The impact of screening on short-term outcome after surgery for colorectal cancer.

AIM: To investigate the influence of a screening program on the short-term outcome of patients undergoing surgery for colorectal cancer. METHODS: Between April 2010 and December 2012 patients diagnosed with colorectal cancer via the screening program (n = 80) were compared with patients diagnosed elsewhere (n = 106). Only patients of ≥ 50 and ≤ 69 years of age diagnosed outside the program were selected as controls. The clinical variables included age, sex, American Society of Anesthesiologists (ASA) status, Charlson index, preoperative hemoglobin and serum albumin levels, surgical approach, tumor location and stage, perioperative transfusion and postoperative morbidity. A multivariate analysis was used to identify variables independently associated with outcome. RESULTS: There were no significant differences with regard to age, sex and ASA status. Preoperative hemoglobin (14.1 ± 1.6 g/dl vs 12.3 ± 2.3 g/dl; p < 0.001) and serum albumin (4.45 ± 0.26 g/dl vs 4.0 ± 0.6 g/dl; p < 0.001) levels were significantly higher in the screening group. The overall morbidity was significantly lower in the screening group (38.8% vs 63.2; p < 0.001) and mainly related to a higher rate of Clavien-Dindo grade II complications in controls. There were no differences with regard to wound infection, postoperative ileus, anastomotic leakage or reoperations. The median length of hospital stay was shorter in the screening group (6 vs 9 days; p = 0.003). Multivariate analysis showed that diagnosis outside the screening program, type of surgical procedure, open surgery and Charlson index were independent risk factors for postoperative complications. CONCLUSIONS: The diagnosis of colorectal cancer via the screening program is associated with a lower rate of postoperative minor complications and a shorter hospital stay.

[Treatment of colorectal cancer with unresectable metastasis with chemotherapy without primary tumor resection: analysis of tumor-related complications]. / Tratamiento del cáncer colorrectal con metástasis irresecables con quimioterapia sin resección del primario: análisis de las complicaciones relacionadas con el tumor.

INTRODUCTION: Although the conventional treatment of patients with stage iv colorectal cancer involves resection of the primary tumor followed by chemotherapy, several studies suggest that in patients with few symptoms the first and only treatment should be chemotherapy. The objective of this study is to analyze the complications related to the primary tumor in a series of patients with unresectable metastatic colorectal cancer treated with chemotherapy without surgery. MATERIAL AND METHODS: Retrospective descriptive study. The study included all patients with unresectable metastatic colorectal cancer treated with chemotherapy without resection of the primary tumor (January 2007-February 2011). RESULTS: The mean age of the 61 patients analyzed was 67±13 years and the performance status was 0-1 in 53 (87%). Twenty (33%) patients developed complications during follow-up. The most common complication was intestinal obstruction in 15 (25%) patients followed by perforation. Complications required surgery in 6 (10%) cases. We did not find differences in patient characteristics between those who had a complication and those without, although the complication rate in patients with a colonic stent (53%) was twice that of other patients (26%). CONCLUSIONS: Chemotherapy without surgery is a good option in most patients with unresectable metastatic colorectal cancer. However, although the percentage of patients requiring surgery is low, the total number of complications related to the primary tumor is not negligible. Studies are needed to identify those patients in whom a prophylactic colectomy could be indicated.

[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.

[Multimodal (fast-track) rehabilitation in elective colorectal surgery: evaluation of the learning curve with 300 patients]. / Rehabilitación multimodal en cirugía electiva colorrectal: evaluación de la curva de aprendizaje con 300 pacientes.

