Economic impact of outpatient follow-up using telemedicine vs in-person visits for patients in general surgery: A secondary analysis of a randomized clinical trial.

INTRODUCTION: Innovation in internet connectivity and the Covid 19 pandemic have caused a dramatic change in the management of patients in the medical field, boosting the use of telemedicine. A comparison of clinical outcomes and satisfaction between conventional face-to-face and telemedicine follow-up in general surgery, an economic evaluation is mandatory. The aim of the present study was to compare the differences in economic costs between these two outpatient approaches in a designed randomized controlled trial (RCT). METHODS: A RCT was conducted enrolling 200 patients to compare conventional in-person vs. digital health follow-up using telemedicine in the outpatient clinics in patients of General Surgery Department after their planned discharge. After a demonstration that no differences were found in clinical outcomes and patient satisfaction, we analyzed the medical costs, including staff wages, initial investment, patent's transportation and impact on social costs. RESULTS: After an initial investment of 7527.53€, the costs for the Medical institution of in-person conventional follow-up were higher (8180.4€) than those using telemedicine (4630.06€). In relation to social costs, loss of productivity was also increased in the conventional follow-up. CONCLUSION: The use of digital Health telemedicine is a cost-effective approach compared to conventional face-to-face follow-up in patients of General Surgery after hospital discharge.

Urethral Injury in Rectal Cancer Surgery: A Comprehensive Study Using Cadaveric Dissection, Imaging Analyses, and Clinical Series.

Male urethral injury during rectal cancer surgery is rare but significant. Scant information is available about the distances between the rectourethral space and neighboring structures. The aim of this study is to describe the anatomical relations of the male urethra. This three-pronged study included cadaveric dissection, retrospective MRI analysis, and clinical cases. Measurements included the R-Mu distance (shortest distance between the rectum and the membranous urethra), R-Am distance (distance from the anterior rectal wall to anal margin nearest to the membranous urethra), and the anal canal-rectum axis angle. The clinical study analyzed the incidence of urethral injury and associated factors among 244 consecutive men from January 2016 to January 2023. The overall incidence of urethral injury in our series was low (0.73%), but in men with tumors < 10 cm from the anal margin, it was 4% in abdominoperineal resection and 3.2% in TaTME. On preoperative MRI, the median R-Mu distance was 1 cm (IQR, range, 0.2-2.3), the median R-Am distance was 4.3 cm (range, 2-7.3), and the median anorectal angle was 128° (range, 87-160). In the cadaveric study (nine adult male pelvises), the mean R-Mu distance was 1.18 cm (range 0.8-2), and the mean R-Am distance was 2.64 cm (range 2.1-3). Avoiding urethral injury is crucial. The critical point for injury lies 2-7.3 cm from the anal margin, with a 0.2-2.3 cm distance between the rectum and the membranous urethra. Collaborating with anatomists and radiologists improves surgeons' anatomy knowledge.

Impact on defecatory, urinary and sexual function after high-tie sigmoidectomy: a post-hoc analysis of a multicenter randomized controlled trial comparing extended versus standard complete mesocolon excision.

