Utility guideline and considerations for the novel Hugo™ RAS (robotic-assisted surgery) system in colorectal surgery: surgical outcomes and initial experience in a tertiary center.

PURPOSE: A novel robotic platform-Hugo™ RAS (robotic-assisted surgery) system-has been introduced with several innovations that may prove advantageous for surgeons, such as an open console and four interchangeable modular arms. Our study aims to evaluate this platform's safety, efficacy, and potential impact on the surgical treatment of colorectal pathology. METHODS: Patients underwent robotic-assisted colorectal procedures with the Hugo™ RAS system at the General University Hospital of Elche from October 2023 to July 2024. Patient characteristics, intraoperative and postoperative variables, and robotic technical issues were recorded. RESULTS: Forty consecutive patients were included (14 right, 13 left, and 8 rectum neoplasms; 4 left diverticulitis; and 1 ileocecal Crohn's disease). The patients' characteristics were as follows: median age, 69.5 years; 24 males and 16 females; 45% ASA III-IV; and Charlson Comorbidity Index > 5:42.5%. We recorded four medical (2 anemia, 1 phlebitis, and 1 admission to the intensive care unit) and three surgical (1 hematoma of the incision, 1 intestinal occlusion, and 1 dehiscence of the anastomosis) postoperative complications. We had no conversions neither open nor laparoscopic surgery. The average hospital stay was 3 days, with no mortality or readmission. CONCLUSIONS: The Hugo™ RAS system is safe and feasible for colorectal procedures. The modularity of the arms provides the versatility of configurations adjusted depending on the patient's body features and the surgeon's preferences and greater adaptability to operating rooms. The open console is highly comfortable and ergonomic for the surgeon, allowing communication with the operating room environment. TRIAL REGISTRATION: NCT06512480.

Physical Activity Levels, Eating Habits, and Well-Being Measures in Students of Healthcare Degrees in the Second Year of the COVID-19 Pandemic.

BACKGROUND: When the first cases of COVID-19 (caused by SARS-CoV-2 virus infection) were discovered, exceptional norms to fight the spread of the virus were established by applying movement restrictions (lockdown) in many countries. These unprecedented norms led to sedentary behaviours and less healthy diets which could persist for much longer after lockdown. The aim of this study was to analyse the physical activity, eating habits, self-perceived well-being, and toxic habits, as well as the perceived changes of these habits with respect to the pre-pandemic period, in a population of university students in the second year of the COVID-19 pandemic. METHODS: A single-centre, cross-sectional study was conducted in a population of university students of healthcare degrees. A total of 961 students (639 (66.5%) women and 322 (33.5%) men) signed the informed consent and completed the questionnaire. The study was conducted through an anonymous survey, which was voluntarily self-completed by the students on an online platform. The questionnaire was based on the Spanish Health Survey and it was divided into six main parts: demographic and anthropometric characteristics, physical activity, eating habits, well-being measures (sleeping habits, health state, and stress), toxic habits, and perception of the influence of the COVID-19 pandemic on the variables described. RESULTS AND CONCLUSIONS: The results showed that, during the second year of the pandemic, statistically significant dependence was identified for those students that showed higher levels of physical activity with greater perceived physical activity (p < 0.05), healthier eating habits (p < 0.05), and a better self-perceived health state (p < 0.05), with respect to the 12 months before the COVID-19 pandemic. On the other hand, there was a negative correlation between the sedentary students and greater perceived physical activity (p < 0.05). With regard to toxic habits and physical activity, a significant correlation was only detected between sedentary behaviour and cocaine consumption (p < 0.05). Analysing eating habits, it was observed that the students who smoked, consumed alcohol, and binge drank had low adherence to the Mediterranean diet (p < 0.05). In addition, those students with high stress levels slept less than 7 h (p < 0.05).

Toxic Habits and Well-Being Measures in Spanish Healthcare University Students during the COVID-19 Pandemic.

