INTRODUCTION: Clinical pathways are standardized plans for the integral care of specific processes. In March 2002, a clinical pathway for laparoscopic cholecystectomy was introduced in our service. The aim of the present study was to evaluate this pathway 1 year after its implementation. METHODOLOGY: All patients included in the clinical pathway since its introduction were studied. Evaluation criteria included compliance, indicators of the effectiveness of clinical care, economic impact and indicators of satisfaction based on a survey. The results were compared with those in a series of patients who underwent surgery in the year before the introduction of the clinical pathway. Our hospital uses analytical accounting and the mean cost per process before and after the introduction of the clinical pathway was analyzed. RESULTS: A series of 160 consecutive patients who underwent surgery during the year prior to the creation of the clinical pathway and who fulfilled the accepted inclusion criteria was evaluated. The mean length of hospital stay was 3.27 days. The mean cost per process before the introduction of the pathway was 2149 (+/- 768) euros. During the first year after the introduction of the pathway, 140 patients were included with an inclusion rate of 100%. The mean length of hospital stay in patients included in the clinical pathway was 2.2 days. The degree of compliance with length of hospital stay was 66.7%. The most frequent causes of breach were staff-related, followed by patient-related (oral intolerance, pain, etc.). The mean cost in patients included in the clinical pathway was 1845 (+/- 618) euros. CONCLUSIONS: Laparoscopic cholecystectomy is a suitable process with which to initiate systematization of clinical pathways. The results show that length of hospital stay has been significantly reduced without increasing morbidity. Patient satisfaction has been high.