ABSTRACT
Introduction: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. Methods: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). Results: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. Conclusions: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. (AU)
Introducción: La efectividad de los protocolos de recuperación intensificada o ERAS en la cirugía del cáncer gástrico sigue siendo controvertida. Métodos: Estudio de cohortes prospectivo multicéntrico de pacientes intervenidos de cáncer gástrico. Se evaluó la adherencia a 22 elementos ERAS en todos los pacientes, independientemente de la existencia de un protocolo ERAS. Cada centro tuvo un período de reclutamiento de tres meses, con un seguimiento de 30 días. La medida de resultado primario fue el numero de complicaciones posoperatorias moderadas a graves. Las medidas de resultado secundarias fueron el número total de complicaciones, la adherencia a los elementos ERAS, la mortalidad y la estancia. Resultados: Se incluyeron 743 pacientes en 72 hospitales, 211 (28,4 %) en centros ERAS. 245 pacientes (33 %) experimentaron complicaciones posoperatorias, moderadas o graves en 172 (23,1 %). No hubo diferencias en la incidencia de complicaciones moderadas a graves (22,3 % vs. 23,5 %; OR, 0,92 (IC 95 %, 0,59 a 1,41); P = 0,068), o complicaciones posoperatorias totales entre los centros ERAS y no ERAS (33,6 % vs. 32,7 %; OR, 1,05 (IC 95 %, 0,70 a 1,56); P = 0,825). La adherencia a los elementos ERAS fue del 52% [IQR 45 a 60]. No hubo diferencias entre los cuartiles de cumplimiento ERAS más alto (Q1, > 60 %) y más bajo (Q4, ≤ 45 %). Conclusiones: Ni la aplicación parcial de medidas ERAS ni el tratamiento en centros ERAS mejoraron los resultados en pacientes sometidos a cirugía gástrica por cáncer. (AU)
Subject(s)
Humans , Male , Female , Middle Aged , Aged , Stomach Neoplasms/surgery , Perioperative Care , Postoperative Complications , Prospective Studies , Cohort Studies , Spain , Digestive System Surgical ProceduresABSTRACT
La endoscopia flexible (EF) es un procedimiento de gran utilidad para el manejo diagnóstico y terapéutico de lesiones del tracto digestivo superior. A pesar de que su uso intraoperatorio se ha extendido con el paso de los años, su empleo por parte de cirujanos es aún limitado en nuestro medio. Las oportunidades de capacitación en EF varían ampliamente entre instituciones, especialidades y países. La endoscopia intraoperatoria (EIO) presenta ciertas peculiaridades que aumentan su complejidad respecto a la EF estándar. La realización de EIO repercute positivamente en los resultados quirúrgicos aportándoles seguridad y calidad así como disminución de las complicaciones asociadas a estas técnicas. Debido a sus innumerables ventajas, su uso intraoperatorio por parte de cirujanos es actualmente un proyecto vigente en muchos países y forma parte de un futuro próximo en otros, extendiéndose su uso dentro de la especialidad de cirugía general gracias a la creación de proyectos de formación mejor estructurados. En este manuscrito se realiza una revisión y puesta al día de las indicaciones y utilidades de la endoscopia digestiva alta intraoperatoria en la cirugía esofagogástrica. (AU)
Flexible endoscopy (FE) plays a major role in the diagnosis and treatment of gastrointestinal disease. Although its intraoperative use has spread over the years, its use by surgeons is still limited in our setting. EF training opportunities are different among many institutions, specialties, and countries. Intraoperative endoscopy (IOE) presents peculiarities that increase its complexity compared to standard EF. IOE has a positive impact on surgical results, due to increased safety and quality, as well as a reduction in the complications. Due to its innumerable advantages, its intraoperative use by surgeons is currently a current project in many countries and is part of the near future in others because of the creation of better structured training projects. This manuscript reviews and updates the indications and uses of intraoperative upper gastrointestinal endoscopy in esophagogastric surgery. (AU)
Subject(s)
Humans , Endoscopy/methods , Esophagogastric Junction/surgery , Endoscopy, Digestive System , Gastrointestinal Tract/diagnostic imaging , Gastrointestinal Neoplasms/surgeryABSTRACT
INTRODUCTION: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. METHODS: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). RESULTS: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. CONCLUSIONS: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03865810.