BACKGROUND: Unhealthy lifestyles are strongly entrenched in healthcare universities and have sometimes been linked to stress or lack of sleep. This study investigated the prevalence of toxic habits (smoking, patterns of harmful alcohol use, and illicit drug use), stress levels, perceived health status, and sleep duration and assessed the connections between toxic habits and said well-being measures, as well as healthcare students' perception of the influence of the COVID-19 pandemic on these health-related behaviors. METHODS: In a cross-sectional study, healthcare students from Alfonso X University (Spain) completed a health survey composed of Alcohol Use Disorders Identification Test (AUDIT-C), Perceived Stress Scale (PSS-10), self-perceived health status, and the number of hours of sleep. RESULTS: A total of 997 healthcare students completed the survey, of which 982 were analyzed. Being a smoker (32.2%) was associated with worse health status and insufficient sleep. Risk drinkers (33.2%) were associated with being female, and the consumption of cannabinoids (6.7%), with being male. These three toxic habits were related to each other. High levels of stress (28.2%) were correlated with worse ratings in the perception of health status (29.2%) and with insufficient sleep (45.8%), and all of them were associated with the female sex. Respectively, 49.3% and 44.2% of students recognized a worsening in their perception of stress and their sleep habits during the pandemic. CONCLUSION: Healthcare universities must carry out health promotion programs for stress management, sleep habits, and unhealthy lifestyles.

[Direct medical costs in a cohort of patients with breast cancer]. / Costos médicos directos de la atención médica de pacientes con cáncer de mama.

Background: The economic cost of breast cancer (BC) treatment and the increase in incidence and prevalence challenges the financial stability of any healthcare system. Objective: To determine direct medical costs (DMC) of BC treatment and factors associated with DMC. Material and methods: Partial economic evaluation in a retrospective cohort of 160 patients with a confirmed diagnosis of BC. DMC was considered from the IMSS perspective. Bootstrapping analysis was used to deal with uncertainty and generalized linear model to identify factors associated with DCM. Results: The total average annual cost of BC treatment was $251,018 mexican pesos. In clinical stage I was $116,123, stage II $242,132, stage III $287,946, and stage IV $358,792 pesos. In progression disease, DMC were more elevate ($380,117) vs. without progression ($172,897), (p < 0.0001). In patients who died, DMC were $357,579 mexican pesos compared to those who survived ($218,699) (p < 0.0001). Conclusions: The average annual cost of CM treatment was $251,018 pesos. DMCs increase significantly as patients present more advanced stages of the disease. Factors associated with costs were age, stages II, III and the progression of BC.

Introducción: el costo económico del tratamiento de cáncer de mama (CM) y el aumento en su incidencia y prevalencia desafía la estabilidad financiera de cualquier sistema de salud. Objetivo: determinar los costos médicos directos (CMD) del tratamiento de CM y los factores asociados a estos costos. Material y métodos: evaluación económica parcial en una cohorte retrospectiva de 160 pacientes con diagnóstico confirmado de CM. Se consideraron CMD desde la perspectiva del IMSS. Se utilizó análisis de bootstrapping para tratar incertidumbre y el modelo lineal generalizado para identificar factores asociados a costos. Resultados: el costo promedio anual (CPA) del tratamiento de CM fue de $ 251,018 pesos. En estadio 1, $ 116,123; estadio II, $ 242,132; estadio III, $ 287,946, y estadio IV, $ 358,792 pesos. El CPA fue mayor en progresión del CM ($ 380,117 frente a no progresión $ 172,897), y en pacientes que fallecieron durante el seguimiento ($ 357,579) frente a aquellas que sobrevivieron ($ 218,699). Conclusiones: el CPA del tratamiento de CM fue de $ 251,018 pesos. Los CMD aumentan significativamente conforme las pacientes presentan estadios más avanzados de la enfermedad. Los factores asociados al CMD fueron edad, estadios II, III y la progresión del CM.

Circulating nitrate-nitrite reduces oxygen uptake for improving resistance exercise performance after rest time in well-trained CrossFit athletes.

This study aimed to determine the effects of circulating nitrate plus nitrite (NOx) concentrations on resistance exercise performance, VO2 and biomarkers of muscle damage. Eleven well-trained male CrossFit athletes (29.2 ± 3.7 years, 78.9 ± 5.4 kg, 175.1 ± 6.3 cm) carried out a resistance exercise test after drinking 140 mL of beetroot juice (BJ) or placebo. The test consisted of repeating the same resistance exercise routine twice: wall ball shots plus full back squat with 3-min rest (1st routine) or without rest (2nd routine) between the two exercises. Higher NOx plasma levels were verified after BJ than placebo in the pretest and post-test (p < 0.001). A higher number of repetitions was observed after BJ intake compared to placebo in the full back squat exercise during the first routine (p = 0.004). A significantly reduced VO2 was detected after BJ intake compared to placebo during rest and full back squat execution in the first routine (p < 0.05). Plasma myoglobin concentrations were significantly increased with BJ compared to placebo (p = 0.036). These results showed that plasma NOx levels reduced VO2 after BJ intake during rest time. These reduced VO2 was a key factor for improving full back squat performance during the first routine.

