Estudio observacional prospectivo unicéntrico sobre el efecto de la prehabilitación trimodal en cirugía colorrectal / A single-center prospective observational study on the effect of trimodal prehabilitation in colorectal surgery

INTRODUCCIÓN: Se ha diseñado un protocolo de prehabilitación trimodal con el objetivo de valorar si contribuye a disminuir la morbilidad postoperatoria, valorar el efecto de la prehabilitación en la estancia hospitalaria global y analizar la evolución de la capacidad funcional antes y después de cirugía. MÉTODOS: Estudio observacional unicéntrico con pacientes con cáncer colorrectal intervenidos quirúrgicamente con intención curativa después de un protocolo de prehabilitación trimodal. Se recoge morbilidad postoperatoria según el Comprehensive Complication Index y estancia hospitalaria, y se compara con una matriz histórica. También se recoge capacidad funcional antes y después de la aplicación del protocolo de prehabilitación. RESULTADOS: En comparación con la población histórica se consigue disminuir el Comprehensive Complication Index global de forma estadísticamente significativa de 13,2 a 11,5. Desglosando por tipo de morbilidad, todas disminuyen en porcentaje sin conseguir significación (infección espacio quirúrgico del 11,7 al 8,4%; infección nosocomial del 15,8 al 10%, y morbilidad médica del 8,6 al 4,2%). La estancia hospitalaria global pasa de 6 a 4 días y el porcentaje de pacientes que se preparan en casa disminuye de forma estadísticamente significativa en ambos casos. CONCLUSIONES: La prehabilitación trimodal puede contribuir a disminuir la morbilidad postoperatoria y la estancia hospitalaria global de los pacientes intervenidos de neoplasia colorrectal

INTRODUCTION: A trimodal prehabilitation protocol was designed with the aim to evaluate whether it contributes to reducing postoperative morbidity, to evaluate the effect of prehabilitation on overall hospital stay, and to analyze the evolution of functional capacity before and after surgery. METHODS: A single-center observational study of patients with colorectal cancer who underwent surgery with curative intent after a trimodal prehabilitation protocol. We collected data for postoperative morbidity according to the Comprehensive Complication Index and hospital stay, which were compared with a historical matrix. Functional capacity data were also collected before and after the application of the prehabilitation protocol. RESULTS: Compared to the historical population, the overall Comprehensive Complication Index was reduced from 13.2 to 11.5, which was statistically significant. Analyzed by morbidity type, all decreased in percentage, although without achieving significance (surgical site infection from 11.7% to 8.4%, nosocomial infection 15.8 to 10% and medical morbidity 8.6% to 4.2%). The overall hospital stay went from 6 to 4 days, and the decrease in the percentage of patients who prepared at home was statistically significant in both cases. CONCLUSIONS: Trimodal prehabilitation can contribute to lowering the postoperative morbidity and overall hospital stay of patients undergoing colorectal cancer surgery

A single-center prospective observational study on the effect of trimodal prehabilitation in colorectal surgery. / Estudio observacional prospectivo unicéntrico sobre el efecto de la prehabilitación trimodal en cirugía colorrectal.

INTRODUCTION: A trimodal prehabilitation protocol was designed with the aim to evaluate whether it contributes to reducing postoperative morbidity, to evaluate the effect of prehabilitation on overall hospital stay, and to analyze the evolution of functional capacity before and after surgery. METHODS: A single-center observational study of patients with colorectal cancer who underwent surgery with curative intent after a trimodal prehabilitation protocol. We collected data for postoperative morbidity according to the Comprehensive Complication Index and hospital stay, which were compared with a historical matrix. Functional capacity data were also collected before and after the application of the prehabilitation protocol. RESULTS: Compared to the historical population, the overall Comprehensive Complication Index was reduced from 13.2 to 11.5, which was statistically significant. Analyzed by morbidity type, all decreased in percentage, although without achieving significance (surgical site infection from 11.7% to 8.4%, nosocomial infection 15.8 to 10% and medical morbidity 8.6% to 4.2%). The overall hospital stay went from 6 to 4 days, and the decrease in the percentage of patients who prepared at home was statistically significant in both cases. CONCLUSIONS: Trimodal prehabilitation can contribute to lowering the postoperative morbidity and overall hospital stay of patients undergoing colorectal cancer surgery.

