[Consensus of the ambulatory surgery commite section of the Spanish Association of Surgeons on the role of ambulatory surgery in the SARS-CoV-2 pandemic]. / Consenso de la sección de cirugía mayor ambulatoria de la Asociación Española de Cirujanos sobre el papel de la cirugía mayor ambulatoria en la pandemia SARS-CoV-2.

The current situation of the SARS-CoV-2 pandemic has paralyzed non-urgent and/or oncological surgery in many hospitals in our country with what it means for the health of citizens who are awaiting a surgical procedure. Outpatient Surgery can afford more than 85% of the surgical procedures that are performed in a surgical department and is presented as a feasible and safe alternative at the present time since it does not require admission and decreases clearly the risk of infection. In addition, it is the tool that should be generalized to solve the accumulation of patients on the waiting list that the pandemic is generating, so it seems appropriate that the Ambulatory Surgery section of the Spanish Association of Surgeons present a series of recommendations for the implementation of outpatient surgery in these exceptional circumstances that we have to live.

Towards the centralization of digestive oncologic surgery: changes in activity, techniques and outcome.

The purpose of our letter is to provide some feedback about the article published by C Tebé and collaborators*, as it addresses a topic of arduous debate, therefore, we feel it is important to put both our opinions and points of view forward.

Intraoperative peripheral nerve injury in colorectal surgery. An update.

Intraoperative peripheral nerve injury during colorectal surgery procedures is a potentially serious complication that is often underestimated. The Trendelenburg position, use of inappropriately padded armboards and excessive shoulder abduction may encourage the development of brachial plexopathy during laparoscopic procedures. In open colorectal surgery, nerve injuries are less common. It usually involves the femoral plexus associated with lithotomy position and self-retaining retractor systems. Although in most cases the recovery is mostly complete, treatment consists of physical therapy to prevent muscular atrophy, protection of hypoesthesic skin areas and analgesics for neuropathic pain. The aim of the present study is to review the incidence, prevention and management of intraoperative peripheral nerve injury.

General surgery training in Spain: core curriculum and specific areas of training.

The royal decree RD 639/2014 has been published, regulating among others, the core curriculum, and specific areas of training (SAT). It is of great interest for the specialty of General and Digestive Surgery (GS and DS). The aim is to expose and clarify the main provisions and reflect on their implications for the practical application of the core curriculum and SAT in the specialty of General and Digestive Surgery, to promote initiatives and regulations. This RD will be a milestone in our specialty that will test the strength of the specialty, if it does not finally culminate in its degradation against the emergence of new surgical specialties. A new stage begins in which the Spanish Association of Surgeons should be involved to define the conceptual basis of GS and DS in the XXI century, and the creation of new SAT to continue to maintain the "essence of our specialty".

DUCMA 2.0 project: Update on the current situation of the outpatient surgery units in Spain.

INTRODUCTION: Ambulatory surgery is a safe and efficient management system to solve surgical problems, but its implementation and development has been variable. The aim of this study is to describe the characteristics, structure and functioning of ambulatory surgery units (ASU) in Spain. METHODS: Multicenter, cross-sectional, observational study based on an electronic survey, with data collection between April and September 2022. RESULTS: In total, 90 ASUs completed the survey. The mean overall ambulatory index is 63%. More than half of the ASUs (52%) are integrated units. Around half of the units provide training for physicians (51%) and for nurses (55%). The most frequently used quality indicators are suspension rate (87%) and the rate of unplanned admissions (80%). CONCLUSIONS: Greater coordination between administrations is needed to obtain reliable data. It is also necessary to implement quality management systems in the different units, as well as to develop tools for the adequate training of the professionals involved.

Morbidity and mortality of emergency surgery in octogenarian patient.

