Colorectal surgery and surgical site infection: is a change of attitude necessary?

INTRODUCTION: Surgical site infection (SSI) can be as high as 30% in patients undergoing colorectal surgery and is associated with an increase in morbidity and mortality. The aim of this study is to evaluate the impact of a set of simple preventive measures that have resulted in a reduction in surgical site infection in colorectal surgery. APPLIED METHOD: Prospective study with two groups of patients treated in the colorectal unit of the "Clinico Universitario Lozano Blesa" hospital in Zaragoza. One group was subject to our measures from February to May 2015. The control group was given conventional treatment within a time period of 3 months before the set of measures were implemented. RESULTS: One hundred forty-nine patients underwent a major colorectal surgical procedure. Seventy (47%) belonged to the control group and were compared to the remaining 79 patients (53% of the total), who were subject to our treatment bundle in the period tested. Comparing the two groups revealed that our set of measures led to a general reduction in SSI (31.4 vs. 13.6%, p = 0.010) and in superficial site infection (17.1 vs. 2.5%, p = 0.002). As a consequence, the postoperative hospital stay was shortened (10.0 vs. 8.0 days, p = 0.048). However, it did not, the number of readmissions nor the re-operation rate. SSI was clearly related to open surgery. CONCLUSIONS: The preventive set of measures applied in colorectal surgery led to a significant reduction of the SSI and of the length of hospital stay.

Factores ecográficos predictivos de invasión linfática en el cáncer de recto. Estudio “ex-corpore” / Predictive ultrasound factors of lymphatic invasion in rectal cancer: "extra-corporeal" study

Objetivo: la eficacia en la valoración preoperatoria mediante ecografía endorrectal de los ganglios linfáticos se sitúa en torno al 50-70%, no existiendo unos patrones eco-morfológicos de amplio uso clínico. En este estudio valoramos los parámetros morfológicos conocidos para buscar una herramienta de ayuda clínica que mejore la precisión diagnóstica en la valoración de los ganglios linfáticos del mesorrecto. Material y método: las piezas quirúrgicas de 24 pacientes sometidos a cirugía radical por cáncer de recto sin radioterapia previa fueron sumergidas en un baño de agua caliente inmediatamente después de la cirugía y estudiadas mediante ecografía endoluminal (sonda circular de 360° y transductor de 10 Mhz). Se tomaron imágenes de todos los ganglios visualizados que fueron marcados adecuadamente para su estudio anatomopatológico. Resultados: el estudio “in vitro” de las 24 piezas de resección llevó a la identificación de 318 nódulos (218 no neoplásicos y 100 neoplásicos). Todas las variables ecográficas estudiadas se mostraron significativas, pero solo la lobulación, la ecogenicidad y la reflexión hiliar lo fueron independientes. Usando el sumatorio de todos los parámetros morfológicos se diseñó un sistema de puntuación con una sensibilidad del 98% y una especificidad del 99,1%. Conclusiones: el análisis pormenorizado de las imágenes ganglionares ecográficas puede conseguir una eficacia diagnóstica muy elevada y ayudar en la selección del tratamiento más adecuado para cada paciente (AU)

Objective: the accuracy of preoperative endorectal ultrasound in the status evaluation of lymph nodes is around 50-70%, with a lack of eco-morphological patterns of clinical use. Since, accurate local staging is of great value in prognosis and decision-making we decided to analyze the referenced eco-morphological parameters in a try to find a proper predictive tool of clinical help that could improve the accuracy of rectal ultrasound. Material and method: the resected specimens of 24 patients that were operated on by radical surgery because rectal cancer, without preoperative radiotherapy were suspended in warm water and ultrasound scanned (360° circular probe with a transducer of 10 Mhz). All souspicious nodes were recorded and marked for the definitive histological report. Results: from the 24 specimens, 318 nodes were imaged (210 benign and 100 involved). All ultrasound parametes analysed were significant but only lobulation, echogenicity and hilar reflection were independent values. An score system was design with the addition of all parameters that showed a sensitivity of 98% and specificity of 99,1%. Conclusions: our study shows that a careful study of ultrasound lymph node images can get a high level of accuracy and better help in tailoring the treatment of any particular case (AU)

Incidencia de efectos adversos en un servicio de cirugía general / Incidence of adverse events in a general surgery unit