Study of anorectal function after transanal endoscopic surgery.

AIM: To evaluate the impact of Transanal Endoscopic Microsurgery (TEM) on anorectal function, using clinical and manometric assessments. To identify subgroups likely to develop incontinence after TEM, by stratifying the sample. METHOD: Descriptive, prospective study. Between December 2004 and May 2011, 222 patients were operated on at our hospital, of whom 21 were excluded from the study. Patients underwent anal manometry and answered a clinical incontinence questionnaire (the Wexner scale) prior to surgery, one month post-surgery, and then at four months post-surgery. RESULTS: There were no statistically significant differences between preoperative Wexner questionnaire scores and values at one month and four months post-surgery. Preoperative baseline pressure (BP) values were 64 mmHg±26.18, falling to 44.26 mmHg±20.11 at one month and to 48.86 mmHg±21.14 at four months. Voluntary Contraction Pressure (VCP) reached preoperative values of 200.49 mmHg±88.85, falling to 169.5 mmHg±84.95 and to 173.6±79 at four months. The differences in BP and VCP were statistically significant. The sample was stratified in order to identify subsets susceptible to incontinence after surgery, but no at-risk subgroups were found. Multivariate analysis did not detect any predictors of incontinence. CONCLUSION: The sustained, controlled anal dilatation produced with TEM caused statistically significant decreases in VCP and BP one month and four months after surgery. However, the Wexner questionnaire scores did not show any association with clinical incontinence. No predictors of postoperative incontinence were observed. We conclude that TEM is a safe technique and does not affect continence.

The prevalence of parastomal hernia after formation of an end colostomy. A new clinico-radiological classification.

INTRODUCTION: Parastomal hernia (PH) is a common complication of end colostomy, found in over 50% of patients. Abdominal computerized tomography (CT) may help diagnosis. The prevalence of PH may be higher than previously reported. We present a new CT classification for use in clinical practice. METHOD: A cross-sectional, descriptive observational study was carried out, assessing the clinical and radiological prevalence of PH in 75 patients with an end colostomy operated on since 1997. Clinical examinations were performed by a single surgeon. Abdominal CTs were assessed by a single radiologist. RESULTS: PH was observed clinically in 33 (44%) of 75 patients and 27 (82%) were symptomatic. Using the classification 0 (Normal), I (Hernial sac containing stoma loop), II (Sac containing omentum), III (Sac containing a loop other than stoma), radiological PH was observed in 35 (47%) patients. Clinical/radiological concordance (Kappa index = 0.4) increased proportionally with sac size. All type-III PHs (n = 9) were symptomatic. The combined prevalence of PH detected by one or other method was 60.8%. CONCLUSION: Clinical and radiological prevalence of PH is high. As there is no gold standard for PH detection, we recommend a combination of the two methods. A new classification for use in clinical practice is proposed.

Percepción de seguridad clínica tras el alta hospitalaria / Perceptions of clinical safety after hospital discharge

