Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey.

BACKGROUND: The methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown. The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. METHODS: Using a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. RESULTS: The survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population. Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients' discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. CONCLUSIONS: This study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.

Diagnostic value of ascites immunohistochemistry in carcinomatosis of unknown origin.

We present the case of a patient diagnosed with carcinomatosis when admitted urgently for an occlusive condition. It is the immunohistochemistry that clarifies which is the primary tumor. Sigma neoplasia was initially suspected to recur due to operative findings. It was surprising that the primary tumor was of pulmonary origin. It became known thanks to the immunohistochemical cytology of the ascetic fluid.

Photodynamic Therapy for the Treatment of Complex Anal Fistula.

BACKGROUND AND OBJECTIVES: To validate and analyze the results of intralesional photodynamic therapy in the treatment of complex anal fistula. STUDY DESIGN/MATERIALS AND METHODS: This prospective multicentric observational study enrolled patients treated for complex anal fistula who underwent intralesional photodynamic therapy (i-PDT). The included patients were treated from January 2016 to December 2018 with a minimum follow-up of 1 year to evaluate recurrence, continence and postoperative morbidity. Intralesional 5-aminolevulinic acid (ALA) gel (2%) was injected directly into the fistula. The internal and external orifices were closed. After an incubation period of 2 hours, the fistula was irradiated using an optical fiber connected to a red laser (Multidiode 630 PDT) operating at 1 W/cm for 3 minutes (180 J). RESULTS: In total, 49 patients were included (61.2% male). The mean age was 48 years, and the mean duration of fistula was 13 months. Of the fistulas included, 75.5% were medium transphincteric, and 24.5% were high transphincteric. The median fistula length was 4 ± 1,14 cm (range: 3-5). A total of 41 patients (83.7%) had a previous history of fistula surgery. Preoperatively, some degree of anal incontinence was found in 5 patients (10.2%). No center reported any other procedure-related complications intraoperatively. Phototoxicity was found in one patient. In the first 48 hours after the procedure, fever was reported in 2 patients (4%). At the end of follow-up, total healing was observed in 32/49 patients (65.3%). No patient reported new incontinence postoperatively. CONCLUSION: i-PDT could be considered a good choice in patients with complex anal fistulas to avoid surgery and its complications. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Standard outcome indicators after colon cancer resection. Creation of a nomogram for autoevaluation. / Resultados quirúrgicos estándar tras resección oncológica de colon. Creación de un nomograma para la autoevaluación.

INTRODUCTION: Lately there has been an increasing interest in identifying quality standards in different pathologies, among them colon cancer due to its great prevalence. The main goal of this study is to define the quality standards of colon cancer surgery based on a large prospective national study dataset. METHODS: Data from the prospective national study ANACO were used. This study included a consecutive series of patients operated on for colon cancer in 52 Spanish hospitals (2011-2012). Centers with less than 30 patients were excluded. The present analysis finally included 42 centers (2975 patients). Based on the results obtained in 4main indicators from each hospital (anastomotic leak, lymph-nodes found in the specimen, mortality and length of stay), a nomogram that allows the evaluation of the performance of each center was designed. Standard results for further 5 intraoperative and 5 postoperative quality indicators were also reported. RESULTS: Median of anastomotic leak and mortality rate was 8.5% (25th-75th percentiles 6.1%-12.4%) and 2.5% (25th-75th percentiles 0.6%-4.7%), respectively. Median number of nodes found in the surgical specimen was 15,1 (25th-75th percentiles 18-14 nodes). Median length of postoperative stay was 7.7 days (25th-75th percentiles 6.9-9.2 days). Based on these data, a nomogram for hospital audit was created. CONCLUSIONS: Standard surgical results after colon cancer surgery were defined, creating a tool for auto-evaluation and allowing each center to identify areas for improvement in the surgical treatment of colon cancer.

Recommendations of «not-to-do¼: Proposals of the Spanish Association of Surgeons to the project «Commitment to quality of scientific societies¼. / Recomendaciones de «no hacer¼: propuestas de la Asociación Española de Cirujanos al proyecto de «Compromiso por la calidad de las sociedades científicas¼.