Objetivo La práctica clínica es una actividad acompañada de riesgos e incertidumbre. Los objetivos son estimar la incidencia de pacientes quirúrgicos con efectos adversos (EA), analizar los factores asociados y estimar su impacto e identificar las posibilidades de prevención. Pacientes y método Estudio ambispectivo de los pacientes atendidos en una unidad de un servicio de cirugía general de un hospital de tercer nivel. La revisión de todos los ingresos se realizó de forma prospectiva con una guía de cribado, examinándose de manera retrospectiva con un cuestionario modular todas las historias clínicas que cumplieron criterios de cribado. Resultados Se revisaron 989 historias con un valor predictivo positivo (VPP) para EA de la guía de cribado de 53%. La incidencia acumulada de pacientes con EA fue del 17,8% y la densidad de incidencia de EA de 1,92/100 días de hospitalización. Los factores intrínsecos y extrínsecos se asociaron a mayor riesgo de EA; los eventos más frecuentes fueron las infecciones nosocomiales (54,4%) y los problemas quirúrgicos (31,8%) y los de medicación (7,4%). El 66,8% de los EA fueron considerados moderados (el 53,5% de todos los EA evitables).Conclusiones El cuestionario de cribado ha sido útil para la valoración de EA. Los EA son frecuentes en pacientes quirúrgicos y repercuten en la utilización de los recursos hospitalarios. Los factores asociados más relevantes fueron la estancia, la intervención quirúrgica y los factores extrínsecos. De los EA, destacó la infección de herida quirúrgica. Por su impacto, dos tercios fueron moderados y se consideró evitables la mitad de todos los EA (AU)

Objective Clinical practice is an activity accompanied by risks and uncertainties. The objectives are: to determine the incidence of patients with adverse events (AE) in a general surgery unit; to analyse the associated factors; to consider their impact and to identify the prevention possibilities. Patients and method Ambispective study in patients taken care of in a general surgery unit in a tertiary hospital. Every admission was prospectively reviewed using a screening guide, with all the clinical histories that fulfilled screening criteria being examined retrospectively using a modular questionnaire. Results A total of 989 histories were reviewed, the positive predictive value (PPV) of the screening guide for AE was 53%. The accumulated incidence of patients with AE was 17.8% and the incidence density of AE was 1.92 for every 100 days of hospitalisation. Intrinsic and extrinsic risk factors were associated to greater risk of EA, the most frequent events being: nosocomial infections (54.4%), surgical problems (31.8%) and problems associated with medication (7.4%). A total of 66.8% of the AE were considered moderate, with 53.5% of all AE being preventable. Conclusions The screening questionnaire was useful for the valuation of adverse events. AE are common in surgical patients which has an effect on the use of other hospital resources. The most important associated factors were: length of stay, surgical and extrinsic factors and surgical wound infection as the main AE. Two thirds of AE were considered moderate and half of all AE were considered avoidable (AU)

[Incidence of adverse events in a general surgery unit]. / Incidencia de efectos adversos en un servicio de cirugía general.

OBJECTIVE: Clinical practice is an activity accompanied by risks and uncertainties. The objectives are: to determine the incidence of patients with adverse events (AE) in a general surgery unit; to analyse the associated factors; to consider their impact and to identify the prevention possibilities. PATIENTS AND METHOD: Ambispective study in patients taken care of in a general surgery unit in a tertiary hospital. Every admission was prospectively reviewed using a screening guide, with all the clinical histories that fulfilled screening criteria being examined retrospectively using a modular questionnaire. RESULTS: A total of 989 histories were reviewed, the positive predictive value (PPV) of the screening guide for AE was 53%. The accumulated incidence of patients with AE was 17.8% and the incidence density of AE was 1.92 for every 100 days of hospitalisation. Intrinsic and extrinsic risk factors were associated to greater risk of EA, the most frequent events being: nosocomial infections (54.4%), surgical problems (31.8%) and problems associated with medication (7.4%). A total of 66.8% of the AE were considered moderate, with 53.5% of all AE being preventable. CONCLUSIONS: The screening questionnaire was useful for the valuation of adverse events. AE are common in surgical patients which has an effect on the use of other hospital resources. The most important associated factors were: length of stay, surgical and extrinsic factors and surgical wound infection as the main AE. Two thirds of AE were considered moderate and half of all AE were considered avoidable.

[Prevalence of anal diseases after Scopinaro's biliopancreatic bypass for super-obese patients]. / Prevalencia de afección anal en el paciente superobeso mórbido tras bypass biliopancreático de Scopinaro.