The Relationship between the IC50 Values and the Apparent Inhibition Constant in the Study of Inhibitors of Tyrosinase Diphenolase Activity Helps Confirm the Mechanism of Inhibition.

Tyrosinase is the enzyme involved in melanization and is also responsible for the browning of fruits and vegetables. Control of its activity can be carried out using inhibitors, which is interesting in terms of quantitatively understanding the action of these regulators. In the study of the inhibition of the diphenolase activity of tyrosinase, it is intriguing to know the strength and type of inhibition. The strength is indicated by the value of the inhibition constant(s), and the type can be, in a first approximation: competitive, non-competitive, uncompetitive and mixed. In this work, it is proposed to calculate the degree of inhibition (iD), varying the concentration of inhibitor to a fixed concentration of substrate, L-dopa (D). The non-linear regression adjustment of iD with respect to the initial inhibitor concentration [I]0 allows for the calculation of the inhibitor concentration necessary to inhibit the activity by 50%, at a given substrate concentration (IC50), thus avoiding making interpolations between different values of iD. The analytical expression of the IC50, for the different types of inhibition, are related to the apparent inhibition constant (KIapp). Therefore, this parameter can be used: (a) To classify a series of inhibitors of an enzyme by their power. Determining these values at a fixed substrate concentration, the lower IC50, the more potent the inhibitor. (b) Checking an inhibitor for which the type and the inhibition constant have been determined (using the usual methods), must confirm the IC50 value according to the corresponding analytical expression. (c) The type and strength of an inhibitor can be analysed from the study of the variation in iD and IC50 with substrate concentration. The dependence of IC50 on the substrate concentration allows us to distinguish between non-competitive inhibition (iD does not depend on [D]0) and the rest. In the case of competitive inhibition, this dependence of iD on [D]0 leads to an ambiguity between competitive inhibition and type 1 mixed inhibition. This is solved by adjusting the data to the possible equations; in the case of a competitive inhibitor, the calculation of KI1app is carried out from the IC50 expression. The same occurs with uncompetitive inhibition and type 2 mixed inhibition. The representation of iD vs. n, with n=[D]0/KmD, allows us to distinguish between them. A hyperbolic iD vs. n representation that passes through the origin of coordinates is a characteristic of uncompetitive inhibition; the calculation of KI2app is immediate from the IC50 value. In the case of mixed inhibitors, the values of the apparent inhibition constant of meta-tyrosinase (Em) and oxy-tyrosinase (Eox), KI1app and the apparent inhibition constant of metatyrosinase/Dopa complexes (EmD) and oxytyrosinase/Dopa (EoxD), KI2app are obtained from the dependence of iD vs. n, and the results obtained must comply with the IC50 value.

Costos médicos directos de la atención médica de pacientes con cáncer de mama / Direct medical costs in a cohort of patients with breast cancer

Introducción: el costo económico del tratamiento de cáncer de mama (CM) y el aumento en su incidencia y prevalencia desafía la estabilidad financiera de cualquier sistema de salud. Objetivo: determinar los costos médicos directos (CMD) del tratamiento de CM y los factores asociados a estos costos. Material y métodos: evaluación económica parcial en una cohorte retrospectiva de 160 pacientes con diagnóstico conf irmado de CM. Se consideraron CMD desde la perspectiva del IMSS. Se utilizó análisis de bootstrapping para tratar incertidumbre y el modelo lineal generalizado para identificar factores asociados a costos. Resultados: el costo promedio anual (CPA) del tratamiento de CM fue de $ 251,018 pesos. En estadio 1, $ 116,123; estadio II, $ 242,132; estadio III, $ 287,946, y estadio IV, $ 358,792 pesos. El CPA fue mayor en progresión del CM ($ 380,117 frente a no progresión $ 172,897), y en pacientes que fallecieron durante el seguimiento ($ 357,579) frente a aquellas que sobrevivieron ($ 218,699). Conclusiones: el CPA del tratamiento de CM fue de $ 251,018 pesos. Los CMD aumentan significativamente conforme las pacientes presentan estadios más avanzados de la enfermedad. Los factores asociados al CMD fueron edad, estadios II, III y la progresión del CM.