Fundamentos y Objetivo: La percepción de seguridad clínica que poseen los pacientes ha sido poco estudiada. En este estudio se describe la frecuencia de errores clínicos desde el punto de vista del paciente, su percepción de seguridad y su relación con la información recibida. Material y Métodos: Estudio descriptivo basado en una encuesta postal tras 20 días del alta a 336 pacientes quirúrgicos (tasa corregida de respuesta del 75,58%, error del 5,7% para un nivel de confianza del 95%). Resultados: Un 13,05% (intervalo de confianza [IC] del 95%, 9,16- 16,95%) informaron sufrir un error clínico. Un 10,5% con complicaciones graves. Esta experiencia disminuye la percepción de seguridad en tratamientos futuros ( 2 1,2 = 30,84; p = 0,0001). Un 11,9% (IC del 95%, 7,2-16,6%) consideraron que el riesgo de ser víctima de un error médico con consecuencias graves es alto, aunque menor al de sufrir un accidente de tráfico, robo/atraco o presentar una enfermedad grave. Ver noticias en los medios sobre errores disminuye la percepción de seguridad (p < 0,001). Los pacientes que valoran positivamente la información recibida sobre tratamiento y que pueden formular preguntas al médico son quienes menos errores informan (p < 0,001). Conclusiones: Un 1,37% de pacientes quirúrgicos informan de errores con consecuencias graves, mientras que 12 de cada 100 creen que el riesgo de un error con consecuencias graves es elevado. Tras un error se incrementa la desconfianza. Mejorar la comunicación con el paciente contribuye a reducir errores, lo que refuerza el papel de los programas para incrementar la seguridad que fomentan un papel más activo en el paciente (AU)

Objetive: Patient perception of clinical safety has been scantly studied. This study describes the frequency of clinical errors from a patient point of view, their perception of safety and its relationship with the information received. Material and Methods: Descriptive study based on a postal survey to 336 surgical patients, 20 days after the discharge from the hospital (the corrected rate of response is 75.58%, the error is 5.7% for a confidence level of 95%). Results: In the responses, 13.05% (95% CI, 9.16-16.95%) reported suffering a clinical error. Of these, 10.5% had severe complications. This experience decreases the perception of safety in future treatments (p = 0.0001). The risk of being a victim of a medical error with serious consequences is high was considered by 11.9% (95% CI, 7.2-16.6%) of the patients, although less than suffering from a traffic accident, a robbery or a serious illness. A higher frequency in the media related to medical mistakes, decreases the perception of safety (p < .001). The patients who positively value the information received regarding the treatment and who can formulate questions to ask the doctor are those who report less errors (p < .001). Conclusions: A total of 1.37% of surgical patients report mistakes with severe consequences, whereas 12% believe that the risk of a mistake with serious consequences is high. Distrust increases after an error. Improving communication with the patient helps to reduce mistakes, which strengthens the role of programs to increase safety that encourage more active patient involvement (AU)

[Perceptions of clinical safety after hospital discharge]. / Percepción de seguridad clínica tras el alta hospitalaria.

OBJECTIVE: Patient perception of clinical safety has been scantly studied. This study describes the frequency of clinical errors from a patient point of view, their perception of safety and its relationship with the information received. MATERIAL AND METHODS: Descriptive study based on a postal survey to 336 surgical patients, 20 days after the discharge from the hospital (the corrected rate of response is 75.58%, the error is 5.7% for a confidence level of 95%). RESULTS: In the responses, 13.05% (95% CI, 9.16-16.95%) reported suffering a clinical error. Of these, 10.5% had severe complications. This experience decreases the perception of safety in future treatments (p = 0.0001). The risk of being a victim of a medical error with serious consequences is high was considered by 11.9% (95% CI, 7.2-16.6%) of the patients, although less than suffering from a traffic accident, a robbery or a serious illness. A higher frequency in the media related to medical mistakes, decreases the perception of safety (p < .001). The patients who positively value the information received regarding the treatment and who can formulate questions to ask the doctor are those who report less errors (p < .001). CONCLUSIONS: A total of 1.37% of surgical patients report mistakes with severe consequences, whereas 12% believe that the risk of a mistake with serious consequences is high. Distrust increases after an error. Improving communication with the patient helps to reduce mistakes, which strengthens the role of programs to increase safety that encourage more active patient involvement.

Mid term analysis of safety and quality of life after the laparoscopic repair of paraesophageal hiatal hernia.

