Emergency endoscopy for gastrointestinal bleeding after bariatric surgery. Therapeutic algorithm.

OBJECTIVE: Gastrointestinal bleeding (GB) is a potential complication after bariatric surgery and its frequency is around 2-4% according to the literature. The aim of this study is to present our experience with GB after bariatric surgery, its presentation and possible treatment options by means of an algorithm. PATIENTS AND METHOD: From January 2004 to December 2012, we performed 300 consecutive laparoscopic bariatric surgeries. A total of 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of a gastrojejunal anastomosis using a circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. Demographics, clinical presentation, diagnostic evaluation and treatment were reviewed. A total of 20 patients underwent a sleeve gastrectomy. RESULTS: Twenty-seven cases (9%) developed GB. Diagnosis and therapeutic endoscopy was required in 13 patients. The onset of bleeding occurred between the 1(st)-6(th) postop days in 10 patients, and the origin was at the gastrojejunostomy staple-lines, and 3 patients had bleeding from an anastomotic ulcer 15-20 days after surgery. All other patients were managed non-operatively. CONCLUSION: Conservative management of gastrointestinal bleeding is effective in most cases, but endoscopy with therapeutic intent should be considered in patients with severe or recurrent bleeding. Multidisciplinary postoperative follow- up is very important for early detention and treatment of this complication.

Clinical Pathway for Thyroidectomy.

Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.

[GRADE system: classification of quality of evidence and strength of recommendation]. / Sistema GRADE: clasificación de la calidad de la evidencia y graduación de la fuerza de la recomendación.

The acquisition and classification of scientific evidence, and subsequent formulation of recommendations constitute the basis for the development of clinical practice guidelines. There are several systems for the classification of evidence and strength of recommendations; the most commonly used nowadays is the Grading of Recommendations, Assessment, Development and Evaluation system (GRADE). The GRADE system initially classifies the evidence into high or low, coming from experimental or observational studies; subsequently and following a series of considerations, the evidence is classified into high, moderate, low or very low. The strength of recommendations is based not only on the quality of the evidence, but also on a series of factors such as the risk/benefit balance, values and preferences of the patients and professionals, and the use of resources or costs.

Reduction in inappropriate hospital use based on analysis of the causes.

BACKGROUND: To reduce inappropriate admissions and stays with the application of an improvement cycle in patients admitted to a University Hospital. The secondary objective is to analyze the hospital cost saved by reducing inadequacy after the implementation of measures proposed by the group for improvement. METHODS: Pre- and post-analysis of a sample of clinical histories studied retrospectively, in which the Appropriateness Evaluation Protocol (AEP) was applied to a representative hospital sample of 1350 clinical histories in two phases. In the first phase the AEP was applied retrospectively to 725 admissions and 1350 stays. The factors associated with inappropriateness were analysed together with the causes, and specific measures were implemented in a bid to reduce inappropriateness. In the second phase the AEP was reapplied to a similar group of clinical histories and the results of the two groups were compared. The cost of inappropriate stays was calculated by cost accounting. SETTING: General University Hospital with 426 beds serving a population of 320,000 inhabitants in the centre of Murcia, a city in south-eastern Spain. RESULTS: Inappropriate admissions were reduced significantly: 7.4% in the control group and 3.2% in the intervention group. Likewise, inappropriate stays decreased significantly from 24.6% to 10.4%. The cost of inappropriateness in the study sample fell from 147,044 euros to 66,642 euros. The causes of inappropriateness for which corrective measures were adopted were those that showed the most significant decrease. CONCLUSIONS: It is possible to reduce inadequacy by applying measures based on prior analysis of the situation in each hospital.

[Frozen section doesn't reduce the number of reoperations for cancer after hemithyroidectomy]. / La biopsia intraoperatoria no reduce la tasa de reintervenciones por cáncer tras hemitiroidectomía.

UNLABELLED: FUNDAMENTALS AND OBJECTIVES: Frozen section (FS) constitutes a diagnostic procedure in patients following hemithyroidectomy. It is used to diagnose malignant lesions and to avoid reoperations. Our objective is to confirm this test as useless to rule out cancer. PATIENTS AND METHODS: Retrospective and comparative trial between two series of patients following hemithyroidectomy. G I: 179 patients operated in 1995-2002. In this period we performed systematic FS. Sensitivity (S), specificity (E) and predictive values (PPV, NPV) are analyzed. G II: 126 patients were operated between 2003-2008. Selective FS was performed (23 patients). Both groups are compared: hospital stay, number of FS, percentage of cancer, definitive biopsy and reoperations. RESULTS: Data analyzed in the first period: S: 48%, E: 100%, PPV: 100%, NPV: 90%, positive likelihood ratio>10, negative likelihood ratio 0.52. When both periods are compared no significant differences between reoperations are found. CONCLUSION: FS during hemithyroidectomy does not reduce reoperations for cancer.