INTRODUCTION: The aim of this paper is to assess the learning curve on compliance to the application of a multimodal rehabilitation program (MMRP) protocol and patient recovery after elective colorectal surgery. MATERIAL AND METHODS: A comparative prospective study of 3 consecutive cohorts of 100 patients (P1, P2 and P3) who had colonic or rectal surgery. The same MMRP protocol was applied in all cases. Compliance to the protocol, tolerance to the diet and walking have been analysed. The percentages of early hospital discharges have also been compared. RESULTS: Compliance gradually improved, reaching statistical significance between P1 and P3. Starting the diet on day 1 post-surgery was 52% vs 86% (p=0.0001) and the removal of drips was 21% vs 40% (p=0.005). This difference remained during days 2 and 3. Tolerance to the diet on day 1 (P1: 34% vs. P3: 66%; p=0.0001) and walking on day 2 (P1: 41% vs. P3: 68%; p=0.0002) were also better in the third period. No differences in morbidity were found between the three periods. The percentage of hospital discharges on day 3 P1: 1% vs. P3: 15%; p=0.0003), day 4 (P1: 12% vs. P3: 32%; p=0.001) and day 5 (P1: 30% vs. P3: 50%; p=0.002) was higher in the third period. CONCLUSIONS: The compliance to the protocol and the results of applying the MMRP improved significantly with the greater experience of the professionals involved.

[Incidence of iatrogenic perforation during colonoscopy and their treatment in a university hospital]. / Incidencia de la perforación iatrogénica por colonoscopia y resultados del tratamiento en un hospital universitario.

INTRODUCTION: Colon perforation is a fairly uncommon, but serious, complication during endoscopy of the lower gastrointestinal tract. Treatment is controversial, although surgery is used in the majority of cases. The aims of this study were to determine the incidence of perforations due to colonoscopy in our hospital and to find out the results of the treatment options used. MATERIAL AND METHODS: Retrospective study of perforations caused by colonoscopy between January 2004 and October 2008. The variables analysed were: demographic characteristics, colonoscopy indication, clinical signs and symptoms, diagnostic tests used, time between perforation and the diagnosis, treatment type, hospital stay and complications. RESULTS: A total of 13,493 colonoscopies were performed during the study period. A perforation of the colon was found in 13 (0.1%) patients. Nine perforations occurred whilst performing a diagnostic colonoscopy (0.08%) and the remaining 4 after a therapeutic colonoscope (0.16%). In 10 of the cases the diagnosis was made within the first 12h, and in 5 of these the perforation was identified during the procedure itself. The most common location was the sigmoid, in 7 cases. Surgical treatment was carried out on 11 patients, and in the other two it was resolved by conservative treatment. The most used surgical technique was simple suture followed by resection with anastomosis. One patient died due to intra-abdominal sepsis. CONCLUSION: Perforations caused by colonoscopy are rare, but serious, complications. The majority of these patients required surgical treatment, with conservative treatment being reserved for selected patients.

Management of lower gastrointestinal bleeding after colorectal resection and stapled anastomosis.

BACKGROUND: Although limited haematochezia with the first bowel movement is frequent in patients undergoing colorectal resection, postoperative life-threatening lower gastrointestinal bleeding is very rare. The purpose of this study was to review our results in the management of this complication. METHODS: We analysed the cases of patients with severe lower gastrointestinal bleeding after colorectal surgery from 2000 to 2006 in our hospital. We studied the general characteristics, diagnostic data, therapeutic management and outcome. We also reviewed the published articles regarding this issue. RESULTS: This complication appeared in 7 (0.5%) of 1,389 colorectal procedures in the study period. In all the patients the anastomosis was stapled. In six of the seven patients bleeding resolved with conservative treatment including endoscopy. However, one patient required surgical treatment. There was no mortality and there were no anastomotic leaks in these seven patients. CONCLUSION: Severe lower gastrointestinal bleeding after colorectal resection and stapled anastomosis is a rare complication. Only in unstable patients or failure of conservative measures is surgery indicated.

[Treatment of a rectourethral fistula after radical prostatectomy by York Mason posterior trans-sphincter exposure]. / Tratamiento de la fístula rectouretral tras prostatectomía radical mediante la exposición transesfinteriana posterior de York Mason.