BACKGROUND: Initial experience with the laparoscopic repair of paraesophageal and type III mixed hiatal hernias showed that it is safe and feasible, with excellent immediate and short-term results. However, after a longer follow-up, a recurrence rate of < or =40% has been demonstrated. Data related to the outcome of paraesophageal hernia repair and the recurrence rate are still lacking. Quality-of-life scores may offer a better means of assessing the impact of surgical treatment on the overall health status of patients. Therefore, we performed prospective evaluation of anatomic and/or symptomatic recurrences after paraesophageal or large hiatal hernia repair. In addition, we investigated the correlation between recurrence and the patient's quality of life. METHODS: All patients after who had undergone repair of paraesophageal of mixed hiatal hernia were identified prospectively from a database consisting of all patients who had had laparoscopic operations for gastroesophageal pathology at our hospital between February 1998 and December 2002. The preoperative symptoms were taken from patients' clinical files. In March 2003, all patients with > or =6 months of follow-up had a barium swallow and were examined for radiological and clinical signs of recurrence. Thereafter, the patients' quality of life after surgery was evaluated using three standard questionnaires (Short Form 36 [SF-36], Glasgow Dyspepsia Severity Score [GDSS], and Gastrointestinal Quality of Life Index [GIQLI]. RESULT: During the study period, 46 patients had been operated on. The mean age was 63 years (range, 28-93). Thirty seven of them had a follow-up of > or =6 months. Eight patients (21%) had postoperative gastrointestinal symptoms. Barium swallow was performed in 30 patients (81%) and showed a recurrence in six of them (20%). According to SF-36 and GDSS, the patients' postoperative quality of life reached normal values and did not differ significantly from the standard values for the Spanish population of similar age and with similar comorbidities. Successfully operated patients reached a GIQLI value comparable to the standard population. However, symptomatic patients had significantly lower GIQLI scores than the asymptomatic or the Rx-recurrent group. CONCLUSION: The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to establish technical alternatives that would ensure the durability of the repair.

Predictive factors in smoking cessation with combined therapy with bupropion and nicotine patches.

UNLABELLED: The association of bupropion and nicotine is a good choice in the treatment of smoking cessation. However, not all patients actually give up smoking. STUDY OBJECTIVES: This work was undertaken with the aim of finding out the functional or clinical variables that could be associated with the success of the cessation therapy. DESIGN: In one year, 88 patients who were treated with bupropion 300 mg/day and nicotine patches were followed-up, for 1 month and 3 months, respectively. They were all questioned about the number of cigarettes per day, the years they have been smoking, the number of quitting attempts, and concurrent pulmonary conditions were sought for. The Fageström Test, forced spirometry (FVC, FEV-1, FEF25-75), and exhaled carbon monoxide (by co-oxymetry) were also assessed. For the statistical analysis, a logistic regression model allowing to predict the response of new subjects to the treatment, with the lowest error possible, was applied. To choose the working model, the highest and lowest value of each variable were found, drawing the correlation matrix between dependent and independent variables, by means of the box-plot procedure. Then, the model's application conditions were analysed: linearity, homoscedasticity, independence of the applications, and normality of the distributions. To assess the discrimination of the model, a ROC curve was used. RESULTS: Showed that at the end of the follow-up year, 59.1% of the patients quitted smoking. The multivariate analysis with logistic regression showed that no previous history of chronic obstructive pulmonary disease (COPD), a FEF25-75 value and effectively quit after the first week of treatment were independent prognostic factors of treatment success. When the diagnosis precision of our model was analysed by means of the ROC curve, it showed a 78% value, with the 95% confidence interval ranging from 68.5% to 86.9%. At the optimal cut-off point of our model, sensitivity and specificity for quitting smoking were found to be 66.7% and 80%, respectively. CONCLUSIONS: We conclude that with a diagnosis precision of 78.8% patients with no history of COPD, who quitted at the first week of therapy with bupropion and with low FEF25-75, will remain non-smokers after one year follow-up. Contrarily, COPD patients who still smoke after one week of therapy, will not achieve quitting smoking.

