Cirugía mayor ambulatoria del cáncer de mama: factores relacionados con la conversión a hospitalización convencional / Major ambulatory surgery for the treatment of breast cancer: Factors conditioning conversion to conventional hospitalization

Introducción: La realización de cirugía oncológica mamaria en régimen ambulatorio se está convirtiendo en una práctica estándar entre los centros públicos por los distintos beneficios que aporta. En este estudio se analizan los resultados obtenidos con esta modalidad asistencial y se identifican los factores relacionados con su fracaso. Métodos: Se analizaron retrospectivamente los datos de las 206 pacientes intervenidas por cáncer de mama en el año 2016 bajo 3 tipos de régimen: ambulatorio puro, ambulatorio-23 h y hospitalario convencional. Se describen los índices de ambulatorización, éxito y conversión, tanto de forma global como distinguiendo entre cirugía conservadora, mastectomía ± reconstrucción inmediata y cirugía axilar. Se realiza un análisis univariante para hallar aquellos factores relacionados con la conversión a régimen hospitalario. Resultados: Para la muestra global se obtuvo un índice de ambulatorización del 61,2%, con un 16,5% de conversiones y un éxito del 83,4%. Para cirugía conservadora, ambulatorización, éxito y conversión fueron del 78,8, el 88,6 y el 11,4%, respectivamente. En las mastectomías la ambulatorización fue del 28,6%, con un 37,1% de conversión y un éxito del 62,9%. Las 11 cirugías axilares culminaron en régimen ambulatorio. Los factores asociados a una mayor probabilidad de conversión fueron la realización de mastectomía frente a cirugía conservadora y la aparición de complicaciones postoperatorias. Conclusiones: La cirugía del cáncer de mama en régimen ambulatorio es factible y segura. Para la optimización de resultados resultan imprescindibles la cuidadosa selección de las candidatas y el desarrollo de una técnica quirúrgica cuidadosa y lo más conservadora posible

Introduction: The main step in curative treatment for breast cancer is surgery. Its use in an ambulatory setting can contribute towards more efficient healthcare, providing additional benefits for patients. In this study, we analyze the results obtained with this treatment method and identify factors related with conversion to hospitalization.Methods: Results were analyzed from the 206 surgeries performed for breast cancer in 2016, using three different methods: day surgery, overnight ambulatory (23h) and conventional hospitalization. The ambulatory success and conversion rates were calculated for the global sample and stratified, distinguishing between conservative surgery, mastectomy and axillary surgery. A univariate analysis was performed to identify the factors involved in conversion. Results: For the global sample, the ambulatory surgery rate was 61.2%, 16.5% conversions and a success rate of 83.4%. For conservative surgery, ambulatory, success and conversion rates were 78.8%, 88.6 and 11.4%, respectively. For mastectomies, the ambulatory rate was 28.6%, with 62.9% success and 37.1% conversions. The 11 axillary surgeries were performed as day surgeries. Factors associated with conversion were mastectomy vs. vs. conservative surgery and the appearance of postoperative complications. Conclusions: Ambulatory surgery for the surgical treatment of breast cancer should be standard care. Optimized results require adequate patient selection and the performance of surgical technique that needs to be as careful and as conservative as possible

Major ambulatory surgery for the treatment of breast cancer: Factors conditioning conversion to conventional hospitalization. / Cirugía mayor ambulatoria del cáncer de mama: factores relacionados con la conversión a hospitalización convencional.

INTRODUCTION: The main step in curative treatment for breast cancer is surgery. Its use in an ambulatory setting can contribute towards more efficient healthcare, providing additional benefits for patients. In this study, we analyze the results obtained with this treatment method and identify factors related with conversion to hospitalization. METHODS: Results were analyzed from the 206 surgeries performed for breast cancer in 2016, using three different methods: day surgery, overnight ambulatory (23h) and conventional hospitalization. The ambulatory success and conversion rates were calculated for the global sample and stratified, distinguishing between conservative surgery, mastectomy and axillary surgery. A univariate analysis was performed to identify the factors involved in conversion. RESULTS: For the global sample, the ambulatory surgery rate was 61.2%, 16.5% conversions and a success rate of 83.4%. For conservative surgery, ambulatory, success and conversion rates were 78.8%, 88.6 and 11.4%, respectively. For mastectomies, the ambulatory rate was 28.6%, with 62.9% success and 37.1% conversions. The 11 axillary surgeries were performed as day surgeries. Factors associated with conversion were mastectomy vs. vs. conservative surgery and the appearance of postoperative complications. CONCLUSIONS: Ambulatory surgery for the surgical treatment of breast cancer should be standard care. Optimized results require adequate patient selection and the performance of surgical technique that needs to be as careful and as conservative as possible.