Background: The economic cost of breast cancer (BC) treatment and the increase in incidence and prevalence challenges the financial stability of any healthcare system. Objective: To determine direct medical costs (DMC) of BC treatment and factors associated with DMC. Material and methods: Partial economic evaluation in a retrospective cohort of 160 patients with a confirmed diagnosis of BC. DMC was considered from the IMSS perspective. Bootstrapping analysis was used to deal with uncertainty and generalized linear model to identify factors associated with DCM Results: The total average annual cost of BC treatment was $251,018 mexican pesos. In clinical stage I was $116,123, stage II $242,132, stage III $287,946, and stage IV $358,792 pesos. In progression disease, DMC were more elevate ($380,117) vs. without progression ($172,897), (p < 0.0001). In patients who died, DMC were $357,579 mexican pesos compared to those who survived ($218,699) (p < 0.0001). Conclusions: The average annual cost of CM treatment was $251,018 pesos. DMCs increase significantly as patients present more advanced stages of the disease. Factors associated with costs were age, stages II, III and the progression of BC.

Considerations about the Continuous Assay Methods, Spectrophotometric and Spectrofluorometric, of the Monophenolase Activity of Tyrosinase.

With the purpose to obtain the more useful tyrosinase assay for the monophenolase activity of tyrosinase between the spectrofluorometric and spectrophotometric continuous assays, simulated assays were made by means of numerical integration of the equations that characterize the mechanism of monophenolase activity. These assays showed that the rate of disappearance of monophenol (VssM,M) is equal to the rate of accumulation of dopachrome (VssM,DC) or to the rate of accumulation of its oxidized adduct, originated by the nucleophilic attack on o-quinone by a nucleophile such as 3-methyl-2-benzothiazolinone (MBTH), (VssM, A-ox), despite the existence of coupled reactions. It is shown that the spectrophotometric methods that use MBTH are more useful, as they do not have the restrictions of the L-tyrosine disappearance measurement method, of working at pH = 8 and not having a linear response from 100 µM of L-tyrosine. It is possible to obtain low LODM (limit of detection of the monophenolase activity) values with spectrophotometric methods. The spectrofluorimetric methods had a lower LODM than spectrophotometric methods. In the case of 4-hydroxyphenil-propionic acid, the LODM obtained by us was 0.25 U/mL. Considering the relative sensitivities of 4-hydroxyanisole, compared with 4-hydroxyphenil-propionic acid, LODM values like those obtained by fluorescent methods would be expected.

Osmoregulatory Plasticity of Juvenile Greater Amberjack (Seriola dumerili) to Environmental Salinity.

Osmotic costs in teleosts are highly variable, reaching up to 50% of energy expenditure in some. In several species, environmental salinities close to the isosmotic point (~15 psu) minimize energy demand for osmoregulation while enhancing growth. The present study aimed to characterize the physiological status related to osmoregulation in early juveniles of the greater amberjack, Seriola dumerili, acclimated to three salinities (15, 22, and 36 psu). Our results indicate that plasma metabolic substrates were enhanced at the lower salinities, whereas hepatic carbohydrate and energetic lipid substrates decreased. Moreover, osmoregulatory parameters, such as osmolality, muscle water content, gill and intestine Na+-K+-ATPase activities, suggested a great osmoregulatory capacity in this species. Remarkably, electrophysiological parameters, such as short-circuit current (Isc) and transepithelial electric resistance (TER), were enhanced significantly at the posterior intestine. Concomitantly, Isc and TER anterior-to-posterior intestine differences were intensified with increasing environmental salinity. Furthermore, the expression of several adeno-hypophyseal genes was assessed. Expression of prl showed an inverse linear relationship with increasing environmental salinity, while gh mRNA enhanced significantly in the 22 psu-acclimated groups. Overall, these results could explain the better growth observed in S. dumerili juveniles kept at salinities close to isosmotic rather than in seawater.

Kinetic characterization of the oxidation of catecolamines and related compounds by laccase.