OBJECTIVE: To evaluate the health outcomes (postoperative morbidity and mortality) and the functional status at discharge of elderly patients older than 80 years who underwent emergency surgery. METHOD: Patients > 80 years of age who underwent emergency surgery during one year at the Marqués de Valdecilla University Hospital, Santander, Spain. Preoperative data (age, sex, type of surgery, comorbidity) and postoperative data (complications) were evaluated, as well as in-hospital mortality, at 30 days and 6 months after surgery. RESULTS: Five-hundred-sixty-eight patients underwent emergency surgery between 2018 and 2019. After the review, 407 patients were included in the study. Average age: 86.9 years. Women 61.7%. Mean hospital stay: 10.4 days. Traumatic interventions 41.3%, vascular surgery 19.7%, general-digestive surgery 25.3%. Medium ASA risk: 2.88. Functional status at discharge: 3.15. Postoperative complications: Clavien-Dindo I 40.8%, II 40.3%, IIIA 3.4%, IIIB 2.5%, IVA 3.9%, IVB 2.0% and V 7.1%. Hospital mortality 7.1%, 30-day mortality 10.3%, mortality at 6 months 24.6%. CONCLUSIONS: Patients > 80 years of age undergoing urgent surgery have high preoperative comorbidity, postoperative complications, and high mortality at 30 days and 6 months after surgery. This mortality is more significant in those ASA IV, nonagenarians and those undergoing high-risk surgery.

OBJETIVO: Evaluar los resultados en salud (morbilidad y mortalidad posoperatorias) y el estado funcional al alta de los pacientes mayores de 80 años sometidos a cirugía de urgencia. MÉTODO: Pacientes de edad > 80 años sometidos a cirugía de urgencia durante 1 año en el Hospital Universitario Marqués de Valdecilla, Santander, España. Se evaluaron datos preoperatorios (edad, sexo, tipo de cirugía, comorbilidad) y posoperatorios (complicaciones), así como mortalidad hospitalaria, a los 30 días y a los 6 meses de la cirugía. RESULTADOS: En 2018-2019 fueron operados de urgencia 568 pacientes, de los cuales 407 fueron incluidos en el estudio. Edad media: 86.9 años. El 61.7% fueron mujeres. Estancia media hospitalaria: 10.4 días. El 41.3% fueron intervenciones traumatológicas, el 19.7% cirugía vascular, el 25.3% cirugía general-digestiva. Riesgo ASA medio: 2.88. Estado funcional al alta: 3.15. Complicaciones posoperatorias: Clavien-Dindo I 40.8%, II 40.3%, IIIA 3.4%, IIIB 2.5%, IVA 3.9%, IVB 2.0% y V 7.1%. Mortalidad: hospitalaria 7.1%, a los 30 días 10.3% y a los 6 meses 24.6%. CONCLUSIONES: Los pacientes > 80 años sometidos a cirugía urgente presentan elevada comorbilidad preoperatoria, complicaciones posoperatorias y elevada mortalidad a 30 días y 6 meses de la cirugía. Esta mortalidad es más significativa en los ASA IV, nonagenarios y sometidos a cirugía de alto riesgo.

Retrospective observational study correlating traumatic pelvic fractures and their associated injuries according to the Tile classification.

INTRODUCTION: Pelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification. METHODS: Retrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016. RESULTS: A total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P = .032), and Tile B with sacral fractures (P = .033) and visceral injuries (P = .049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock. CONCLUSIONS: Tile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.

Training in ambulatory surgery. A pending subject in our country.

The implementation and generalized use of Ambulatory Surgery worldwide is currently a clear reality. Its progressive growth is expected in the short term, but this globalization can also negatively affect the education and training of future doctors, as well as those who are being trained now, if it is not standardized and regulated, since a significant part of the management of the most common pathology that could be performed in Ambulatory Surgery is completed outside the training circuits of hospitals where resident doctors are trained.

Reaccreditation or recertification of general surgeons in Spain: That's the question. Results of a national survey.