INTRODUCTION: Biliopancreatic diversion by Scopinaro (BD) is a mixed (malabsortive and restrictive) bariatric technique that is successful in achieving long lasting weight lost in super obese patients. In fact, the diarrhoea (steatorrhea) that is expected after any malabsortive technique can sometimes cause significant nutritional changes and anal disease: these patients are frequently referred to our coloproctology outpatient clinic due to haemorrhoids, fissures, anal sepsis and fistula basically due to changes in quality and quantity of their faeces. The aim of this paper is to find out not only the prevalence of anal disease in our series of super obese surgical patients but also to compare the incidence between the two surgical techniques we perform in our department. MATERIAL AND METHOD: We analyzed 263 consecutive patients operated on BD of Scopinaro (50-200 cm) and modified-BD (75-225 cm) in our Department. Patients who had previously suffered from anal surgery were excluded. RESULTS: There were 45 patients (18%) who suffered from anal problems of which 38 cases (84.4%) were BD-S and only 7 cases with BD-M complained of anal disorders (p < 0.05). Overall, at the 18th month review, the mean number of motions per day was 3.5 (range, 1-15). Patients with BD-S had 5 motions per day as a mean. The mean number of motions for BD-M was 2. The frequency order of anal pathology observed was: anal fissure, haemorrhoids, abscess and fistula. CONCLUSIONS: Higher incidence of anal pathology after BD of Scopinaro is another factor to take into account to avoid performing classic Scopinaro BD as opposed to modified BD for the treatment of morbid super obesity. It is mandatory to be conservative when facing anal problems in these patients, and firstly we must modify eating habits and the nutritional status. Surgery must be highly respectful to anal sphincters to avoid incontinence.

Prevalencia de afección anal en el paciente superobeso mórbido tras bypass biliopancreático de Scopinaro / Prevalence of anal diseases after Scopinaro’s biliopancreatic bypass for super-obese patients

Introducción. El bypass biliopancreático de Scopinaro es una técnica bariátrica mixta. Los efectos secundarios indeseables derivados de las diarreas y los cambios de composición cualitativa típicos de las heces esteatorreicas observados con mayor frecuencia en este tipo de pacientes son: hemorroides, fisuras, abscesos y fístulas de ano. El objetivo de esta publicación es valorar la prevalencia de afección anal en los superobesos operados, así como comparar su incidencia entre ambas variantes de bypass biliopancreático practicadas en nuestro servicio. Material y método. Analizamos la afección anal que presentaron 263 pacientes intervenidos de obesidad mórbida en nuestro servicio (1995-2005) tras bypass biliopancreático clásico (BD-C) y bypass biliopancreático modificado (BD-M). Resultados. Un 18% (n = 45) de los pacientes presentó afección anal: BD-C, 38 pacientes, y BD-M, 7 pacientes (p < 0,05). La media de deposiciones diarreicas fue de 3,5 (intervalo, 1-15) deposiciones/día. Los pacientes del grupo BD-C realizaban 5 deposiciones de media frente a 2 del grupo BD-M. Por orden de frecuencia fueron: fisura, hemorroides, absceso y fístula. Conclusiones. La mayor incidencia de afección anal tras BD-C es otro factor que nos debe hacer abandonar esta técnica a favor del BD-M para el tratamiento de la superobesidad mórbida. Además, es fundamental ser conservadores en el tratamiento de la afección anal en este grupo de pacientes; siempre se debe corregir primero las alteraciones digestivas y el estado nutricional y no olvidar que la anatomía del canal anal debe ser preservada al máximo para evitar la incontinencia (AU)

Introduction. Biliopancreatic diversion by Scopinaro (BD) is a mixed (malabsortive and restrictive) bariatric technique that is successful in achieving long lasting weight lost in super obese patients. In fact, the diarrhoea (steatorrhea) that is expected after any malabsortive technique can sometimes cause significant nutritional changes and anal disease: these patients are frequently referred to our coloproctology outpatient clinic due to haemorrhoids, fissures, anal sepsis and fistula basically due to changes in quality and quantity of their faeces. The aim of this paper is to find out not only the prevalence of anal disease in our series of super obese surgical patients but also to compare the incidence between the two surgical techniques we perform in our department. Material and method. We analyzed 263 consecutive patients operated on BD of Scopinaro (50-200 cm) and modified-BD (75-225 cm) in our Department. Patients who had previously suffered from anal surgery were excluded. Results. There were 45 patients (18%) who suffered from anal problems of which 38 cases (84.4%) were BD-S and only 7 cases with BD-M complained of anal disorders (p < 0.05). Overall, at the 18th month review, the mean number of motions per day was 3.5 (range, 1-15). Patients with BD-S had 5 motions per day as a mean. The mean number of motions for BD-M was 2. The frequency order of anal pathology observed was: anal fissure, haemorrhoids, abscess and fistula. Conclusions. Higher incidence of anal pathology after BD of Scopinaro is another factor to take into account to avoid performing classic Scopinaro BD as opposed to modified BD for the treatment of morbid super obesity. It is mandatory to be conservative when facing anal problems in these patients, and firstly we must modify eating habits and the nutritional status. Surgery must be highly respectful to anal sphincters to avoid incontinence (AU)