A quality improvement cycle of the care process in a general surgery hospitalization ward.

BACKGROUND: There could be important failures in clinical data and plan records that potentially influence the surgical care process. OBJECTIVE: To complete a quality of care improvement cycle on the surgical care process in the General Surgery ward rounds. Structured quality criteria were measured, in order to identify major deficiencies, to implement improvement measures and to reassess the quality of surgical care process. Furthermore, we'll value the viability the implementation of a structured registration system and nutritional assessment method. METHOD: Comparative quality study (n = 60) before-after the setting of several improvement measures derived from the analysis of the surgical care process. Evaluated criteria were the information received by the patient, adequate recording of the clinical course and plan of care established by the surgeon in the Electronic Health Record, recording of patient's weight and size and nutritional assessment. Informative sessions, subjective, objective, assessment, plan notes on the electronic clinical record and a nutritional assessment test were implemented. RESULTS: There was a significant improvement in all measured criteria (information, data records and nutritional assessment). CONCLUSION: Simple organizational measures allow a significant improvement in the information process, clinical records and malnutrition risk detection in a surgical ward.

ANTECEDENTES: Podrían existir carencias en el registro de datos relevantes del proceso asistencial de hospitalización quirúrgica. OBJETIVO: Completar un ciclo de mejora de la calidad del proceso asistencial quirúrgico en una planta de cirugía. Mediremos unos criterios de calidad estructurados, identificando las principales deficiencias, implementando medidas de mejora y reevaluando la calidad del proceso asistencial quirúrgico. Además, se valora la viabilidad de la implantación de un sistema nemotécnico de registro de actividad y de un método de evaluación nutricional. MÉTODO: Estudio comparativo (n = 60) antes-después del establecimiento de medidas de mejora basadas en el análisis del proceso asistencial quirúrgico. Los criterios evaluados fueron la información recibida por el paciente, el registro de la evolución clínica y el plan de cuidado establecido por el cirujano en la historia clínica, el registro de peso y talla, y la valoración nutricional. Se realizaron sesiones informativas e implementación electrónica de la nota SOAP (subjetive, objetive, assessment, plan) y de un test de valoración nutricional. RESULTADOS: Hubo mejoría significativa en todos los criterios medidos (información, registro y evaluación nutricional). CONCLUSIÓN: Algunas medidas sencillas permiten una mejoría importante en la información, la evaluación nutricional y el registro del proceso asistencial en una planta de cirugía.

Associated factors and cost of inappropriate hospital admissions and stays in a second-level hospital.

The objective of this study was to analyze the variables related to inappropriate admissions and hospital stays and their financial repercussions. This was a descriptive retrospective study in which the Appropriateness Evaluation Protocol (AEP) was applied to a representative sample of 725 hospital admissions and 1350 hospital stays. The cost of inappropriate stays was calculated by cost accounting. The study found that 7.4% of admissions and 24.6% of stays were inappropriate. Inappropriate admissions were significantly related to medical specialties and younger patient age. Inappropriate stays were related to these factors, plus patients being outside their corresponding areas, nonurgent admissions, and low occupancy rate. The cost of the inappropriate admissions and stays was 147 044 euros. Extrapolated to the hospital as a whole this would represent 2125638 euros per year. Steps must be taken to reduce inappropriate admissions and stays to lower health care costs and to reserve hospital resources for patients who genuinely need them.

[Diagnostic value of intraoperative parathyroid hormone decline in prediction of hypocalcemia after total thyroidectomy]. / Validez diagnóstica del descenso intraoperatorio de paratirina en la predicción de hipocalcemia tras tiroidectomía total.

BACKGROUND AND OBJECTIVE: Transient or definitive hypocalcemia is one of the most important complications following total thyroidectomy. Monitoring of serum calcium levels or calcium replacement in all patients are methods commonly used to avoid this problem. Our objective was to validate the intraoperative parathormone assay (PTH) as a predictive tool in these situations. PATIENTS AND METHOD: We conducted a prospective study of 46 patients undergoing total thyroidectomy. PTH levels were obtained during the anesthetic induction, 10min after the procedure and 24h after surgery. Calcium levels were obtained 24 and 48h after surgery. The predictive value of postoperatory levels of PTH and its decline respect the preoperatory levels for prediction of hypocalcemia was measured. Hypocalcemia was defined as an ionized calcium<4mg/dl (<1mmol/l). RESULTS: Of 46 patients, 13 (28.3%) developed hypocalcemia. Isolated postoperative PTH level was a poor predictor of hypocalcemia. Nevertheless, when the gradient between preoperative and postoperative levels of PTH was considered, the rate of the decline became a good predictor of hypocalcemia, with 85-90% being the most accurate cut-off point. CONCLUSIONS: The decline of PTH in the immediate postoperative period of patients undergoing total thyroidectomy is a reliable test for predicting hypocalcemia.