The pathways of melanization and sclerotization of the cuticle in insects are carried out by the action of laccases on dopamine and related compounds. In this work, the laccase action of Trametes versicolor (TvL) on catecholamines and related compounds has been kinetically characterized. Among them, dopamine, l-dopa, l-epinephrine, l-norepinephrine, dl-isoprenaline, l-isoprenaline, dl-α-methyldopa, l-α-methyldopa and l-dopa methylester. A chronometric method has been used, which is based on measuring the lag period necessary to consume a small amount of ascorbic acid, added to the reaction medium. The use of TvL has allowed docking studies of these molecules to be carried out at the active site of this enzyme. The hydrogen bridge interaction between the hydroxyl oxygen at C-4 with His-458, and with the acid group of Asp-206, would make it possible to transfer the electron to the T1 Cu-(II) copper centre of the enzyme. Furthermore, Phe-265 would facilitate the adaptation of the substrate to the enzyme through Π-Π interactions. To kinetically characterize these compounds, we need to take into consideration that, excluding l-dopa, l-α-methyldopa and dl-α-methyldopa, all compounds are in hydrochloride form. Because of this, first we need to kinetically characterize the inhibition by chloride and, after that, calculate the kinetic parameters KM and VmaxS. From the kinetic data obtained, it appears that the best substrate is dopamine. The presence of an isopropyl group bound to nitrogen (isoprenaline) makes it especially difficult to catalyse. The formation of the ester (l-dopa methyl ester) practically does not affect catalysis. The addition of a methyl group (α-methyl dopa) increases the rate but decreases the affinity for catalysis. l-Epinephrine and l-norepinephrine have an affinity similar to isoprenaline, but faster catalysis, probably due to the greater nucleophilic power of their phenolic hydroxyl.

Estimación de erosión potencial bajo dos sistemas de corte de caña panelera utilizando la ecuación universal de pérdida de suelos / Estimation of potential erosion under two sugarcane cutting systems using the universal soil loss equation

RESUMEN Con el fin de comparar las pérdidas de suelo en dos sistemas de corte tradicionalmente utilizados en el cultivo de caña de azúcar para la producción de panela, se llevó a cabo un estudio, en el que se realizaron mediciones en campo, utilizando un simulador de lluvia y parcelas de escorrentía, en un vertisol del municipio de Quebradanegra, Cundinamarca, en donde se presentan, simultáneamente, los dos tipos de corte: parejo (tipo de corte en el que se cosecha todo a la vez, al tener una madurez homogénea en el cultivo) y entresaque (sistema en el cual no hay madurez homogénea, por lo que se corta solo un porcentaje de las plantas a la vez). Para estimar las pérdidas de suelo potenciales asociadas a ambos sistemas de corte, se utilizó la Ecuación Universal de Pérdida de Suelos (USLE), obteniendo un factor medio C, asociado al tipo de corte, utilizando los datos determinados en campo y la erosividad de las intensidades de precipitación simuladas. Finalmente, se determinó la erosión potencial anual, bajo los dos sistemas de corte, donde se observó que el sistema de corte por parejo presenta un valor 2,2 veces mayor que el sistema de corte por entresaque. Por otra parte, al comparar las pérdidas potenciales de suelo con un lote recién preparado y sembrado, sin cobertura vegetal, se evidencia la capacidad del cultivo de caña panelera para brindar protección al suelo, presentando una erosión potencial 9 veces menor, en el caso del corte por parejo, con respecto a una condición de suelo sin cobertura vegetal.

ABSTRACT In order to compare soil losses in two cutting systems traditionally used in the cultivation of sugar cane for the production of panela, a study was carried out in which measurements were made in the field using a rainfall simulator and runoff plots in a vertisol of the municipality of Quebradanegra, Cundinamarca, where both types of cut are presented simultaneously: the cut-off system, in which everything is harvested at once having a homogeneous maturity in the crop and the thinning cut system, in which have an inhomogeneous maturity so that only a percentage of the plants is cut at the same time. To estimate the potential soil losses associated with both cutting systems, the Universal Soil Loss Equation (USLE) was used to obtain a mean C factor associated with the type of cut, using the data determined in the field and the erosivity of simulated rainfall intensities. Finally, the anual potential losses of soil was determined under the two cutting systems, where it was observed that the cut-off system has an annual potential erosion 2.2 times greater than the thinning cuy system. On the other hand, when comparing the potential losses of soil with a newly prepared and planted lot, without plant cover, the capacity of the sugarcane cane crop is demonstrated to offer a protection to the soil, presenting a potential erosion 9 times smaller, in the case of the cut-off system, with respect to a soil condition without plant cover.