Síndrome de HELLP con disfunción hepática severa: presentación de cuatro casos / HELLP syndrome with severe liver dysfunction: A presentation of three cases

El síndrome de HELLP (SH) aparece en el 0,5-0,9% de las gestantes. Se caracteriza por anemia hemolítica, trombopenia y disfunción multiorgánica según los criterios de Tennessee. El objetivo de nuestro trabajo es la presentación de 4 mujeres gestantes diagnosticadas del SH con afectación hepática severa. Pacientes y método Aportamos 4 mujeres gestantes de 24, 27, 28 y 36 semanas de gestación respectivamente, diagnosticadas de SH asociado a hematoma hepático. En los 4 casos se realizó interrupción del embarazo mediante cesárea urgente. El primer caso precisó la realización de hepatectomía derecha con buena evolución postoperatoria, la segunda paciente desarrolló un fallo hepático fulminante, falleciendo por fallo multiorgánico en espera de trasplante hepático. La tercera paciente evolucionó satisfactoriamente con tratamiento médico conservador. La cuarta paciente precisó 2 trasplantes de hígado siendo alta a los 3 meses. Conclusiones Ante la sospecha clínica de un SH es esencial descartar un hematoma hepático, ya que el tratamiento de elección está en función de la severidad clínico-radiológica del mismo. Si hay rotura del hematoma, es imprescindible un abordaje quirúrgico urgente y, en caso de insuficiencia hepática grave, está indicado un trasplante de hígado (AU)

HELLP syndrome (HS) occurs in 0.5-0.9% of pregnant women. According to the Tennessee criteria, it is characterised by haemolytic anaemia, thrombopenia and multi-organ dysfunction. The purpose of this article is to present the cases of four pregnant women diagnosed with HS with severe liver involvement. Patients and method We present the cases of 4 pregnant women of 24, 27, 28 and 36 weeks gestation, respectively. Pregnancy was terminated by urgent Caesarean section in all 4 cases. The first case required a right hepatectomy, with a good post-operative outcome; the second patient developed fulminant liver failure, dying due to multi-organ failure while waiting for a liver transplant. The third patient progressed satisfactorily with conservative medical treatment. The fourth patient required two livers transplants, being discharged from hospital three months later. Conclusions When faced with the clinical suspicion of a HS it is essential to rule out a liver haematoma, since the treatment of choice depends on its clinical-radiological severity. If there is a rupture of the haematoma, urgent surgery is essential and, in the case of severe liver failure, a liver transplant is indicated (AU)

[HELLP syndrome with severe liver dysfunction: a presentation of three cases]. / Síndrome de HELLP con disfunción hepática severa: presentación de cuatro casos.

UNLABELLED: HELLP syndrome (HS) occurs in 0.5-0.9% of pregnant women. According to the Tennessee criteria, it is characterised by haemolytic anaemia, thrombopenia and multi-organ dysfunction. The purpose of this article is to present the cases of four pregnant women diagnosed with HS with severe liver involvement. PATIENTS AND METHOD: We present the cases of 4 pregnant women of 24, 27, 28 and 36 weeks gestation, respectively. Pregnancy was terminated by urgent Caesarean section in all 4 cases. The first case required a right hepatectomy, with a good post-operative outcome; the second patient developed fulminant liver failure, dying due to multi-organ failure while waiting for a liver transplant. The third patient progressed satisfactorily with conservative medical treatment. The fourth patient required two livers transplants, being discharged from hospital three months later. CONCLUSIONS: When faced with the clinical suspicion of a HS it is essential to rule out a liver haematoma, since the treatment of choice depends on its clinical-radiological severity. If there is a rupture of the haematoma, urgent surgery is essential and, in the case of severe liver failure, a liver transplant is indicated.

Cambios en el manejo diagnóstico-terapéutico del traumatismo hepático. Estudio retrospectivo comparando 2 series de casos en periodos diferentes (1997-1984 vs. 2001-2008) / Changes in the diagnosis and therapeutic management of hepatic trauma. A retrospective study comparing 2 series of cases in different (1997-1984 vs. 2001-2008)