INTRODUCTION: The Law for the Regulation of Health Professions (LOPS) indicates that health professionals will carry out continuous training throughout their professional life, and will regularly prove their professional competence. The objective of the study was to carry out a national survey to find out the opinion of Spanish surgeons and thus be able to prepare a recertification project by the Spanish Association of Surgeons. METHODS: Cross-sectional observational study carried out in June-July 2020, through a survey sent to the members of the Spanish Association of Surgeons. RESULTS: The survey had a total of 1230 visits and an overall completion rate of 784 responses (67.3%). 69.6% were unaware of the LOPS forecasts and 83.4% were unaware of similar initiatives in other specialties and 95.5% agreed to demand adequate information. 71.4% believed it necessary but only 57% believed that it should be mandatory. 82.9% would agree that it should be regulated through an objective and predictable official procedure. CONCLUSIONS: The concept of re-accreditation is not well known in our specialty and in view of the results obtained, adequate and reliable information seems necessary. Therefore, it would be pertinent to propose by the A.E.C. a specific project to assess activities and skills.

Consensus of the ambulatory surgery commite section of the Spanish Association of Surgeons on the role of ambulatory surgery in the SARS-CoV-2 pandemic.

The current situation of the SARS-CoV-2 pandemic has paralyzed non-urgent and/or oncological surgery in many hospitals in our country with what it means for the health of citizens who are awaiting a surgical procedure. Outpatient Surgery can afford more than 85% of the surgical procedures that are performed in a surgical department and is presented as a feasible and safe alternative at the present time since it does not require admission and decreases clearly the risk of infection. In addition, it is the tool that should be generalized to solve the accumulation of patients on the waiting list that the pandemic is generating, so it seems appropriate that the Ambulatory Surgery section of the Spanish Association of Surgeons present a series of recommendations for the implementation of outpatient surgery in these exceptional circumstances that we have to live.

Early laparoscopic cholecystectomy in oldest-old patients: a propensity score matched analysis of a nationwide registry.

The role of early laparoscopic cholecystectomy (ELC) in "oldest-old" patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study is to assess the safety of ELC for ACC in ≥ 85-year-old patients. Multicentric retrospective study that analysed data of patients who underwent ELC for ACC between 2013 and 2018. Patients ≥ 85-year-old (oldest-old patients) were compared with younger patients, before and after propensity score matching (PSM). The main outcomes were mortality, post-operative complications, length of stay (LOS), and readmissions. The study included 1670 patients. The unmatched comparison revealed a selection bias towards the oldest-old group, which was associated with higher Charlson Comorbidity Index (5 vs 1, p < 0.001), more ASA III/IV subjects (54.2% vs 19.3%, p < 0.001), class II/III ACC (80.1% vs 69.1%, p = 0.016) and higher Chole-Risk Score (p > 0.001). The oldest-old also required more conversion to open surgery (20% vs 10.3%, p = 0.005). Postoperatively, they had a higher 90-day mortality rate (7.6% vs 1%, p < 0.001), more total complications (40.6% vs 17.7%, p < 0.001), complications ≥ IIIa Clavien-Dindo (14.4% vs 5.8%, p = 0.002), longer LOS (6 vs 5 days, p < 0.001), and more readmissions (6.6% vs 2.6%, p < 0.001). After PSM (n = 206), the two groups were comparable in terms of baseline characteristics and intraoperative outcomes. No differences were observed in post-operative complications; bile leak; incisional, intrabdominal, urinary or respiratory tract infections; LOS or readmissions. In the oldest-old, ELC for ACC is still associated with significant morbidity and mortality. However, it seems to be safe in selected patients. Therefore, age itself should not be regarded as a contraindication to ELC for ACC.

Reaccreditation or recertification of general surgeons in Spain: That's the question. Results of a national survey. / Reacreditación o recertificación de los cirujanos generales en España: esa es la cuestión. Resultados de una encuesta nacional.

INTRODUCTION: The Law for the Regulation of Health Professions (LOPS) indicates that health professionals will carry out continuous training throughout their professional life, and will regularly prove their professional competence. The objective of the study was to carry out a national survey to find out the opinion of Spanish surgeons and thus be able to prepare a recertification project by the Spanish Association of Surgeons (AEC). METHODS: Cross-sectional observational study carried out in June-July 2020, through a survey sent to the members of the AEC. RESULTS: The survey had a total of 1230 visits and an overall completion rate of 784 responses (67.3%). 69.6% were unaware of the LOPS forecasts and 83.4% were unaware of similar initiatives in other specialties and 95.5% agreed to demand adequate information. 71.4% believed it necessary but only 57% believed that it should be mandatory. 82.9% would agree that it should be regulated through an objective and predictable official procedure. CONCLUSIONS: The concept of re-accreditation is not well known in our specialty and in view of the results obtained, adequate and reliable information seems necessary. Therefore, it would be pertinent to propose by the AEC a specific project to assess activities and skills.