OBJECTIVE: To assess the effect of high inferior mesenteric artery tie on defecatory, urinary, and sexual function after surgery for sigmoid colon cancer. Performing a sigmoidectomy poses a notable risk of causing injury to the preaortic sympathetic nerves during the high ligation of the inferior mesenteric artery, as well as to the superior hypogastric plexus during dissection at the level of the sacral promontory. Postoperative defecatory and genitourinary dysfunction after sigmoid colon resection are often underestimated and underreported. METHODS: This study is a secondary research of a multicenter, single-blind, randomized clinical trial. The trial involved patients with sigmoid cancer who underwent either extended complete mesocolic excision (e-CME) or standard CME (s-CME). Patients completed questionnaires to assess defecatory, urinary, and sexual function before, 1 month after surgery, and 1 year after surgery. Multivariate analysis was conducted to identify factors associated with functional dysfunction. RESULTS: Seventy-nine patients completed functional assessments before and 1 year after surgery. One year after sigmoidectomy with a high tie of the inferior mesenteric artery, 15.2% of patients had minor low anterior resection syndrome (LARS) and 12.7% had major LARS; 22.2% of males and 29.4% of females had urinary dysfunction; and 43.8% of males and 27.3% of females had sexual dysfunction. After multivariate analysis, no significant associations were found between clinical and surgical factors and gastrointestinal or urinary dysfunction after 1 year of surgery. Age was identified as the only factor linked to sexual dysfunction in both sexes (women, ß = - 0.54, p = 0.002; men ß = - 0.38, p = 0.010). Regarding recovery outcomes, diabetes mellitus was identified as a contributing factor to suboptimal gastrointestinal recovery (p = 0.033) and urinary recovery in women (p = 0.039). Furthermore, the treatment arm was found to be significantly associated with the recovery of erectile function after 1 year of surgery (p = 0.046). CONCLUSIONS: A high tie of the inferior mesenteric artery during sigmoidectomy is associated with a high incidence of defecatory and genitourinary dysfunction. Age was identified as a significant factor associated with sexual dysfunction 1 year after sigmoid colon resection in both sexes. TRIAL REGISTRATION: Clinical trials NCT03083951 HIGHLIGHTS: • One year after high-tie sigmoidectomy, 27.9% of patients had LARS; 22.2% of the men and 29.4% of the women had urinary dysfunction; and 43.8% of the men and 27.3% of the women had sexual dysfunction. • e-CME is associated with a high rate of urinary dysfunction in men 1 year after surgery. However, after multivariate analysis, no association was found between e-CME and urinary dysfunction in men. • Age was correlated with the recovery of sexual function in both sexes 1 year after surgery. Furthermore, diabetes mellitus was identified as the factor associated with poorer recovery of urinary function in females.

Endoscopic treatment (endoscopic balloon dilation/self-expandable metal stent) vs surgical resection for the treatment of de novo stenosis in Crohn's disease (ENDOCIR study): an open-label, multicentre, randomized trial.

BACKGROUND: Stenosis is one of the most common complications in patients with Crohn's disease (CD). Endoscopic balloon dilation (EBD) is the treatment of choice for a short stenosis adjacent to the anastomosis from previous surgery. Self-expandable metal stents (SEMS) may be a suitable treatment option for longer stenoses. To date, however, there is no scientific evidence as to whether endoscopic (EBD/SEMS) or surgical treatment is the best approach for de novo or primary stenoses that are less than 10 cm in length. METHODS/DESIGN: Exploratory study as "proof-of-concept", multicentre, open-label, randomized trial of the treatment of de novo stenosis in the CD; endoscopic treatment (EBD/SEMS) vs surgical resection (SR). The type of endoscopic treatment will initially be with EDB; if a therapeutic failure occurs, then a SEMS will be placed. We estimate 2 years of recruitment and 1 year of follow-up for the assessment of quality of life, costs, complications, and clinical recurrence. After the end of the study, patients will be followed up for 3 years to re-evaluate the variables over the long term. Forty patients with de novo stenosis in CD will be recruited from 15 hospitals in Spain and will be randomly assigned to the endoscopic or surgical treatment groups. The primary aim will be the evaluation of the patient quality of life at 1 year follow-up (% of patients with an increase of 30 points in the 32-item Inflammatory Bowel Disease Questionnaire (IBDQ-32). The secondary aim will be evaluation of the clinical recurrence rate, complications, and costs of both treatments at 1-year follow-up. DISCUSSION: The ENDOCIR trial has been designed to determine whether an endoscopic or surgical approach is therapeutically superior in the treatment of de novo stenosis in CD. TRIAL REGISTRATION: ClinicalTrials.gov NCT04330846. Registered on 1 April 1 2020. https://clinicaltrials.gov/ct2/home.

Prognostic Value of the Circumferential Resection Margin After Curative Surgery for Rectal Cancer: A Multicenter Propensity Score-Matched Analysis.