INTRODUCTION: Recto-urethral fistula is an uncommon complication after radical prostatectomy, occurring in less than 2% of patients. Our aim is to review our experience for repairing these fistulas with the posterior trans-sphincter approach of York Mason. PATIENTS AND METHOD: Retrospective review. All patients who underwent repair of postoperative recto-urethral fistula in our unit were included. The procedure described by York Mason was performed in all cases. RESULTS: During the last 6 years, 5 patients with recto-urethral fistulas after radical prostatectomy were repaired by using this method. Symptoms, including faecaluria and/or passing of urine via the anus, appeared between the postoperative day 4 and 7 weeks after surgery, and confirmation was obtained by cystography. Initial faecal diversion with sigmoid loop colostomy was performed in 3 cases, whereas in the other 2 patients a loop ileostomy was performed at the time of surgical repair. The posterior trans- sphincter approach and fistula repair was performed between 5 and 10 months after diagnosis. Morbidity included wound infection in 2 cases and skin dehiscence in another 2 patients. Successful fistula closure was achieved in all cases with complete faecal continence. No recurrence has been observed after a mean follow-up of 22 (4-40) months. CONCLUSIONS: The posterior trans-sphincter approach of York Mason is effective for the repair of recto-urethral fistulas after radical prostatectomy with minor morbidity and no impairment of continence.

The impact of screening on short-term outcome after surgery for colorectal cancer

Aim: To investigate the influence of a screening program on the short-term outcome of patients undergoing surgery for colorectal cancer. Methods: Between April 2010 and December 2012 patients diagnosed with colorectal cancer via the screening program (n = 80) were compared with patients diagnosed elsewhere (n = 106). Only patients of ≥ 50 and ≤ 69 years of age diagnosed outside the program were selected as controls. The clinical variables included age, sex, American Society of Anesthesiologists (ASA) status, Charlson index, preoperative hemoglobin and serum albumin levels, surgical approach, tumor location and stage, perioperative transfusion and postoperative morbidity. A multivariate analysis was used to identify variables independently associated with outcome. Results: There were no significant differences with regard to age, sex and ASA status. Preoperative hemoglobin (14.1 ± 1.6 g/ dl vs 12.3 ± 2.3 g/dl; p < 0.001) and serum albumin (4.45 ± 0.26 g/dl vs 4.0 ± 0.6 g/dl; p < 0.001) levels were significantly higher in the screening group. The overall morbidity was significantly lower in the screening group (38.8% vs 63.2; p < 0.001) and mainly related to a higher rate of Clavien-Dindo grade II complications in controls. There were no differences with regard to wound infection, postoperative ileus, anastomotic leakage or reoperations. The median length of hospital stay was shorter in the screening group (6 vs 9 days; p = 0.003). Multivariate analysis showed that diagnosis outside the screening program, type of surgical procedure, open surgery and Charlson index were independent risk factors for postoperative complications. Conclusions: The diagnosis of colorectal cancer via the screening program is associated with a lower rate of postoperative minor complications and a shorter hospital stay (AU)

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[Anal intraepithelial neoplasia: application of a diagnostic protocol in risk patients using anal cytology]. / Neoplasia intraepitelial anal: resultados de la aplicación de un protocolo diagnóstico en pacientes de riesgo mediante el uso de citología anal.

INTRODUCTION: Anal intraepithelial neoplasia is a precursor condition of squamous anal carcinoma. The groups at risk of this lesion are patients with anogenital condylomata, cervical dysplasia, human immunodeficiency virus infection and, in general, patients with HPV infection. The aim of this study was to analyse the results of a diagnostics protocol of Anal Intraepithelial Neoplasia in high risk population using anal cytology. PATIENTS AND METHOD: The protocol is based on a visit in the outpatient department, clinical interview, physical examination and anal cytology evaluated by Bethesda criteria. The cross-sectional observational study was designed to study the anal smear results and their relationship with risk factors. RESULTS: A total of 64 patients were included from January 2005 to December 2006. In the overall series, 25 patients have been diagnosed with abnormal anal cytology: 9 atypical squamous cells of undetermined significance (ASCUS), 15 low-grade and 1 high-grade squamous intraepithelial lesions. There were no significant associations between abnormal cytology results and the presence of anal condyloma (p = 0.22). Neither were there statistical associations found with high risk-HPV infection (p = 0.84), HIV infection (p = 0.98) or tobacco use (p = 0.14). CONCLUSIONS: Our diagnostic protocol of anal intraepithelial neoplasia revealed 25% of patients with pre-invasive lesions of squamous anal cancer.

[Endoanal ultrasound findings in patients with faecal incontinence using a scoring system]. / Descripción de los hallazgos de la ecografía endoanal en pacientes con incontinencia fecal mediante un sistema de puntuación.