Carcinomatosis peritoneal de origen colorrectal, problema ético hoy, un problema legal en el futuro. Respuesta de los autores / Peritoneal carcinomatosis of colorectal origin. An ethical problem today, a legal problem in the future. Authors’ response

No disponible

Recidiva local en el cáncer de colon y recto / Local recurrence in colon and rectal cancer

datos de incidencia del cáncer colorrectal son alarmantes y lo sitúan en estos momentos en la segunda causa de muerte por cáncer; la recidiva es la causa de la mayoría de las muertes tras cirugía con intención curativa. Los factores asociados a la recidiva locorregional se relacionan fundamentalmente con las características histopatológicas y el grado de invasión del tumor. El factor cirujano no debe aparecer más entre estos factores, pues se evita con una adecuada preparación. En el cáncer de recto, esta preparación pasa por la técnica de escisión del mesorrecto, un adecuado margen circunferencial y la radioquimioterapia neoadyuvante selectiva. Tras la cirugía curativa, los enfermos deben ser controlados para intentar detectar la recidiva asintomática. La recurrencia local aislada sucede en el 20-30% de los casos, pero incluso con metástasis hepáticas o pulmonares se puede intentar la cirugía curativa, el éxito depende de una correcta valoración preoperatoria multidisciplinaria. Cuando el diagnóstico se realiza en una fase incurable, nuestra misión es mejorar la calidad de vida (AU)

Data on the incidence of colorectal cancer are alarming and reveal that it is currently the second cause of death from cancer. Most of these deaths are due to recurrence after surgery with curative intent. The factors associated with locoregional recurrence are mainly related to the tumor's histopathological characteristics and grade of invasion. With adequate training the surgeon should not appear among these factors. In rectal cancer this training involves the technique of mesorectal excision, adequate circumferential margin and selective neoadjuvant chemoradiotherapy. After curative resection, patients should be followed-up to detect asymptomatic recurrence. Isolated local recurrence occurs in 20-30% of patients, but even with liver or lung metastases curative surgery can be attempted and success depends on correct multidisciplinary preoperative evaluation. If the diagnosis is made when the tumor is in an incurable phase, the aim is to improve the patient's quality of life (AU)

[Local recurrence in colon and rectal cancer]. / Recidiva local en el cáncer de colon y recto.

Data on the incidence of colorectal cancer are alarming and reveal that it is currently the second cause of death from cancer. Most of these deaths are due to recurrence after surgery with curative intent. The factors associated with locoregional recurrence are mainly related to the tumor's histopathological characteristics and grade of invasion. With adequate training the surgeon should not appear among these factors. In rectal cancer this training involves the technique of mesorectal excision, adequate circumferential margin and selective neoadjuvant chemoradiotherapy. After curative resection, patients should be followed-up to detect asymptomatic recurrence. Isolated local recurrence occurs in 20-30% of patients, but even with liver or lung metastases curative surgery can be attempted and success depends on correct multidisciplinary preoperative evaluation. If the diagnosis is made when the tumor is in an incurable phase, the aim is to improve the patient's quality of life.

Nutrición perioperatoria. Estado actual basado en la evidencia científica / Perioperative nutrition. Current approach based on scientific evidence

Existe una elevada incidencia de desnutrición en los pacientes quirúgircos debido al periodo de dieta absoluta previa a la cirugía y a las complicaciones postoperatorias que inducen un estado hipercatabólico. La malnutrición además, es un factor precipitante para la aparición de complicaciones en el postoperatorio. Por esto cobra un especial interés el soporte nutricional del paciente tanto antes, como después de la cirugía, ya que se ha demostrado que la nutrición peri-operatoria reduce la morbimortalidad postoperatoria. En este documento, realizamos una revisión de la literatura sobre el estado actual de la nutrición postopeatoria, su tipos, ventajas, beneficios e indicaciones de cada una de ellas (AU)

There is a high incidence o malnutrition in surgical patients due to presurgery period and psotoperative complications that originate an hypercatabolic status. Besides, malnutrition induces itself the appearance of complications in the postoperatory. that is why artificial nutrition gets an important interest, because it has been proved that perioperative nutrition support, reduces surgical complications and mortality. In this paper, were make a revision about current state of postoperatory nutrition, its types, their advantages and benefits (AU)