Evaluation of the clinical pathway for laparoscopic bariatric surgery.

BACKGROUND: Clinical pathways (CP) are comprehensive systematized patient care plans for specific procedures. The CP for morbid obesity was implemented in our department in September 2005. The aim of this study is to evaluate the clinical pathway for this procedure 1 year after implementation. METHODS: A study was conducted on all the patients included in the CP since its implementation. The assessment criteria include degree of compliance, indicators of clinical care effectiveness, financial impact, and survey-based indicators of satisfaction. The results are compared to a series of patients undergoing surgery the year before the implementation of the CP. We analyzed the mean cost per procedure before and after CP implementation. RESULTS: Evaluation was made of a series of 49 consecutive patients who underwent surgery over the period of 1 year before the development of the CP and met the accepted inclusion criteria. The mean length of hospital stay was 7.95 days, and the mean cost per procedure before pathway implementation was 5,270.37 (+/-2,251.19) euros. One year after the implementation of the pathway, 70 patients were included. The mean length of hospital stay of the patients included in the CP was 5.1 days. The degree of compliance with stays was 71.4%. The most frequent reason for noncompliance was patient-dependent causes. The mean cost in the series of patients included in the CP was 4,532 (+/-1,753) euros. CONCLUSION: The CP for morbid obesity reduced both variability in professional care patterns and hospital costs; justifying the work involved in its development and implementation.

Evaluation and monitoring of the clinical pathway for thyroidectomy.

The aim of this study is to present the evaluation and monitoring of a clinical pathway for thyroidectomy 1 year after its implementation and after 4 years' follow up. We compare the results of an evaluation and monitoring indicators series before and after the establishment of the clinical pathway for thyroidectomy in the Surgery Department of Morales Meseguer Hospital, a general university hospital in Murcia, Spain. Implementation of the clinical pathway led to a reduction in length of hospital stay for all the surgery patients (4.8 +/- 2.1 and 3.6 +/- 1.9 days before and after pathway implementation, respectively; P < 0.001). Implementation of the clinical pathway led to a reduction in cost in all the operated patients (3357 +/- 966 and 2695 +/- 970 US$ before and after implementing the clinical pathway, respectively; P < 0.001). Evolution of the mean hospital cost according to year of study shows a reduction from 2000 (3400 +/- 1056 US$) to 2004 (2404 +/- 666 US$) with a slight increase during 2005 (2721 +/- 1335 US$) (P < 0.001). Implementation of the clinical pathway for thyroidectomy has successfully reduced clinical variation and therefore the length of hospital stay and mean cost of the process. In subsequent years, no such major improvements have been made with regard to hospital stay, although they are still clearly better than those before pathway implementation.

Incidental versus non-incidental thyroid carcinoma: Clinical presentation, surgical management and prognosis. / Carcinoma de tiroides incidental versus no incidental: presentación clínica, tratamiento quirúrgico y pronóstico.

BACKGROUND AND OBJECTIVE: Thyroid cancer may be clinically evident as a tumor mass in the neck or as a histopathological incidental finding after thyroid surgery for an apparent benign condition. Our objective was to assess the differences in clinical signs, surgical management, and course between incidental and clinically diagnosed thyroid tumors. METHODS: A retrospective study was conducted on patients operated on for benign or malignant thyroid disease from January 2000 to March 2014. Among the 1415 patients who underwent any thyroid surgery, 264 neoplasms were found, of which 170 were incidental. A comparison was made of incidental versus non-incidental carcinomas. Among incidental carcinomas, cases whose indication for surgery was Graves' disease were compared to those with multinodular goiter. RESULTS: Incidental carcinomas were in earlier stages and required less aggressive surgery. There were no differences in surgical complications between incidental and clinical tumors, but mortality and relapses were markedly higher in non-incidental cancers (4.4% vs 0% and 13.2% vs 4.8% respectively). Carcinomas developing on Graves' disease showed no differences from all other incidental tumors in terms of complications, mortality, or relapse after surgery. CONCLUSIONS: Early stage thyroid cancer has better survival and prognosis after surgical treatment.