Subject(s)
Enhanced Recovery After Surgery , Stomach Neoplasms , Adult , Humans , Perioperative Care , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Prospective Studies , Stomach Neoplasms/surgery , Stomach Neoplasms/complicationsABSTRACT
INTRODUCTION: The impact of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) has not been widely quantified, and the data in the literature remain controversial. MATERIALS AND METHODS: Candidates for LSG underwent barium swallow, esophageal manometry, ambulatory 24-h esophageal pH monitoring (APM), and gastric emptying scintigraphy before and after surgery (1 and 18 months). Symptoms were evaluated using a gastroesophageal reflux disease questionnaire (GERDq). Esophagogastroduodenoscopy was performed preoperatively in all patients and at 18 months postoperatively in patients who had suffered from preoperative esophagitis. RESULTS: Fifty-two patients were included in the study (64.4% women and 34.6% men) with a median age of 46 years (25-63 years) and BMI of 45.0 ± 5.6 kg/m2. The follow-up rates at 1 and 18 months were 82.7% and 80.8%. At 18 months, the percentage of weight loss (%TWL) was 33.6 ± 10.4% and the percentage of excess BMI loss (%EBMIL) was 77.6 ± 25%. Postoperatively, a significant increase in accelerated gastric emptying and impaired esophageal body motility occurred at 1 and 18 months. A significant worsening of all the values obtained at both 1 and 18 months postoperatively becomes evident when comparing the results of the APM. After surgery, 76.4% of patients had developed "de novo" GERD at 1 month and 41% at 18 months. No improvement was found in patients with symptomatic GERD. CONCLUSION: Based on the results of this study, LSG led to a considerable rate of postoperative "de novo" GERD. In addition, no improvement was found in patients with symptomatic GERD.
Subject(s)
Gastroesophageal Reflux , Laparoscopy , Obesity, Morbid , Esophageal pH Monitoring , Female , Gastrectomy/methods , Gastroesophageal Reflux/surgery , Humans , Laparoscopy/methods , Male , Middle Aged , Obesity, Morbid/surgeryABSTRACT
No disponible
Subject(s)
Humans , Esophageal Neoplasms/epidemiology , Esophageal Neoplasms/pathology , Esophageal Neoplasms/therapy , Esophagogastric Junction , Bibliometrics , Incidence , Patient Care TeamABSTRACT
MC4R gene is a hypothalamic satiety control mediator in which mutations cause a monogenic form of obesity. The aim of this study was to perform a genetic screening to identify variations in the entire region of MC4R gene. A total of 236 unrelated and severely obese patients (BMIâ¯≥â¯40â¯kg/m2) with Spanish ancestry and severe overweight familiar history have been enrolled into the study. Seven MC4R gene variants were identified in the heterozygous state in 21 patients. Coding variants p.Thr101Ile and p.Ala259Asp are new and variants p.Ser30Phe, p.Val103Ile and p.Ile251Leu were previously described. Two variants have been also observed in the promoter region of the MC4R gene; the c.-24G>A mutation, described for the first time, and the known c.-178A>C variant. Both in silico and family segregation analysis confirm the correlation between novel identified mutations in MC4R gene and obesity development. The correlation between the four variants (c.-24G>A, p.Thr101Ile, p.Ala259Asp and p.Ser30Phe) and the obesity phenotype, therefore, allows the conclusion that all of the four mutations cause a monogenic form of obesity.