Introducción Presentamos una serie de 146 casos de traumatismos hepáticos (TH) atendidos en nuestro hospital en un periodo de 8 años (2001-2008), comparándola con una serie previa de 92 casos (1977-1984).Material y método En la serie actual, la edad media fue de 29,6 años, predominando los hombres. Los traumatismos cerrados predominan sobre los penetrantes, siendo la causa más frecuente los accidentes de tráfico. Resultados Para valorar el grado de lesión hepática utilizamos la clasificación de la American Association for the Surgery of Trauma (AAST). El 79,5% de los enfermos presentaron lesiones asociadas abdominales y/o extraabdominales, siendo las más frecuentes los traumatismo torácicos vs. las fracturas óseas en la serie anterior. La lesión intraabdominal asociada más frecuente fue la esplénica en ambas series. La técnica diagnóstica más utilizada, en la serie actual, fue TAC abdominal. En la serie anterior, las exploraciones más utilizadas fueron la punción simple y la punción-lavado peritoneal (PLP). En 98 casos se llevó a cabo un tratamiento no operatorio y en 48 restantes se indicó cirugía. En la serie previa, se intervino al 97,8% de los pacientes. En la serie actual, en los 15 pacientes con lesiones hepáticas severas se realizaron 5 hepatectomías derechas, 2 segmentectomías, 6 packing de compresas y los 2 restantes fueron exitus intraoperatorios por avulsión hepática. La mortalidad global fue del 3,4%, siendo del 1% en el grupo TNO y del 8,3% en los pacientes intervenidos. En la serie previa, la mortalidad global fue del 29,3%.ConclusionesEl factor esencial para utilizar el tratamiento no operatorio (TNO) es controlar la estabilidad hemodinámica del paciente dejando el tratamiento quirúrgico a los pacientes hemodinámicamente inestables (AU)

Introduction: We present a series of 146 cases of hepatic trauma (HT) treated in our hospital over a period of 8 yearsm (2001-2008), and comparing it with a previous series of 92 cases(1977-1984).Material and method: The mean age in the current series was 28.6 years and the majority were male. The closed traumas were mainly penetrating, with the most frequent cause being road traffic accidents. Results: The American Association for the Surgery of Trauma (AAST) classification was used to evaluate the grade of the hepatic injury. Associated abdominal and /or extra-abdominal injuries were seen in 79.5% of the patients, with the most frequent being chest trauma, compared to bone fractures in the previous series. The most common associated intraabdominalinjury was the spleen in both series. The most used diagnostic technique in the current series was abdominal CT. Simple peritoneal puncture and lavage (PLP) were the most used examinations used in the previous series. Non-surgical treatment (NST) was given in 98 cases and the surgery was indicated in the remaining 48. In the previous series,97.8% of patients were operated on. In the current series, on the 15 patients with severe liverinjuries, 5 right hepatectomies, 2 segmentectomies and 6 packing compressions were performed, with the remaining two dying during surgery due to hepatic avulsion. The overall mortality was 3.4%, being 1% in the NST group and 8.3% in the surgical patients. In the previous series, the overall mortality was 29.3%.Conclusions: The key factor for using NST is to control haemodynamic stability, leavingsurgical treatment for haemodynamically unstable patients (AU)

[Changes in the diagnosis and therapeutic management of hepatic trauma. A retrospective study comparing 2 series of cases in different (1997-1984 vs. 2001-2008)]. / Cambios en el manejo diagnóstico-terapéutico del traumatismo hepático. Estudio retrospectivo comparando 2 series de casos en periodos diferentes (1997-1984 vs. 2001-2008).

INTRODUCTION: We present a series of 146 cases of hepatic trauma (HT) treated in our hospital over a period of 8 yearsm (2001-2008), and comparing it with a previous series of 92 cases (1977-1984). MATERIAL AND METHOD: The mean age in the current series was 28.6 years and the majority were male. The closed traumas were mainly penetrating, with the most frequent cause being road traffic accidents. RESULTS: The American Association for the Surgery of Trauma (AAST) classification was used to evaluate the grade of the hepatic injury. Associated abdominal and /or extra-abdominal injuries were seen in 79.5% of the patients, with the most frequent being chest trauma, compared to bone fractures in the previous series. The most common associated intra-abdominal injury was the spleen in both series. The most used diagnostic technique in the current series was abdominal CT. Simple peritoneal puncture and lavage (PLP) were the most used examinations used in the previous series. Non-surgical treatment (NST) was given in 98 cases and the surgery was indicated in the remaining 48. In the previous series, 97.8% of patients were operated on. In the current series, on the 15 patients with severe liver injuries, 5 right hepatectomies, 2 segmentectomies and 6 packing compressions were performed, with the remaining two dying during surgery due to hepatic avulsion. The overall mortality was 3.4%, being 1% in the NST group and 8.3% in the surgical patients. In the previous series, the overall mortality was 29.3%. CONCLUSIONS: The key factor for using NST is to control haemodynamic stability, leaving surgical treatment for haemodynamically unstable patients.