INTRODUCTION: The main aim of the study was to apply a severity classification of sphincter lesions detected by endoanal ultrasound using Starck score in patients who suffered faecal incontinence. MATERIAL AND METHOD: Data were analysed on 133 patients with faecal incontinence. Those in whom anal sphincter lesions were detected by endoanal ultrasound are described and their corresponding scores according to Starck classification calculated. This system scores severity of detected sphincter lesions from 0 to 16, involving the three axes of the anal canal. Patient demographic characteristics and anorectal manometry results were also analysed. The relationship between this score, patient gender and age, and anorectal manometric results were also analysed. RESULTS: A total of 83 (62.4%) patients had some type of anal sphincter lesion. The presence of sphincter defects was not related to gender (P=0.172), although it did correlate with younger ages (P=0.028). The severity of anal sphincter damage by Starck score did not show significant correlation to gender (P=0.327) or to the age (P=0.350) of patients. However, a significant correlation was detected between Starck score and anal resting pressure (P=0.008) or anorectal squeeze pressure (P=0.011). CONCLUSIONS: The presence of anal sphincter injuries could be well defined by Starck score in patients with faecal incontinence. Severity of damage scored by Starck correlated with anorectal manometric results.

Tratamiento del cáncer colorrectal con metástasis irresecables con quimioterapia sin resección del primario: análisis de las complicaciones relacionadas con el tumor / Treatment of colorectal cancer with unresectable metastasis with chemotherapy without primary tumor resection: Analysis of tumor-related complications

INTRODUCCIÓN: Aunque el tratamiento convencional de los pacientes con cáncer colorrectal en estadio IV ha consistido en la resección del tumor primario seguida de quimioterapia, varios estudios defienden que en pacientes poco sintomáticos el primer y único tratamiento debe ser quimioterapia. El objetivo es analizar las complicaciones relacionadas con el tumor primario en una serie consecutiva de pacientes con cáncer colorrectal y metástasis irresecables tratados con quimioterapia sin cirugía. MATERIAL Y MÉTODOS: Estudio descriptivo retrospectivo. Se ha incluido a todos los pacientes con cáncer colorrectal y metástasis irresecables en los que se decidió realizar quimioterapia sin resección del tumor primario durante el periodo enero 2007-febrero 2011. RESULTADOS: La edad media de los 61 pacientes analizados era de 67 ± 13 años. Veinte (33%) pacientes presentaron alguna complicación durante el seguimiento. La complicación más frecuente fue la obstrucción intestinal en 15 (25%) seguida de la perforación. Las complicaciones precisaron cirugía en 6 (10%). No hemos encontrado diferencias estadísticamente significativas en las características de los pacientes entre aquellos que presentaron una complicación y los que no, aunque el porcentaje de complicaciones entre los portadores de prótesis colónica (53%) dobló el del resto de pacientes (26%). CONCLUSIONES: La quimioterapia sin cirugía es una buena opción en la mayoría de los pacientes con cáncer colorrectal y metástasis irresecables. Sin embargo, aunque el porcentaje de pacientes que precisan cirugía es bajo, el número de complicaciones relacionadas con el tumor primario no es despreciable. Se necesitan estudios que permitan identificar a aquellos pacientes en los que estaría indicada una colectomía profiláctica

INTRODUCTION: Although the conventional treatment of patients with stage IV colorectal cancer involves resection of the primary tumor followed by chemotherapy, several studies suggest that in patients with few symptoms the first and only treatment should be chemotherapy. The objective of this study is to analyze the complications related to the primary tumor in a series of patients with unresectable metastatic colorectal cancer treated with chemotherapy without surgery. MATERIAL AND METHODS: Retrospective descriptive study. The study included all patients with unresectable metastatic colorectal cancer treated with chemotherapy without resection of the primary tumor (January 2007-February 2011). RESULTS: The mean age of the 61 patients analyzed was 67 ± 13 years and the performance status was 0-1 in 53 (87%). Twenty (33%) patients developed complications during follow-up. The most common complication was intestinal obstruction in 15 (25%) patients followed by perforation. Complications required surgery in 6 (10%) cases. We did not find differences in patient characteristics between those who had a complication and those without, although the complication rate in patients with a colonic stent (53%) was twice that of other patients (26%). CONCLUSIONS: Chemotherapy without surgery is a good option in most patients with unresectable metastatic colorectal cancer. However, although the percentage of patients requiring surgery is low, the total number of complications related to the primary tumor is not negligible. Studies are needed to identify those patients in whom a prophylactic colectomy could be indicated

Variation in clinical, manometric and endosonographic findings in anterior chronic anal fissure: a prospective study.