Subject(s)
Mutation, Missense , Obesity, Morbid/genetics , Receptor, Melanocortin, Type 4/genetics , Adolescent , Adult , Case-Control Studies , Cohort Studies , DNA Mutational Analysis , Female , Genetic Association Studies , Genetic Predisposition to Disease , Genetic Testing , Humans , Male , Middle Aged , Pedigree , Polymorphism, Single Nucleotide , Spain , Young AdultABSTRACT
No disponible
Subject(s)
Humans , Anemia/therapy , Preoperative Care , Consensus , Gastrointestinal Diseases/rehabilitation , Gastrointestinal Diseases/surgeryABSTRACT
La rehabilitación multimodal constituye un conjunto de medidas perioperatorias que sustituye prácticas tradicionales respecto a la analgesia, la fluidoterapia, la nutrición y la movilización, entre otros. Su implementación está basada en criterios de medicina basada en la evidencia. Con base en la vía recuperación intensificada en cirugía abdominal publicada en el año 2015, una amplia revisión de la bibliografía y el consenso establecido en una reunión multidisciplinar del Grupo de Trabajo de Cirugía Esofagogástrica del Grupo Español de Rehabilitación Multimodal celebrada en 2015, se presenta un protocolo de rehabilitación multimodal en cirugía resectiva esofágica. Las medidas a aplicar se dividen en 3 bloques: preoperatorio, perioperatorio y postoperatorio. Su conjunto da lugar al documento de consenso que integra todas las medidas perioperatorias en una matriz temporal. La aplicación de protocolos de rehabilitación multimodal en cirugía resectiva esofágica reduce la morbimortalidad postoperatoria, la estancia y los costes hospitalarios
ERAS is a multimodal perioperative care program which replaces traditional practices concerning analgesia, intravenous fluids, nutrition, mobilization as well as a number of other perioperative items, whose implementation is supported by evidence-based best practices. According to the RICA guidelines published in 2015, a review of the literature and the consensus established at a multidisciplinary meeting in 2015, we present a protocol that contains the basic procedures of an ERAS pathway for resective esophageal surgery. The measures involved in this ERAS pathway are structured into 3 areas: preoperative, perioperative and postoperative. The consensus document integrates all the analyzed items in a unique time chart. ERAS programs in esophageal resection surgery can reduce postoperative morbidity, mortality, hospitalization and hospital costs
Subject(s)
Humans , Combined Modality Therapy/methods , Esophagus/surgery , Hospital Costs , Esophageal Diseases/rehabilitation , Health Personnel/statistics & numerical data , Perioperative Period , Postoperative CareABSTRACT
ERAS is a multimodal perioperative care program which replaces traditional practices concerning analgesia, intravenous fluids, nutrition, mobilization as well as a number of other perioperative items, whose implementation is supported by evidence-based best practices. According to the RICA guidelines published in 2015, a review of the literature and the consensus established at a multidisciplinary meeting in 2015, we present a protocol that contains the basic procedures of an ERAS pathway for resective esophageal surgery. The measures involved in this ERAS pathway are structured into 3areas: preoperative, perioperative and postoperative. The consensus document integrates all the analyzed items in a unique time chart. ERAS programs in esophageal resection surgery can reduce postoperative morbidity, mortality, hospitalization and hospital costs.
Subject(s)
Clinical Protocols , Esophagectomy/rehabilitation , Perioperative Care/methods , Humans , Practice Guidelines as TopicABSTRACT
INTRODUCTION: Enhanced recovery after surgery is a modality of perioperative management with the purpose of improving results and providing a faster recovery of patients. This kind of protocol has been applied frequently in colorectal surgery, presenting less available experience and evidence in gastric surgery. METHODS: According to the RICA guidelines published in 2015, a review of the bibliography and the consensus established in a multidisciplinary meeting in Zaragoza on the 9th of October 2015, we present a protocol that contains the basic procedures of fast-track for resective gastric surgery. RESULTS: The measures to be applied are divided in a preoperative, perioperative and postoperative stage. This document provides recommendations concerning the appropriate information, limited fasting and administration of carbohydrate drinks 2hours before surgery, specialized anesthetic strategies, minimal invasive surgery, no routine use of drainages and tubes, mobilization and early oral tolerance during the immediate postoperative period, as well as criteria for discharge. CONCLUSIONS: The application of a protocol of enhanced recovery after surgery in resective gastric surgery can improve and accelerate the functional recovery of our patients, requiring an appropriate multidisciplinary coordination, the evaluation of obtained results with the application of these measures and the investigation of controversial topics about which we currently have limited evidence.