Light and electron microscopic analysis of liver biopsy samples from rheumatoid arthritis patients receiving long-term methotrexate therapy.

OBJECTIVE: We study liver damage in forty-two patients with rheumatoid arthritis (RA) using light (LM) and electron microscopy (EM) and assess histological changes after four years of treatment with methotrexate (MTX). PATIENTS AND METHODS: liver biopsies (LB) were taken before and after four years of treatment. Patients received weekly doses of between 7.5-15 mg of MTX. RESULTS: Fourteen per cent of the baseline LB presented mild perisinusoidal fibrosis (Roenigk IIIA) and the rest a lower Roenigk grade; EM identified an increase in collagen fibers in the Disse spaces in 50% of baseline LB. Neither microscopy technique revealed histological progression in any of the sequential LB. Variables that correlated with histological abnormalities were patient's age, length of evolution of the disease, alcohol consumption and biochemical data (gammaglutamate transferase and albumin); the cumulative dose of MTX was not correlated with worse histological findings. Correlation between the two microscopy techniques was good, though EM was more sensitive than LM for the detection of fibrosis. CONCLUSIONS: RA patients present with liver damage before treatment with MTX. The alterations are mild. At low doses MTX treatment is safe. In addition to the recommendations of the American College of Rheumatology, other factors associated with liver impairment are patient's age and length of evolution of the RA.

Cáncer bilateral de mama. Revisión de las características clínicas e histológicas / Bilateral breast cancer. Clinical and histologic characteristics

Introducción. La radioquimioterapia neoadyuvante en el cáncer de recto disminuye las recidivas locales y algunos autores comunican un aumento de la supervivencia, también se ha observado un aumento de la morbimortalidad postoperatoria. El objetivo de este estudio es analizar la dificultad operatoria y las complicaciones postoperatorias en los pacientes con radioquimioterapia preoperatoria. Pacientes y método. Se estudian 103 pacientes intervenidos de cáncer de recto entre enero de 1995 y diciembre de 1999, divididos en dos grupos: grupo A, formado por 53 pacientes sometidos a radioterapia preoperatoria con 45 Gy (1,8 Gy/día durante 25 días), junto a quimioterapia con 5-fluorouracilo y ácido folínico (la cirugía se realizó 4-6 semanas después de la finalización del tratamiento), y grupo B, compuesto por 50 pacientes con cáncer de recto a los que se practicó la cirugía tras el diagnóstico. Ambos grupos son homogéneos en los datos preoperatorios analizados. Se compara entre los dos grupos la dificultad técnica mediante datos intraoperatorios, así como la tasa de complicaciones. Resultados. No existen diferencias estadísticamente significativas entre los dos grupos en cuanto a los datos intraoperatorios ni postoperatorios evaluados. En el grupo A existen 20 complicaciones en 17 pacientes (32 por ciento), mientras que en el grupo B existen 22 complicaciones en 19 pacientes (38 por ciento). La tasa de infección de la herida perineal fue similar en los dos grupos: el 9,4 por ciento en el grupo A frente al 10 por ciento en el grupo B. El porcentaje de fugas anastomóticas fue mayor en el grupo A (5,7 por ciento) que en el grupo B (2 por ciento), diferencia sin significación estadística. En el grupo de radioquimioterapia se realizaron un mayor número de resecciones anteriores (75 por ciento) que en el grupo B (60 por ciento). Conclusión. El uso de la radioquimioterapia preoperatoria en el cáncer de recto no aumenta la incidencia de complicaciones postoperatorias y aumenta la tasa de cirugía conservadora de esfínteres (AU)

Evidencia de translocación bacteriana en un modelo experimental de politraumatismo / Fevidence of bacterial translocation in an experimental model of multiple trauma