Resultados a largo plazo de la gastroplastia vertical con banda / Long-term results of vertical banded gastroplasty

Introducción. La gastroplastia vertical con banda (GVB) es una técnica restrictiva con buenos resultados a corto plazo. El objetivo de este trabajo es evaluar los resultados y la morbimortalidad a largo plazo. Pacientes y métodos. Estudio de una serie de casos (n = 80) sometidos a GVB en los que fue posible completar 5 o más años de seguimiento (65 mujeres y 15 varones; edad media, 37 años; índice de masa corporal medio, 49,5 kg/m2).Resultados. En cuanto al porcentaje del sobrepeso perdido, a los 6 meses fue del 59 por ciento; a los 12 meses, del 70 por ciento; a los 2 años, del 66 por ciento; a los 5 años, del 64 por ciento; a los 8 años, del 54 por ciento, y a los 10 años, del 53 por ciento. Se consiguió el éxito con esta técnica (pérdida de más del 50 por ciento del sobrepeso) en el 51 por ciento de los pacientes. Por lo que se refiere al efecto sobre la morbilidad, se observó un descenso de la glucemia, trigliceridemia y presión arterial temprana, sin correlación con el adelgazamiento, mayor en los obesos con cifras elevadas preoperatorias y mantenido en el tiempo pese al reengorde. La mortalidad fue del 1,25 por ciento (tromboembolia pulmonar). La morbilidad en el postoperatorio temprano fue del 25 por ciento (el 20 por ciento por infección de la herida); en el seguimiento presentó hernia incisional el 35 por ciento de los casos, y entre las complicaciones técnicas cabe destacar la interrupción de la línea de grapas (16 por ciento).Conclusiones. A largo plazo la GVB es efectiva en la mitad de los pacientes operados, su mortalidad no es alta, pero presenta una morbilidad amplia que no permite calificarla de segura (AU)

Effect of vertical banded gastroplasty on hypertension, diabetes and dyslipidemia.

BACKGROUND: Operations for morbid obesity that are effective in inducing weight loss improve blood pressure, glycemic control and dyslipidemia. Our purpose was to study the effectiveness of VBG in improving hypertension, diabetes and dyslipidemias in morbidly obese patients. METHODS: Retrospective analysis of a cohort of 80 morbidly, obese patients was conducted. Characteristics of patients were: mean age 37 years; gender: women 65, men 15; mean initial BMI 49.5 kg/m2; follow-up > 5 years in 52 patients. Blood pressure, cholesterol and triglyceride levels and glycemia were assessed preoperatively and 1, 3, 6, 12, 18 months and every year after VBG. RESULTS: Hypertension resolved in 65.5% of patients (38 of 58), serum cholesterol level became normal in 34.28% of patients (12 of 35), triglyceride level became normal in 77.77% (7 of 9) and diabetes resolved in 55.55% (5 of 9). CONCLUSION: Weight loss induced by VBG improves blood pressure, triglyceride levels and glycemia. The beneficial changes occur early in the postoperative period and last 5 years or more, despite of the trend to regain some weight. Improvements in risk factors were greater in patients with higher preoperative values.

Pseudoquiste suprarrenal: dos casos manifestados por dolor abdominal agudo y shock / Adrenal pseudocyst presenting as acute abdomen and shock: report of two cases

OBJETIVOS: Presentar dos casos clínicos de pseudoquiste suprarrenal manifestados clínicamente como abdomen agudo y shock. MÉTODOS: Descripción de los dos casos. 1. Caso 1: mujer de 69 años con cuadro de shock y dolor en hipocondrio izquierdo; 2. Caso 2: mujer de 23 años con dolor en hipocondrio izquierdo y sensación de mareo. RESULTADOS: 1. Exploraciones complementarias: ecografía y TAC abdominal, mostrando masa quística heterogénea; hemograma: descenso de hematocrito y hemoglobina. 2. Intervención quirúrgica: se halla tumoración quística retroperitoneal que se extirpa. 3. Anatomía patológica: pseudoquiste suprarrenal. CONCLUSIONES: 1. El pseudoquiste suprarrenal es una lesión de baja incidencia. 2. Es poco frecuente que produzcan síntomas, siendo excepcional su manifestación como cuadro de abdomen agudo. 3. Las pruebas diagnósticas de mayor utilidad son ecografía y TAC. 4. El tratamiento debe ser quirúrgico si el tumor es grande y cava. Si el campo quirúrgico obtenido por esta vía no permite una cómoda realización de la cirugía, siempre existe la posibilidad de reconvertir a vía transperitoneal (AU)