Subject(s)
Gastrectomy/rehabilitation , Clinical Protocols , Female , Humans , Male , Patient Care TeamABSTRACT
INTRODUCCIÓN: La rehabilitación multimodal es un conjunto de medidas que se aplican durante el período perioperatorio con el fin de mejorar los resultados y facilitar una pronta recuperación de los pacientes. La aplicación de protocolos de este tipo se ha extendido ampliamente en la cirugía colorrectal, siendo menor la experiencia y evidencia disponible en relación con la cirugía gástrica. MÉTODOS: En base a las directrices marcadas por la vía Recuperación Intensificada en Cirugía Abdominal (RICA) publicada en el año 2015, una amplia revisión de la bibliografía y el consenso establecido en una reunión multidisciplinar del Grupo de Trabajo de Cirugía Esofagogástrica del Grupo Español de Rehabilitación Multimodal celebrada en Zaragoza el 9 de octubre de 2015, se presenta una matriz temporal que recoge las recomendaciones fundamentales para la aplicación de un protocolo de rehabilitación multimodal en la cirugía de resección gástrica. RESULTADOS: Las medidas a aplicar se dividen en una etapa preoperatoria, otra perioperatoria y otra postoperatoria. Así, se establecen en este documento recomendaciones sobre la información adecuada y preparación del paciente y su entorno, el ayuno limitado y la ingesta de bebidas carbohidratadas 2h antes de la operación, estrategias anestésicas más especializadas, la cirugía mínimamente invasiva, la no colocación de forma sistemática de sondas o drenajes, la movilización y tolerancia oral precoz durante el postoperatorio inmediato, así como los criterios a considerar para el alta hospitalaria. CONCLUSIONES: La aplicación de un protocolo de rehabilitación multimodal en la cirugía resectiva gástrica puede mejorar y acelerar la recuperación funcional de nuestros pacientes. Sin embargo, para conseguir este objetivo se precisa de una correcta coordinación multidisciplinar, así como de la evaluación de los resultados y del análisis e investigación de los puntos de controversia sobre los que la evidencia científica es aún limitada
INTRODUCTION: Enhanced recovery after surgery is a modality of perioperative management with the purpose of improving results and providing a faster recovery of patients. This kind of protocol has been applied frequently in colorectal surgery, presenting less available experience and evidence in gastric surgery. METHODS: According to the RICA guidelines published in 2015, a review of the bibliography and the consensus established in a multidisciplinary meeting in Zaragoza on the 9th of October 2015, we present a protocol that contains the basic procedures of fast-track for resective gastric surgery. RESULTS: The measures to be applied are divided in a preoperative, perioperative and postoperative stage. This document provides recommendations concerning the appropriate information, limited fasting and administration of carbohydrate drinks 2 hours before surgery, specialized anesthetic strategies, minimal invasive surgery, no routine use of drainages and tubes, mobilization and early oral tolerance during the immediate postoperative period, as well as criteria for discharge. CONCLUSIONS: The application of a protocol of enhanced recovery after surgery in resective gastric surgery can improve and accelerate the functional recovery of our patients, requiring an appropriate multidisciplinary coordination, the evaluation of obtained results with the application of these measures and the investigation of controversial topics about which we currently have limited evidence
Subject(s)
Humans , Gastrectomy/rehabilitation , Stomach Neoplasms/surgery , Combined Modality Therapy/methods , Malnutrition/prevention & control , Postoperative Care/methods , Preoperative Care/methodsABSTRACT
No disponible
Subject(s)
Aged , Humans , Male , Hemoperitoneum/complications , Hemoperitoneum/surgery , Pericardiocentesis/adverse effects , Pericardiocentesis/methods , Pericardiocentesis/trends , Iatrogenic Disease/epidemiology , Pericardiocentesis/standards , Pericardiocentesis , Shock/complications , Shock/surgery , Echocardiography/instrumentation , Echocardiography/methods , Echocardiography/trendsABSTRACT