INTRODUCTION: The initiative of the Spanish Ministry of Health «Commitment to quality of scientific societies¼, aims to reduce unnecessary interventions of healthcare professionals. METHODS: The Spanish Association of Surgeons has selected 22 experts from the different sections that have participated in the identification of 26 proposals «do not do¼ to be ordered by the expected impact its implementation would have according to the GRADE methodology. From these proposals, the Delphi technique was used to select 5 recommendations presented in more detail in this article. RESULTS: The 5 selected recommendations are: Do not perform cholecystectomy in patients with asymptomatic cholelithiasis; do not keep bladder catheterization more than 48hours; do not extend antibiotic prophylaxis treatments more than 24hours after a surgical procedure; do not perform routine antibiotic prophylaxis for uncomplicated clean and no prosthetic surgery; and do not use antibiotics postoperatively after uncomplicated appendicitis. CONCLUSION: The Spanish Association of Surgeons's participation in this campaign has allowed a reflection on those activities that do not add value in the field of surgery and it is expected that the spread of this process serves to reduce its performance.

Analysis of the quality of care in surgical treatment of colorectal cancer: national study. Follow-up results.

OBJECTIVES: Using the cases included in the Study on the quality of care in colorectal cancer conducted by the Spanish Association of Surgeons in 2008, we present follow-up data. METHOD: Multicenter, descriptive, longitudinal and prospective study of patients operated on a scheduled basis of colorectal cancer. 35 hospitals have contributed data on 334 patients. Follow-up data: survival, recurrence and complications. RESULTS: Mean follow-up was 28.61±11.32 months. Follow-up by surgeon: 69.2%, tumor recurrence 23.6%, in 83.3% it was systemic; 28.2% underwent salvage surgery. Overall survival was 76.6%, disease-free survival 65.6% (26.49±11.90 months). Tumor related mortality was 12,6%. Percentage of ventral hernias was 5.8%, intestinal obstruction 3.5%. CONCLUSIONS: Quality and results of follow-up of patients operated on for CRC in Spain are similar to those reported in the Scientific literature. Areas for improvement: follow-up, earlier diagnosis, increase adjuvant and neoadjuvant treatments and total mesorectal excision as standard surgery for rectal cancer.

[Safety of a multiperforated catheter implanted in the surgical wound for the continuous infusion of local anaesthetics in post-operative analgesia]. / Seguridad de un catéter multiperforado implantado en la herida quirúrgica para la infusión continua de anestésicos locales en la analgesia post-operatoria.

OBJECTIVE: To evaluate the incidence of infection at the surgical site in patients who have a multiperforated catheter implant for continuous infusion of a local anaesthetic as a local analgesic. PATIENTS AND METHOD: An observational, descriptive and prospective study, of one month duration. It included 50 patients subjected to selective laparotomy in whom a multiperforated pre-peritoneal catheter was implanted for analgesia purposes (Painfusor®. Baxter). Patients with a surgical incision of less than 15 cm and/or ASA>III, were excluded from the study. RESULTS: The catheter was removed from all patients at 48 hours. An infection at the surgical site was present in 6% of the patients who had the catheter implanted, which was similar to the incidence in clean-contaminated surgery (5.5%; 95% CI: 3.4-8.7%). Colonisation of the catheter was observed in two patients, causing only one infection of the surgical site. CONCLUSIONS: The use of an in-situ pre-peritoneal catheter for post-surgical anaesthesia does not increase the risk of surgical site infection.

[Analysis of the quality of surgical treatment of colorectal cancer, in 2008. A national study]. / Análisis de la calidad asistencial del tratamiento quirúrgico del cáncer colorrectal en 2008. Estudio de ámbito nacional.