Laparoscopic cholecystectomy for acute cholecystitis: is the surgery still safe beyond the 7-day barrier? A multicentric observational study.

Timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. This study assesses ELC for ACC with delayed presentation, according to hospital volume. Multicentric retrospective analysis of 1868 ELC. Patients were classified into two groups according to the timing of surgery from clinical onset and centre volume. Group 1 (G1) within the first 7 days, group 2 (G2) beyond that. Then centres were classified in low volume centres (LVC) and higher volume centres (HVC) according to the number of ELC performed per year. Overall, G2 showed increased conversion rate (17.7% vs 10.7%; p = 0.004), intraoperative complications (7.3% vs 2.9%; p = 0.001); postoperative haemorrhage (3.6% vs 0.8%; p < 0.001), infections (16.6% vs 9.3%; p = 0.003) and global complications (27.6% vs 19.8%; p = 0.011). HVC in comparison with LVC presented decreased conversion rate (17.1% vs 7.6%; p < 0.001), intraoperative bleeding (2.1% vs 1%; p = 0.047), postoperative bile leakage (4.1% vs 2.1%; p = 0.011), infectious (13.7% vs 7.5%; p < 0.001) and global complications (25.7% vs 17.1%; p < 0.001). HVC did not show an increase in any of the above-mentioned outcomes when G1 and G2 were compared. ELC must be indicated cautiously in patients with ACC and more than 1 week of symptom duration. It should be performed in centres with sufficient experience in the management of this disease.

[Surgical training in Spain: results of a national survey]. / Formación quirúrgica en España: resultados de una encuesta nacional.

INTRODUCTION: The aim of the study is to try and find out the state of surgical training in Spain and to determine whether it meets the objectives of the Program. MATERIAL AND METHODS: The results of two surveys carried out on Residents and General Surgery Tutors by the Spanish Surgeons Association, based on the conclusions of the XXVII Congreso Nacional de Cirugía. The questions formulated referred to general aspects of the Service and specific ones related to access, teaching activity, surgery, research and personal perspectives. The responses were defined, adjusted and categorised as quantitative and qualitative variables. The statistics program G Stat 2.0 was used for processing and the descriptive presentation of the results. RESULTS: The surveys were sent to 626 Residents and 142 Tutors, with a response rate of 19% and 29%, respectively. First year residents predominated (32%) compared to later years, with an R-5 response index of 7.2%. A total of 91% knew the speciality Program well, and 76% were satisfied with the training received. CONCLUSIONS: The results obtained as regards surgical activity agree with those established in the Program, both in the number of procedures and in their progression throughout the Residency, although it is not possible to ensure its uniformity. The functions and accreditation of the Tutors which are one of the main foundations of the training process are pending specific regulations.

Surgery for Graves' disease: a 25-year perspective.

BACKGROUND: Optimal treatment of Graves' disease (GD) remains controversial. The authors retrospectively reviewed the surgical cases of GD at a single academic tertiary center. METHODS: Demographic, clinical, and surgical data were analyzed for all patients with GD undergoing thyroidectomy over 25 years, in 3 periods: 1985 to 1993 (n = 32), 1994 to 2002 (n = 91), and 2003 to 2010 (n = 177). RESULTS: There were 300 patients with GD (85.7% women; mean age, 39.3 years; median length of follow-up, 24.6 months). Overall, perioperative morbidity occurred in 36 patients (12.0%), and there was no mortality. Thyroidectomy-specific morbidity was very low, and the incidental malignancy rate was 10.3%. CONCLUSIONS: Surgical treatment of GD has a very high safety profile, with low perioperative and thyroidectomy-specific morbidity, even in patients with overt hyperthyroidism. Incidental malignancy in patients with GD is not uncommon.