BACKGROUND: Recently, positive circumferential resection margin has been found to be an indicator of advanced disease with a high risk of distant recurrence rather than local recurrence. OBJECTIVE: The study aimed to analyze the prognostic impact of the circumferential resection margin on long-term oncological outcomes in patients with rectal cancer. DESIGN: This was a multicenter, propensity score-matched (2:1) analysis comparing the positive and negative circumferential resection margins. SETTINGS: The study was conducted at 5 high-volume centers in Spain. PATIENTS: Patients who underwent total mesorectal excision with curative intent for middle-low rectal cancer between 2006 and 2014 were included. MAIN OUTCOME MEASURES: The main outcomes were local recurrence, distant recurrence, overall survival, and disease-free survival. RESULTS: The unmatched initial cohort consisted of 1599 patients, of whom 4.9% had a positive circumferential resection margin. After matching, 234 patients were included (156 with a negative circumferential margin and 78 with a positive circumferential margin). The median follow-up period was 52.5 (22.0-69.5) months. Local recurrence was significantly higher in patients with a positive circumferential margin (33.3% vs 11.5%; p < 0.001). Distant recurrence was similar in both groups (46.2% vs 42.3%; p = 0.651). There were no statistically significant differences in 5-year overall survival (48.6% vs 43.6%; p = 0.14). Disease-free survival was lower in patients with a positive circumferential margin (36.1% vs 52.3%; p = 0.026). LIMITATIONS: This study was limited by its retrospective design. The different neoadjuvant treatment options were not included in the propensity score. CONCLUSIONS: The positive circumferential resection margin was associated with a higher local recurrence rate and worse disease-free survival in comparison with the negative circumferential resection margin. However, the positive circumferential resection margin was not a prognostic indicator of distant recurrence and overall survival. See Video Abstract at http://links.lww.com/DCR/B950 . VALOR PRONSTICO DEL MARGEN DE RESECCIN CIRCUNFERENCIAL DESPUS DE LA CIRUGA CURATIVA PARA EL CNCER DE RECTO UN ANLISIS MULTICNTRICO EMPAREJADO POR PUNTAJE DE PROPENSIN: ANTECEDENTES:En los últimos años, se ha encontrado que el margen de resección circunferencial positivo es un indicador de enfermedad avanzada con alto riesgo de recurrencia a distancia más que de recurrencia local.OBJETIVO:El objetivo fue analizar el impacto pronóstico del margen de resección circunferencial sobre la recidiva local, a distancia y las tasas de supervivencia en pacientes con cáncer de recto.DISEÑO:Este fue un análisis multicéntrico emparejado por puntaje de propensión 2: 1 que comparó el margen de resección circunferencial positivo y negativo.AJUSTES:El estudio se realizó en 5 centros Españoles de alto volumen.PACIENTES:Se incluyeron pacientes sometidos a escisión total de mesorrecto con intención curativa por cáncer de recto medio-bajo entre 2006-2014. Las características clínicas e histológicas se utilizaron para el emparejamiento.PRINCIPALES MEDIDAS DE RESULTADO:Los resultadoes principales fueron la recurrencia local, la recurrencia a distancia, la supervivencia global y libre de enfermedad.RESULTADOS:La cohorte inicial no emparejada consistió en 1599 pacientes; El 4,9% tuvo un margen de resección circunferencial positivo. Tras el emparejamiento se incluyeron 234 pacientes (156 con margen circunferencial negativo y 78 con margen circunferencial positivo). La mediana del período de seguimiento fue de 52,5 meses (22,0-69,5). La recurrencia local fue significativamente mayor en pacientes con margen circunferencial positivo, 33,3% vs 11,5% [HR 3,2; IC 95%: 1,83-5,43; p < 0,001]. La recidiva a distancia fue similar en ambos grupos (46,2 % frente a 42,3 %) [HR 1,09, IC 95 %: 0,78-1,90; p = 0,651]. No hubo diferencias significativas en la supervivencia global a 5 años (48,6 % frente a 43,6 %) [HR 1,09, IC 95 %: 0,92-1,78; p = 0,14]; La supervivencia libre de enfermedad fue menor en pacientes con margen circunferencial positivo, 36,1% vs 52,3% [HR 1,5; IC 95%: 1,05-2,06; p = 0,026].LIMITACIONES:Este estudio estuvo limitado por el diseño retrospectivo. Las diferentes opciones de tratamientos neoadyuvantes no se han incluido en la puntuación de propensión.CONCLUSIONES:El margen de resección circunferencial positivo se asocia con una mayor tasa de recurrencia local y peor supervivencia libre de enfermedad en comparación con el margen de resección circunferencial negativo. Sin embargo, el margen de resección circunferencial positivo no fue un indicador pronóstico de recidiva a distancia ni de supervivencia global. Consulte el Video del Resumen en http://links.lww.com/DCR/B950 . (Traducción- Dr. Yesenia Rojas-Khalil ).

Challenges and Learning Curves in Adopting TaTME and Robotic Surgery for Rectal Cancer: A Cusum Analysis.