Nearly all chronic anal fissures occur in the posterior midline of the anal canal. However, some of them are in the anterior midline and are rarely double or in the lateral anal walls. The aim of this study was to determine if the clinical, manometric and endosonographic characteristics in patients with chronic anal fissure varied according to topography of the fissure. The patients included in this prospective study were divided according to a fissure site in posterior midline location (Group A, n = 84) and anterior midline location (Group B, n = 30). No differences were found regarding clinical data except that anterior fissures were more common in females. Mean maximal anal resting pressure and internal anal sphincter thickness was higher in Group A. However, these differences were not statistically significant. We found correlation between mean maximal anal resting pressure and internal anal sphincter thickness in patients suffering from anterior chronic anal fissure.

Endosonographic and manometric evaluation of internal anal sphincter in patients with chronic anal fissure and its correlation with clinical outcome after topical glyceryl trinitrate therapy.

BACKGROUND AND AIMS: Anorectal pressure studies have demonstrated internal anal sphincter (IAS) hypertonia in patients with chronic anal fissure. It is unknown however, if these changes in IAS function are associated with any abnormality in sphincter morphology. The first aim was to investigate the clinical characteristics and the manometric and endosonographic findings of the IAS in a cohort of patients with chronic anal fissure. The second aim was to investigate the association between these findings and the outcome with topical Glyceryl trinitrate (GTN) therapy. MATERIALS AND METHODS: All patients who presented with chronic anal fissure from November 1999 to May 2004 were included after failure of conservative therapy. Anorectal manometry and anal endosonography were performed before treatment with 0.2% GTN ointment twice daily was initiated. Patients were evaluated after 8 weeks. RESULTS: One hundred and twenty-four patients (66 women, mean age, 45.2 +/- 14.8 years) were included. Hypertonia of the IAS was found in 84 (68%) patients. The mean maximum IAS thickness was 3.6 +/- 0.76 mm (1.6-5.5). An abnormally thick IAS, adjusted by age, was observed in 113 (91.1%) patients. We found no correlation between resting pressure and IAS thickness (r = 0.074; p = 0.41). At 8 weeks, 52 patients (42%) had healed with complete symptoms resolution. No statistically significant differences were observed when clinical features and manometric and endosonographic findings were compared between healing and no-healing fissures. CONCLUSION: The majority of patients with chronic anal fissure present an abnormally thick IAS. Clinical, manometric and endosonographic features had no association with outcome after GTN treatment.

[Applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis]. / Aplicabilidad, seguridad y eficacia de un protocolo de tratamiento ambulatorio de la diverticulitis aguda no complicada.

INTRODUCTION: The aim of this study was to evaluate the applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis. PATIENTS AND METHODS: All patients diagnosed with uncomplicated acute diverticulitis based on abdominal computed tomography findings during a 2-year period were prospectively included. Patients with vomiting, severe comorbidities, or without an appropriate family environment were excluded. Ambulatory treatment consisted of oral antibiotics for 1 week (amoxicillin-clavulanic 1 g t.i.d. or ciprofloxacin 500 mg b.i.d. plus metronidazole 500 mg t.i.d. in patients with penicillin allergy). A clear liquid diet for the first 2 days and pain control with oral acetaminophen 1 g t.i.d. were also recommended. RESULTS: Fifty-three patients were diagnosed with uncomplicated acute diverticulitis and 13 patients were excluded. Therefore, ambulatory treatment was initiated in 40 patients. Only two patients (5%) required admission after outpatient therapy was started due to vomiting and persistent abdominal pain, respectively. In both patients, the inflammatory process was successfully resolved by intravenous antibiotic treatment. In the remaining 38 patients (95%), ambulatory treatment was completed without complications. CONCLUSIONS: Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective and applicable in most patients with tolerance to oral intake and with an appropriate family environment.