OBJECTIVE: A national study conducted for the Spanish Association of Surgeons with the aim of analysing the surgical treatment of colorectal cancer (CRC) in Spain and to compare it with scientific literature. MATERIAL AND METHODS: A multicentre, descriptive, prospective and longitudinal study of patients with CRC who were treated by elective surgery. A total of 50 hospitals in 15 Autonomous Regions took part, with 496 treated cases in 2008. A total of 88 variables were collected. RESULTS: The median age was 72 years, increase in ASA III patients; correct preoperative studies, 4% with no staging in the rectum. There was a tendency not to use the colon cleansing or to do it only one day. The percentage of complications is within the ranges in the literature, with the exception of surgical wound infections (19%). Mean of resected lymph nodes: 13.2; 4.3% no mesorectal resection. Mechanical anastomosis: 80.8%, 65.9% of the operations performed by a colorectal surgeon. Preoperative radiotherapy in 43.5% of rectal cancers. Chemotherapy: 32.9%. Laparoscopy: 35.1% of cases, conversion rate 13.8%. Use of antibiotics: 37.1%, blood transfusion: 20.6% and parenteral nutrition: 26.5%. CONCLUSIONS: Surgical treatment of CRC in Spain has a level of quality and peri-operative results similar to the rest of Europe. Compared to previous studies, it was observed that there were advances in preparation of the patient, preoperative studies, imaging techniques, and improvements in surgical techniques with adoption of mesorectal excision, appropriate lymphadenectomies and preservation of sphincters. There are areas for improvement, such as a reduction in surgical wound infections, increase use of protective stoma, appropriate use of antibiotics, parenteral nutrition or neoadjuvants and complete colonoscopies.

[Major ambulatory surgery and clinical pathways: a stimulating combination]. / Cirugía mayor ambulatoria y vías clínicas: una asociación estimulante.

The success of major ambulatory surgery (MAS) in Spain is due to the need to shorten the surgical waiting list for procedures of low to medium complexity, and the efficiency, satisfaction and safety that it can obtain. Clinical Pathways (CP) are defined health care plans, supported by scientific evidence, prepared for specific environments, on "Clinical Processes" with, a predictable clinical course, high prevalence and variability. The sequence of all the activities are set out in detail in them, as well as checking the performance of the professionals involved. MAS is performed using strict protocols and coordination between different specialties and health care levels. If CPs have demonstrated their usefulness in elective surgery, it could be assumed that the contribution of CPs could be equally applied to MAS procedures. In this article, we review the methodology for introducing CP into MAS, as well as its obstacles and expectations.

[Guidelines and clinical pathways. Is there really a difference?]. / Guías y vías clínicas, ¿existe realmente diferencia?

Quality Design Activities of Good Clinical Practice guidelines or protocols and clinical pathways (CP) include those clinical plans intended for the patients with a particular disease. They must be based on the clinical evidence, the analysis of the process, and the consensus of the professionals involved in the care of the patient. When these are introduced to surgical professionals, they usually say that they do not understand the the difference between CP and protocols or guidelines. In fact we are speaking quality design activities with the same objectives of decreasing the unjustified variability and helping in the decision making on a specific clinical problem. In this work we attempt to show the differences by defining what is understood by a clinical pathway and protocol or guideline.

[Comparison of the quality of two clinical practice guides in colorectal cancer using the AGREE System]. / Comparación de la calidad de dos guías de práctica clínica en el cáncer colorrectal mediante el sistema AGREE.

INTRODUCTION: Clinical practice guidelines (CPG) must be adapted to the population in which we apply them, therefore it is important that their quality is validated. AGREE Collaboration is a tool mainly designed for helping CPG providers and users in the evaluation of their methodological quality. MATERIAL AND METHOD: We have compared two colorectal cancer CPG (the original guidelines were prepared by Royal Collage of Surgeons of England (RCSE) and the other by the Valencian Society of Surgery (SVC). We used the AGREE Collaboration in both cases. This consists of 23 items organised into 6 areas. Each item is graded on a 4 point scale which measured the item accomplishment, from 4 points (complete agreement) to 1 point (complete disagreement). RESULTS: We observed no significant differences between both guidelines, except in 3 areas: Area 2 (participation of people involved in the study) (SVC: 66% vs RCSE: 73%); Area 5 (Applicability) (SVC: 52% vs RCSE: 47%) and Area 6 (Editorial Independence) (SVC: 58% vs RCSE: 71%). Neither were there any significant differences between items, except in two cases: Item 7: the question is: Are the guidelines tested in target users?; Item 23: euroIs there any conflict of interests between members of the group which contributed to guidelines' development?. SVC guidelines performed 7 recommendations more than the English one, 3 of type A and 4 of type C. In both guidelines the most frequent type of recommendation is B (49% and 57% respectively). Types A and C are more frequent in SVC guidelines. CONCLUSIONS: a) If CPG exist, it is more efficient to adapt them to the local setting than to prepare them "de novo"; b) When new evidence is available, then this should be added to the adapted GPC and c) It is recommended to review compliance to the CPG in order to guaranteee their workability.