New techniques are being developed to improve the results of laparoscopic surgery for rectal cancer. This paper analyzes the learning curves for transanal total mesorectal excision (taTME) and robot-assisted surgery in our colorectal surgery department. We analyzed retrospectively data from patients undergoing curative and elective surgery for rectal cancer ≤12 cm from the anal verge. We excluded extended surgeries. We used cumulative sum (CUSUM) curve analysis to identify inflection points. Between 2015 and 2021, 588 patients underwent surgery for rectal cancer at our center: 67 taTME and 79 robot-assisted surgeries. To overcome the operative time learning curve, 14 cases were needed for taTME and 53 for robot-assisted surgery. The morbidity rate started to decrease after the 17th case in taTME and after the 49th case in robot-assisted surgery, but it is much less abrupt in robot-assisted group. During the initial learning phase, the rate of anastomotic leakage was higher in taTME (35.7% vs. 5.7%). Two Urological lesions occurred in taTME but not in robot-assisted surgery. The conversion rate was higher in robot-assisted surgery (1.5% vs. 10.1%). Incorporating new techniques is complex and entails a transition period. In our experience, taTME involved a higher rate of serious complications than robot-assisted surgery during initial learning period but required a shorter learning curve.

Extended Versus Standard Complete Mesocolon Excision in Sigmoid Colon Cancer: A Multicenter Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to evaluate whether extended complete mesocolic excision (e-CME) for sigmoid colon cancer improves oncological outcomes without compromising morbidity or functional results. BACKGROUND: In surgery for cancer of the sigmoid colon and upper rectum, s-CME removes the lymphofatty tissue surrounding the inferior mesenteric artery (IMA), but not the lymphofatty tissue surrounding the portion of the inferior mesenteric vein that does not run parallel to the IMA. Evidence about the safety and efficacy of extending CME to include this tissue is lacking. METHODS: This single-blind study randomized sigmoid cancer patients at 4 centers to undergo e-CME or s-CME. The primary outcome was the total number of lymph nodes harvested. Secondary outcomes included disease-free and overall survival at 2 years, morbidity, and bowel and genitourinary function. Clinicaltrials.gov: NCT03107650. RESULTS: We analyzed 93 patients (46 e-CME and 47 s-CME). Perioperative outcomes were similar between groups. No differences between groups were found in the total number of lymph nodes harvested [21 (interquartile range, IQR, 14-29) in e-CME vs 20 (IQR, 15-27) in s-CME, P = 0.873], morbidity (P = 0.829), disease-free survival (P = 0.926), or overall survival (P = 0.564). The extended specimen yielded a median of 1 lymph node (range, 0-6), none of which were positive.Bowel function recovery was similar between arms at all timepoints. Males undergoing e-CME had worse recovery of urinary function (P = 0.026). CONCLUSION: Extending lymphadenectomy to include the IMV territory did not increase the number of lymph nodes or improve local recurrence or survival rates.

Is Metformin Associated With Improved Response to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer?

BACKGROUND: Efforts to determine whether metformin can increase the effectiveness of neoadjuvant chemoradiotherapy in rectal cancer have increased in recent years. However, retrospective studies have yielded inconclusive results. OBJECTIVES: The aim of this study was to compare oncological outcomes and survival after neoadjuvant chemoradiotherapy in patients with rectal cancer taking metformin versus in those not taking metformin. METHODS: This study analyzed 423 consecutive patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy and curative surgery between January 2010 and May 2020; of these, 59 were taking metformin and 364 were not taking metformin. RESULTS: Patients taking metformin had a lower proportion of tumor regression (6.8% versus 22.0%, P = 0.012) as well as a lower proportion of patients achieving a pathological complete response (6.8% versus 20.6%, P = 0.011). In the multivariate analysis, independent predictors of pathologic complete response were not taking metformin (OR: 5.26, 95% CI: 1.12-24.85, P= 0.035) and cT2 stage (OR: 3.49, 95% CI: 1.10-11.07, P= 0.034); the interval was also an independent predictor of tumor regression (OR: 1.78, 95% CI: 1.06-2.96, P= 0.028). No differences were observed in survival between groups. CONCLUSION: Metformin was not associated with better tumor responses or survival after neoadjuvant treatment.

Risk factors for suboptimal laparoscopic surgery in rectal cancer patients.