[Endosonographic and manometric assessment of the internal anal sphincter in patients with chronic anal fissure]. / Estudio ecográfico y manométrico del esfínter anal interno en individuos con fisura anal crónica.

INTRODUCTION: High anal resting pressures have been implicated in the pathophysiology of chronic anal fissure. It is not known, however, whether altered function is associated with any morphological abnormalities of the internal anal sphincter (IAS). The aims of the present study were to determine IAS thickness in patients with chronic anal fissure and to investigate the correlation between IAS thickness and anal resting pressure. PATIENTS AND METHOD: Patients with chronic anal fissure were prospectively included between November 1999 and December 2002. Patients with a history of inflammatory bowel disease, anal surgery, and those previously treated with nitroglycerine ointment or botulinum toxin were excluded. Anal endosonography and manometry were performed. IAS thickness was considered to be increased when it was > 2.5 mm in patients < 50 years and > 3 mm in patients > or = 50 years. Anal resting pressure was considered to be increased when it was higher than 80 mmHg. RESULTS: Sixty-three patients were analyzed. An abnormally thick IAS was observed in 58 patients (92%). The mean IAS thickness was 3.7 +/- 0.7 mm. IAS hypertonia was found in 47 patients (66%). The mean anal resting pressure was 91 +/- 28 mmHg. No correlation was found between IAS thickness and anal resting pressure (r = 0.05; p < 0.68). CONCLUSIONS: Most of the patients with chronic anal fissure had an abnormally thick IAS. However, increased thickness of the IAS did not correlate with increased anal resting pressure.

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

Introducción El tratamiento ambulatorio de la diverticulitis aguda no complicada es seguro y eficaz. El objetivo de este estudio es cuantificar el impacto que el tratamiento ambulatorio tiene en la reducción de costes sanitarios. Pacientes y métodos Estudio comparativo de cohortes retrospectivo. Grupo ambulatorio: pacientes diagnosticados de diverticulitis aguda no complicada tratados con antibióticos vía oral de forma ambulatoria. Grupo de tratamiento hospitalario: pacientes que cumplían criterios de tratamiento ambulatorio pero que fueron ingresados con tratamiento antibiótico intravenoso. La valoración de costes se ha realizado a través del sistema de contabilidad analítica del hospital, basado en costes totales: suma de todos los costes variables (costes directos) más el conjunto de costes generales repartidos por actividad (costes indirectos).Resultados Se incluyó a 136 pacientes, 90 en el grupo ambulatorio y 46 en el grupo de ingreso. No hubo diferencias en las características de los pacientes entre los 2 grupos. No hubo diferencias en el porcentaje de fracaso del tratamiento entre los 2 grupos (5,5 vs. 4,3%; p = 0,7). El coste global por episodio fue de 882 ± 462 euros en el grupo ambulatorio frente a 2.376 ± 830 euros en el grupo hospitalario (p = 0,0001).Conclusiones El tratamiento ambulatorio de la diverticulitis aguda no solo es seguro y eficaz sino que también reduce más de un 60% los costes sanitarios (AU)

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% (AU)

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

Introducción Los programas de rehabilitación multimodal (RHMM) en cirugía han demostrado un beneficio en la recuperación funcional de los pacientes. Nuestro objetivo fue evaluar el impacto de un programa de RHMM en los costes hospitalarios.Material y métodosEstudio prospectivo comparativo de cohortes consecutivas de pacientes intervenidos de cirugía colorrectal electiva. En la primera cohorte analizamos 134 pacientes que recibieron un control postoperatorio convencional (grupo control). En la segunda cohorte se incluye a 231 pacientes tratados con un programa de RHMM (grupo RHMM). Se analiza el cumplimiento del protocolo y la recuperación funcional de los pacientes del grupo RHMM. Se comparan las complicaciones postoperatorias, la estancia hospitalaria y los reingresos en ambos grupos. El análisis de costes se ha basado en la contabilidad analítica del centro.ResultadosLas características demográficas y clínicas de los pacientes fueron similares entre grupos. No encontramos diferencias en la morbimortalidad global. La estancia media postoperatoria fue 3 días menor en el grupo RHMM. No se observaron diferencias significativas en la tasa de reingresos. Los costes totales por paciente fueron significativamente menores en el grupo RHMM (RHMM: 8.107 ± 4.117 euros vs. control: 9.019 ± 4.667 euros; p = 0,02). El principal factor que contribuyó a la reducción de los costes fue el descenso de los gastos de la Unidad de Hospitalización.ConclusionesLa aplicación de un protocolo de RHMM en cirugía electiva colorrectal reduce, no solo la estancia hospitalaria, sino también los costes hospitalarios, sin aumentar la morbilidad postoperatoria ni el porcentaje de reingresos (AU)