Effects of a single dose of beetroot juice on cycling time trial performance at ventilatory thresholds intensity in male triathletes.

BACKGROUND: Beetroot juice (BJ) is classified as a high-level supplement for improving sports performance. There is some controversy over the benefits of BJ supplementation for endurance exercise performance, especially when referring to well-trained athletes. This study examines the effects of acute BJ supplementation on cardioventilatory responses, exercise economy/efficiency, slow component of oxygen uptake, time trial performance, blood lactate, energy consumption, and carbohydrate and fat oxidation. METHODS: Twelve well-trained, male triathletes (aged 21-47 yr) were assigned in a randomized, double-blind, crossover design to receive 70 ml of BJ (6.5 mmol NO3-) or placebo (PL). Three hours after taking the supplement, participants completed an endurance test on a cycle ergometer at a constant work rate (W) corresponding to first ventilatory threshold (VT1) (30 min) and second ventilatory threshold (VT2) time trial (~ 15 min). RESULTS: Maximal oxygen uptake was 54.78 ± 3.13 mL·min- 1·kg- 1, and gross efficiency was > 22% at each load intensity and experimental condition. No significant interaction effect (supplement*intensity) was observed on any of the cardioventilatory variables, efficiency/economy, VT2 time trial, energy expenditure, carbohydrate oxidation and fat oxidation (p > 0.05). CONCLUSION: Our findings do not support an improvement in the variables examined in response to acute BJ supplementation. Probably, higher doses are needed for improving time trial performance in male triathletes during a cycle ergometer test conducted at a load intensity equivalent to the first and second ventilatory threshold.

Incidence of postoperative nausea and vomiting after laparoscopic sleeve gastrectomy with staple line reinforcement with oversewing and staple line inversion vs buttressing material: A randomized clinical trial.

BACKGROUND: Postoperative nausea and vomiting are relevant complications after restrictive bariatric procedures, such as sleeve gastrectomy, mainly secondary to a drastic reduction in the gastric volume. However, other causes can be involved. The aim of this study was to determine the incidence of postoperative nausea and vomiting (PONV) after laparoscopic sleeve gastrectomy (LSG), with staple line reinforcement with oversewing vs buttressing material. PATIENTS AND METHODS: A prospective randomized clinical trial of all the patients undergoing LSG was performed. Patients were divided into 2 groups: patients undergoing staple line inversion (Group 1) and patients undergoing staple line reinforcement with buttressing material (Group 2). Nausea and vomiting were assessed by the Postoperative Nausea and Vomiting Intensity Scale. RESULTS: A total of 100 females were included in the study, 50 in each group. Mean operative time was 66.1 ±â€¯11.6 min in Group 1 and 55.4 ±â€¯9.4 in Group 2 (p < 0.001). There were no significant differences in staple line leaks and bleeds between groups. The PONV intensity score at 6 h was 316.4 in Group 1 and 77.1 in Group 2 (p < 0.001). 24 h after surgery, the PONV intensity score was 86 in Group 1 and 7.9 in Group 2 (p = 0.022). CONCLUSION: The reinforcement with a running suture in LSG creates more PONV and increases the duration of the symptoms during the first hours after surgery, and prevents from early oral intake in a greater number of cases, when compared with the use of buttressing material as reinforcement method.

Procalcitonin and C-reactive protein as early markers of anastomotic leak after laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) program.

BACKGROUND: C-reactive protein (CRP) and procalcitonin (PCT) have been described as good predictors of anastomotic leak after colorectal surgery, obtaining the highest diagnostic accuracy on the 5th postoperative day. However, if an enhanced recovery after surgery (ERAS) program is performed, early predictors are needed in order to ensure a safe and early discharge. The aim of this study was to investigate the efficacy of CRP, PCT, and white blood cell (WBC) count determined on first postoperative days, in predicting septic complications, especially anastomotic leak, after laparoscopic colorectal surgery performed within an ERAS program. METHODS: We conducted a prospective study including 134 patients who underwent laparoscopic colorectal surgery within an ERAS program between 2015 and 2017. The primary endpoint investigated was anastomotic leak. CRP, PCT, and WBC count were determined in the blood sample extracted on postoperative day 1 (POD 1), POD 2 and POD 3. RESULTS: Anastomotic leak (AL) was detected in 6 patients (4.5%). Serum levels of CRP and PCT, but not WBC, determined on POD 1, POD 2, and POD 3 were significantly higher in patients who had AL in the postoperative course. Using ROC analysis, the best AUC of the CRP and PCT levels was on POD 3 (0.837 and 0.947, respectively). A CRP cutoff level at 163 mg/l yielded 85% sensitivity, 80% specificity, and 99% negative predictive value (NPV). A PCT cutoff level at 2.5 ng/ml achieved 85% sensitivity, 95% specificity, 44% positive predictive value, and 99% NPV. CONCLUSIONS: CRP and PCT are relevant markers for detecting postoperative AL after laparoscopic colorectal surgery. Furthermore, they can ensure an early discharge with a low probability of AL when an ERAS program is performed.