PURPOSE: Laparoscopic surgery for rectal cancer is technically complex. This study aimed to identify risk factors for suboptimal laparoscopic surgery (involved margins, incomplete mesorectal excision, and/or conversion to open surgery) in patients with rectal cancer. METHODS: We included patients undergoing laparoscopic anterior resection for rectal cancer between June 2009 and June 2018. We defined the outcome variable suboptimal laparoscopic surgery as conversion to open surgery or inadequate histopathological specimens (margins < 1 mm or involved and/or poor-quality mesorectal excision). To identify independent predictors of suboptimal laparoscopic surgery, we analyzed 15 prospectively recorded demographic, clinical, and anthropometric variables obtained from our rectal cancer unit's database. Subanalyses examined the same variables with respect to conversion and to inadequate histopathological specimens. RESULTS: Of the 323 patients included, 91 (28.2%) had suboptimal laparoscopic surgery. In the multivariate analysis, the independent factors associated with all suboptimal laparoscopic surgery were tumor location ≤ 5 cm from the anal verge (OR = 2.95, 0.95% CI 1.32-6.60; p = 0.008) and the intertuberous distance (OR = 0.79, 0.95% CI 0.65-0.96; p = 0.019). In the subanalyses, the promontorium-retropubic axis was an independent predictor of conversion (OR 0.70, 0.95% CI 0.51-0.96; p = 0.026), and tumor location ≤ 5 cm from the anal verge (OR 3.71, 0.95% 1.51-9.15; p = 0.004) was an independent predictor of inadequate histopathological specimens. CONCLUSIONS: Predictive factors for suboptimal laparoscopic anterior resection for rectal cancer were tumor location and the intertuberous distance. These results could help surgeons decide whether to use other surgical approaches in complex cases. TRIAL REGISTRATION: The study was registered at Clinicaltrials.org (No. NCT03107650).

Randomized clinical trial comparing side to end vs end to end techniques for colorectal anastomosis.

BACKGROUND: Low anterior resection syndrome affects 60%-90% of patients with anastomoses after colorectal resection. Consensus regarding the best anastomosis is lacking. OBJECTIVE: To compare outcomes after end-to-end versus side-to-end anastomoses. DESIGN: Randomized clinical trial. SETTINGS: University hospital (April 2016-October 2017). PATIENTS: Patients aged ≥18 years with rectal or sigmoid adenocarcinoma. INTERVENTIONS: Patients were randomized to undergo mechanical end-to-end or side-to-end (n = 33) anastomosis after laparoscopic resection. MAIN OUTCOME MEASURES: Primary outcome was to assess intestinal function (COREFO and LARS questionnaires) 12 months after surgery or ileostomy closure. Secondary outcomes were postoperative complications and intestinal function and quality of life (SF-36® questionnaire) at different time points after surgery or ileostomy closure. RESULTS: No significant differences in intestinal function were observed between the two groups 12 months after surgery. Subanalysis of low-mid rectum tumors with end-to-end anastomosis yielded better function at 12 months. Postoperative complications did not differ between the two groups (p = 0.070), but reinterventions were more common in the side-to-end group (p = 0.040). Multivariate analysis found neoadjuvant treatment was independently associated with intestinal dysfunction at 12 months (ß = 0.41, p = 0.033, COREFO; ß = 0.41, p = 0.024, LARS). CONCLUSIONS: End-to-end anastomosis yielded low rates of severe complications and reintervention, as well as better intestinal function at 12 months in the subgroup with tumors in the low-mid rectum. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT02746224.

Highly sensitive MLH1 methylation analysis in blood identifies a cancer patient with low-level mosaic MLH1 epimutation.

Constitutional MLH1 methylation (epimutation) is a rare cause of Lynch syndrome. Low-level methylation (≤ 10%) has occasionally been described. This study aimed to identify low-level constitutional MLH1 epimutations and determine its causal role in patients with MLH1-hypermethylated colorectal cancer.Eighteen patients with MLH1-hypermethylated colorectal tumors in whom MLH1 methylation was previously undetected in blood by methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) were screened for MLH1 methylation using highly sensitive MS-melting curve analysis (MS-MCA). Constitutional methylation was characterized by different approaches.MS-MCA identified one patient (5.6%) with low-level MLH1 methylation (~ 1%) in blood and other normal tissues, which was confirmed by clonal bisulfite sequencing in blood. The patient had developed three clonally related gastrointestinal MLH1-methylated tumor lesions at 22, 24, and 25 years of age. The methylated region in normal tissues overlapped with that reported for other carriers of constitutional MLH1 epimutations. Low-level MLH1 methylation and reduced allelic expression were linked to the same genetic haplotype, whereas the opposite allele was lost in patient's tumors. Mutation screening of MLH1 and other hereditary cancer genes was negative.Herein, a highly sensitive MS-MCA-based approach has demonstrated its utility for the identification of low-level constitutional MLH1 epigenetic mosaicism. The eventual identification and characterization of additional cases will be critical to ascertain the cancer risks associated with constitutional MLH1 epigenetic mosaicism.