INTRODUCCIÓN: Las mallas autoadhesivas se plantean como una alternativa para disminuir el dolor crónico y las recidivas en la hernioplastia inguinal. Pretendemos determinar si el empleo de estas mallas representa algún beneficio en el resultado a largo plazo en comparación con la técnica clásica de Lichtenstein fijando la malla con suturas. MATERIAL Y MÉTODOS: Estudio prospectivo y aleatorizado de pacientes intervenidos de hernia inguinal entre marzo de 2009 y marzo del 2010, incluyendo en el grupo autoadhesivo (AA) 45 individuos en los que se realizó la hernioplastia con malla autoadhesiva y en el grupo Lichtenstein clásico (LC) otros 45 utilizando una malla de polipropileno fijada con sutura monofilar. Se evaluaron tiempo de inactividad, posibles complicaciones, recidivas y grado de dolor al año de la intervención. RESULTADOS: La edad media del grupo AA fue de 60 años frente a los 49 del grupo LC. En ambos, la mayor parte eran varones sin diferencias en las comorbilidades asociadas, siendo el tamaño medio del defecto herniario de 3 cm; en torno al 60% de las hernias eran indirectas. Al año de la intervención, 39 pacientes fueron evaluados en el grupo LC y 38 en el AA. La mediana del tiempo de recuperación de la actividad diaria normal fue de 15 días en ambos grupos. En el grupo AA, el 86,8% estaban asintomáticos, ninguno presentó recidiva herniaria ni precisó tomar analgésicos de forma continua, siendo la mediana del grado de dolor de 0. En el grupo LC, el 87,2% permanecían asintomáticos, un paciente (2,6%) presentó una recidiva y un paciente (2,6%) requería la toma continua de analgésicos por dolor intenso, siendo la mediana de dolor de 0. No hubo mortalidad ni otras complicaciones a largo plazo. CONCLUSIÓN: El empleo de mallas autoadhesivas y parcialmente reabsorbibles en la reparación de la hernia inguinal no presenta diferencias significativas en recuperación, dolor ni complicaciones postoperatorias a largo plazo frente a la hernioplastia con malla de polipropileno fijada con sutura monofilar
INTRODUCTION: The use of autoadhesive meshes with hooks that allow fixation without sutures is a therapeutic alternative to decrease recurrence and chronic pain after inguinal hernia repair. The aim of this study was to evaluate if this kind of mesh has any advantage in long term results in comparison with the classic Lichtenstein technique with sutures and polypropylene mesh. MATERIAL AND METHODS: We report a prospective and randomized study of patients who have been operated on for inguinal hernia between march of 2009 to march 2010, divided into 2 groups of 45 patients. In AutoAdhesive (AA) group, we included patients operated on with an autoadhesive mesh and in Classic Lichtenstein (CL) group we included cases with an inguinal hernioplasty with sutured polypropylene mesh. We evaluated time of inactivity, complications, recurrences and grade of pain after one year. RESULTS: The mean age was 60 years in AA group and 49 in LC group. There were more men than women and there were no differences in co-morbilities between groups. The mean size of hernia orifice was 3 cm in both groups and 60% of the hernias were indirect. After one year, 77 patients were evaluated; 39 in LC group and 38 in AA group. 86,8% and 87,2% of them were asymptomatic. The mean time of recovery of daily activities was 15 days in both groups. There were neither recurrences nor severe chronic pain in the AA group. The mean of grade of pain was 0 (range:0-4) in AA group and 0 (range: 0-5) in LC group. In this group, there was one recurrence and one patient was taking analgesics for intense pain. No mortality nor other long term complications were found. CONCLUSION: The use of autoadhesive and parcial reabsorbible meshes in inguinal hernia repair has no effect on recovery of daily activities, postoperative pain and long term complications compared with hernioplasty with polypropylene mesh fixed with monofilament suture
Subject(s)
Humans , Hernia, Inguinal/surgery , Surgical Mesh , Suture Techniques , Time , Prospective Studies , Chronic Pain/surgery , Pain Management/methods , RecurrenceABSTRACT
No disponible