Objetivo. Analizar la relación entre el politraumatismo y la translocación bacteriana en un modelo experimental. Material y métodos. Se ha utilizado 132 ratones Balb/c de 8 a 12 semanas de vida, siendo traumatizados mediante el Aparato Generador de Politraumatismo, con una mortalidad prevista del 20 por ciento. Se ha determinado la translocación bacteriana a las 0, 4, 8, 12, 24, 48 y 72 h tras la agresión. Se ha analizado mediante test exacto de Fisher. Resultados. La translocación global en el grupo control fue del 14,3 por ciento; la translocación en el grupo politraumatizado fue del 70 por ciento (p < 0,00001). Con un intervalo de confianza del 95 por ciento, el número de colonias por gramo de ganglio linfático fue de 1 a 3.6 en el grupo control y entre 20,7 y 127,7 en el grupo traumatizado. Las diferencias entre el grupo control y el traumatizado a los intervalos de tiempo descritos son significativas a las 8 h (p = 0,01), 12 h (p = 0,041), 24 h (p = 0,041) y a las 72 h (p = 0,041), según test exacto de Fisher. Conclusión. Existe una translocación bacteriana precoz tras un politraumatismo experimental. Creemos que esta translocación puede actuar como un importante activador del fallo multiorgánico tras el politraumatismo (AU)

[Bupropion combined with nicotine patches in smoking cessation]. / Asociación de bupropión y parches de nicotina como terapia para dejar de fumar.

Smoking cessation is a first-line treatment for patients with bronchial and pulmonary diseases. Various strategies have been developed to help patients quit. Bupropion, a drug initially developed as an antidepressant, has recently been shown to have effects that increase the ability of a smoker to quit. This descriptive study, enrolling 86 patients who volunteered for a smoking cessation program, assesses the use of 300 mg of bupropion over a 4-week period combined with 12 weeks of nicotine patch application at doses that were lowered every 4 weeks. Abstinence was achieved by 69% of patients after 6 months of follow-up and no significant side effects were described. The percentage decreased to 58.6% after one year of follow-up. No significant differences were found between success in quitting in this study and either the number of prior attempts to quit or concomitant respiratory disease. We conclude that bupropion combined with transdermal nicotine is a good option to aid patients to achieve smoking cessation.

Spontaneous rupture of the spleen associated with pneumonia.

Spontaneous rupture of the spleen is a rare and life-threatening complication of bacterial pneumonia, only six properly documented cases having been reported to date. A case of spontaneous splenic rupture associated with pneumonia caused by Legionella pneumophila is presented, together with a review of the literature. Most of the patients were aged over 50, but none had predisposing conditions. Left lung involvement predominated. Legionellosis and Q fever were the most frequent etiologic diagnoses. Empiric antibiotic therapy was adequate in all but two patients. One patient died; he had not undergone laparotomy. Spontaneous rupture of the spleen is an extremely rare complication of bacterial pneumonia that endangers the patient's life if surgery is not performed immediately. This complication should be borne in mind in patients with atypical pneumonia who have left quadrant pain and a falling hematocrit, even in the absence of prior splenomegaly.

[Tuberculous pancreatic abscess: differential diagnosis and favorable response to medical treatment]. / Absceso tuberculoso pancreático: diagnóstico diferencial y respuesta favorable al tratamiento médico.

Pancreatic tuberculosis is rare and may present differential diagnostic problems, specially with cancer of the pancreas. An immunocompetent patient with a pancreatic tuberculous abscess whose clinical manifestations were epigastric pain and a toxic syndrome of one month of evolution is presented. A cystic mass was detected on computerized axial tomography in the tail of the pancreas suggestive of irresectable carcinoma because of vascular invasion with negative percutaneous cytologic puncture for malignant cells. The patient was surgically treated with no histologic confirmation of malignancy. A second laparotomy was performed at 6 months since spontaneous size reduction, external pancreatic fistula with miliary peritoneal dissemination and biopsy compatible with tuberculous granulomas was found. Staining for resistant acid-alcohol bacilli were always negative. Medical treatment achieved complete disappearance of the pancreatic tumor in one year.