A randomized clinical trial comparing the initial vascular approach to the inferior mesenteric vein versus the inferior mesenteric artery in laparoscopic surgery of rectal cancer and sigmoid colon cancer.

BACKGROUND: The inferior mesenteric artery approach with a selective lateral splenic flexure mobilization is the most widely used initial step in laparoscopic rectal and left colon surgery. Surgery started through the inferior mesenteric vein (IMV) with systematic medial mobilization (MM) has some theoretical advantages that have never been analyzed in a clinical trial. The aim of this study was to compare the two techniques with regards to surgical technique variables (conversion, surgical time, bleeding, morbidity, and mortality) and pathological outcomes. METHODS: A single-blinded, randomized, controlled trial of patients operated electively by laparoscopic with curative intention for rectal or sigmoid cancer was performed at a single, specialized colorectal surgery department from April 2016 to October 2017. RESULTS: 49 patients were included in each group. There were no statistical differences in patient demographics between the two approaches. Pathological outcomes did not differ between the two groups. Intra-operative characteristics showed a higher conversion rate in patients in which the inferior mesenteric artery was dissected first (p = 0.031). The artery approach also increased intra-operative bleeding (p = 0.049), but there were no differences regarding operative time. On multivariate analysis, the artery approach was associated with a higher risk of conversion (OR 8.68; p = 0.050). Post-operatory complications did not differ between artery and vein dissection. CONCLUSIONS: In our study, the initial approach by the IMV with a systematic MM of the splenic flexure has allowed us to reduce the conversion rate without increasing complications or the surgical time. No differences were observed in the pathological results. Both approaches seem to be safe and effective and well-trained laparoscopic surgeons should have the two techniques available to them for use as needed.

Subtotal colectomy versus left hemicolectomy for the elective treatment of splenic flexure colonic neoplasia.

BACKGROUND: Optimal elective surgical treatment for splenic flexure neoplasm (SFN) is unclear. Subtotal colectomy (STC) and left hemicolectomy (LHC) are the two more common strategies used. METHODS: Observational multicentric study comparing postoperative morbidity, mortality and long-term survival on patients with SFN electively operated by STC versus LHC between 2003 and 2014. RESULTS: After revision of the databases, 144 patients were included (STC group, n = 68; LHC group, n = 76). No differences were found on epidemiological and surgical data. A higher global morbidity (58%vs37%, p = 0.014), surgical morbidity (50%vs33%, p = 0.037), postoperative ileus (37%vs20%, p = 0.023) and harvested lymph nodes (26vs18, p = 0.0001) were found on the STC group. No significant differences in complications according to severity, reoperation rate, hospital stay, mortality, recurrence or long-term survival were found between groups. CONCLUSIONS: A higher surgical morbidity was found on the STC group, mainly due to mild postoperative ileus. No differences on long-term oncological results were found.

[Teaching Bioethics to Students of Medicine with Problem-Based Learning (PBL)]. / Enseñar Bioética a Estudiantes de Medicina Mediante el Aprendizaje Basado en Problemas (ABP).

We present the experience of the introduction of the subject of bioethics in a medical school in order to give to the 73 students of 5th degree skills to handle ethical conflicts in their practice. The main teaching method used was problem-based learning (PBL). Skills objectives are described. The course was structured with a theoretical seminar (2 hours of duration), a workshop (2 hours of duration), 4 cases of PBL (24 hours of duration in total) and a role playing workshop (2 hours of duration). The seminar was aimed at the acquisition of theoretical knowledge. The PBL cases provided critical appraisal, obtaining knowledge, and application. The Role Playing set out for the practical demonstration of skills acquired in a simulated environment. A continuous assessment of students was performed throughout their practice on the PBL cases (40% of the final score) and also a final evaluation of the course was carried out via exam (60% of the final score). Students completed a course and faculty evaluation anonymously, which came out with positive results (median score of 8.5/10).