Implementation of the Spanish ERAS program in bariatric surgery.

Introduction: The essence of Enhanced Recovery After Surgery (ERAS) programs is the multimodal approach, and many authors have demonstrated safety and feasibility in fast track bariatric surgery. According to this concept, a multidisciplinary ERAS program for bariatric surgery has been developed by the Spanish Fast Track Group (ERAS Spain). The aim of this study was to analyze the initial implementation of this Spanish National ERAS protocol in bariatric surgery, comparing it with a historical cohort receiving standard care. Material and methods: A multi-centric prospective study was performed, including 233 consecutive patients undergoing bariatric surgery during 2015 and following ERAS protocol. It was compared with a historical cohort of 286 patients, who underwent bariatric surgery at the same institutions between 2013 and 2014 and following standard care. Compliance with the protocol, morbidity, mortality, hospital stay and readmission were evaluated. Results: Bariatric techniques performed were Roux-en-Y gastric bypass and sleeve gastrectomy. There were no significant differences in complications, mortality and readmission. Postoperative pain and hospital stay were significantly lower in the ERAS group. The total compliance to protocol was 80%. Conclusion: The Spanish National ERAS protocol is a safe issue, obtaining similar results to standard care in terms of complications, reoperations, mortality and readmissions. It is associated with less postoperative pain and earlier hospital discharge.

Changes in Frequency Intake of Foods in Patients Undergoing Sleeve Gastrectomy and Following a Strict Dietary Control.

PURPOSE: Dietary intake and food preferences change after bariatric surgery, secondary to gastrointestinal symptoms and dietitian counseling. The aim of this study was to evaluate the changes in the frequency intake of different foods in patients undergoing sleeve gastrectomy and following a strict dietary control. PATIENTS AND METHODS: A prospective observational study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric procedure between 2007 and 2012 was performed. Dietary assessment was performed using the Alimentary Frequency Questionnaire 1991-2002, developed and validated by the Department of Epidemiology of Miguel Hernandez University (Elche, Alicante Spain). RESULTS: Ninety-three patients were included for analysis, 73 females and 20 males, with a mean preoperative BMI of 46.4 ± 7.9 kg/m2. One year after surgery, excess weight loss was 81.1 ± 8.3% and 5 years after surgery, 79.9 ± 6.4%. Total weight loss at 1 year was 38.8 ± 5.3% and at 5 years, 35.4 ± 4.9%. Postoperatively, a reduction in the intake of dairy products, red meat, deli meat products, shellfish, fried potatoes, sweets, rice, pasta, beer, and processed foods was observed. Vegetables, fruits, and legumes intake increased after surgery. In the first postoperative year, there was a slight intolerance to red meat, fruits, vegetables and legumes, dairy products, pasta, and rice that mostly disappeared 5 years after surgery. CONCLUSION: One year after sleeve gastrectomy, calibrated with a 50-French bougie, there are not important problems in the intake of foods a priori difficult to digest. These problems mostly disappeared 5 years after surgery. The decrease intake of other unhealthy foods is mostly based on the dietary counseling.

C-reactive protein, fibrinogen, and procalcitonin levels as early markers of staple line leak after laparoscopic sleeve gastrectomy in morbidly obese patients within an Enhanced Recovery After Surgery (ERAS) program.