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.MethodA 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-costing».ResultsThere 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.ConclusionThe 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 (AU)

Incidencia de la perforación iatrogénica por colonoscopia y resultados del tratamiento en un hospital universitario / Incidence of iatrogenic perforation during colonoscopy and their treatment in a university hospital

Introducción: La perforación del colon es una complicación poco frecuente, aunque grave, de la endoscopia digestiva baja. El tratamiento es controvertido, aunque en la mayoría de los casos es quirúrgico. Los objetivos de este estudio fueron determinar la incidencia de las perforaciones por colonoscopia en nuestro centro y conocer los resultados de las opciones terapéuticas empleadas. Material y métodos: Estudio retrospectivo de las perforaciones producidas por colonoscopia entre enero de 2004 y octubre de 2009. Las variables analizadas fueron las siguientes: características demográficas, indicación de la colonoscopia, manifestaciones clínicas, pruebas diagnósticas utilizadas, tiempo entre la perforación y el diagnóstico, tipo de tratamiento, estancia hospitalaria y complicaciones. Resultados: Durante el período de estudio se realizaron 13.493 colonoscopias. En 13 pacientes (0,1%) se produjo una perforación del colon. Nueve perforaciones ocurrieron durante la realización de una colonoscopia diagnóstica (0,08%) y las restantes 4 después de una colonoscopia terapéutica (0,16%). En 10 casos, el diagnóstico se realizó durante las primeras 12h y en 5 de ellos, la perforación se identificó durante el mismo procedimiento. La localización más frecuente fue el sigma en 7 casos. En 11 pacientes se realizó tratamiento quirúrgico y en 2 pacientes se resolvió con tratamiento conservador. La técnica quirúrgica más utilizada fue la sutura simple seguida de la resección con anastomosis. Un paciente falleció por sepsis intraabdominal. Conclusión: Las perforaciones causadas por colonoscopia son complicaciones poco frecuentes, aunque graves. La mayoría de estos pacientes precisarán tratamiento quirúrgico, y quedará reservado el tratamiento conservador para pacientes seleccionados (AU)

Introduction: Colon perforation is a fairly uncommon, but serious, complication during endoscopy of the lower gastrointestinal tract. Treatment is controversial, although surgery is used in the majority of cases. The aims of this study were to determine the incidence of perforations due to colonoscopy in our hospital and to find out the results of the treatment options used. Material and methods: Retrospective study of perforations caused by colonoscopy between January 2004 and October 2008. The variables analysed were: demographic characteristics, colonoscopy indication, clinical signs and symptoms, diagnostic tests used, time between perforation and the diagnosis, treatment type, hospital stay and complications. Results: A total of 13,493 colonoscopies were performed during the study period. A perforation of the colon was found in 13 (0.1%) patients. Nine perforations occurred whilst performing a diagnostic colonoscopy (0.08%) and the remaining 4 after a therapeutic colonoscope (0.16%). In 10 of the cases the diagnosis was made within the first 12h, and in 5 of these the perforation was identified during the procedure itself. The most common location was the sigmoid, in 7 cases. Surgical treatment was carried out on 11 patients, and in the other two it was resolved by conservative treatment. The most used surgical technique was simple suture followed by resection with anastomosis. One patient died due to intra-abdominal sepsis. Conclusion: Perforations caused by colonoscopy are rare, but serious, complications. The majority of these patients required surgical treatment, with conservative treatment being reserved for selected patients (AU)