INTRODUCTION: The performance of most bariatric procedures within an Enhanced Recovery After Surgery program has resulted in significant advantages, including a reduction in the length of hospital stay to 2-3 days. However, some postoperative complications may appear after the patient has been discharged. The aim of this study was to investigate the efficacy of various acute-phase parameters determined 24 h after a laparoscopic sleeve gastrectomy for predicting staple line leak in the postoperative course. PATIENTS AND METHODS: A prospective study of 208 morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric procedure between 2012 and 2015 was performed. Blood analysis was performed 24 h after surgery. Acute-phase parameters (C-reactive protein, procalcitonin, fibrinogen, and White Blood Cell count) were investigated. RESULTS: Staple line leak appeared in eight patients (3.8%). Using receiver operating characteristic analysis at 24 h postoperatively, a cutoff level of CRP at 9 mg/dL achieved 85% sensitivity and 90% specificity for predicting staple line leak, a cutoff level of procalcitonin at 0.85 ng/mL achieved 70% sensitivity and 90% specificity, and a cutoff level of fibrinogen at 600 mg/dL achieved 80% sensitivity and 87.5% specificity. CONCLUSION: An elevation of CRP > 9 mg/dL, procalcitonin > 0.85 ng/mL and fibrinogen > 600 mg/dL should alert the surgeon the possibility of occurrence of postoperative staple line leak.

Conservative management in ureteric hydronephrosis due to deep endometriosis: Could the levonorgestrel-intrauterine device be an option?

Endometriosis can affect up to 10% of women of reproductive age, in a wide range of clinical presentations that vary from mild to severe or deep endometriosis. Deep endometriosis can affect the urinary tract in 1-5% to 15-25% cases. Even though deep endometriosis' surgeries are usually complex with higher rate of complications, conservative management is not always considered as an option because of its high failure rates. This paper describes two cases of deep endometriosis with ureteric involvement (hydronephrosis) treated conservatively with a double-pigtail stent plus a Levonorgestrel intrauterine device, after conservative surgery, who remained symptom free with no evidence of recurrence at 3 years follow-up, avoiding radical high-risk surgery. Impact statement Several treatments have been described for endometriosis. From a symptomatic perspective, conservative medical management has been proposed with a variable response. Concerning deep endometriosis (affecting the urinary or digestive tract), the definitive treatment has always been thought to be radical surgery. However, this can lead to several complications. To illustrate a possible more conservative approach this paper describes two cases of deep infiltrating endometriosis affecting the ureter, treated conservatively with a temporary pigtail ureter stent plus a Levonorgestrel intrauterine device. The management demonstrates that, in a selected population, conservative treatment solves the urinary disease avoiding the surgical complications and, what is more, improving patients' symptoms in a permanent way. Further prospective studies are needed to confirm whether the introduction of this management in clinical practice would reduce the need for surgery thereby, avoiding high-risk surgery and improving the success rate of conservative management.

Failure of fragmented parathyroid gland autotransplantation to prevent permanent hypoparathyroidism after total thyroidectomy.

PURPOSE: Parathyroid autotransplantation during total thyroidectomy leads to higher rates of postoperative hypocalcaemia. It has been argued, however, that it prevents permanent hypoparathyroidism. The impact of autografted normal parathyroid gland fragments on long-term parathyroid status has not been assessed properly. To clarify this, the short- and long-term parathyroid function was assessed in patients with three glands remaining in situ after total thyroidectomy, in whom the fourth gland was either autotransplanted (Tx) or accidentally resected (AR). METHODS: Consecutive patients (n = 669) undergoing first-time total thyroidectomy were prospectively studied recording the number of parathyroid glands remaining in situ: PGRIS =4-(glands autografted + glands in the specimen). The study was focused on the subgroup of 186 patients with three parathyroid glands remaining in situ as a result of either accidental resection (AR, n = 76) or autotransplantation into the sternocleidomastoid muscle (Tx, n = 110). Prevalence of postoperative hypocalcaemia, protracted, and permanent hypoparathyroidism were compared between the two groups. Demographic, disease-related, laboratory, and surgical variables were recorded. All patients were followed for at least 1 year. RESULTS: Both groups were comparable in terms of disease and extent of surgery. Mean postoperative serum calcium was the same (AR: 1.97 ± 0.2 vs Tx: 1.97 ± 0.22 mmol/L). Rates of protracted (AR: 24% vs Tx: 25.5%) and permanent hypoparathyroidism (AR: 5.3% vs Tx: 7.3%) were similar in both groups. CONCLUSIONS: The prevalence of parathyroid failure syndromes after total thyroidectomy was similar whether a parathyroid gland was inadvertently excised or autotransplanted. Autotransplantation did not influence the permanent hypoparathyroidism rate.