Innovation in surgical trauma care education: assessment of a Panamerican Trauma Society online surgical skills course hosted by the Spanish Surgical Association.

PURPOSE: Incorporating surgical skills education in trauma care is essential for young surgeons and surgical trainees. This study describes an innovative e-learning course for teaching trauma care surgical skills in an international cooperative setting. Furthermore, it aims to offer valuable insights on enhancing e-learning practices. METHODS: The Panamerican Trauma Society and the Spanish Surgical Association have joined forces to launch an online course focusing on advanced trauma care surgical skills. This report provides an in-depth examination of the project and scrutinizes participant feedback through a post-course survey. The survey thoroughly evaluates their satisfaction level, the usefulness of the course content, and their view on its clinical relevance. RESULTS: Three hundred eighty-two surgeons from 16 countries completed an online course. Three hundred seventy-nine of them responded to the post-course survey. The mean age was 36, with 64% females and 36% males. The course consisted of 9.9 h of academic content, including 5 h of video lectures and 4.9 h of live discussions. Ninety-seven percent of the participants were practicing general and acute care surgeons, and only 2% were exclusively dedicated to trauma surgery. Sixty-one percent of participants highly valued real-time interaction with faculty, and 95% believed their trauma surgical skills would improve. Additionally, 93% of the participants were satisfied or very satisfied with the e-learning experience. CONCLUSIONS: The use of video-based instructional materials has revolutionized surgical education. With online courses in trauma surgery, surgeons can now improve their skills and better prepare themselves to handle severe trauma cases. This innovative approach to surgical education has proven to be very effective and can potentially enhance patients' quality of care.

Open versus laparoscopic cholecystectomies in patients with or without type 2 diabetes mellitus in Spain from 2003 to 2013.

BACKGROUND: This study aimed to compare the rates of open and laparoscopic cholecystectomies and outcomes in patients with or without type 2 diabetes mellitus (T2DM) in Spain from 2003 to 2013. METHODS: We collected all cases of open and laparoscopic cholecystectomies using national hospital discharge data and evaluated the annual cholecystectomy rates stratified by T2DM status. We analyzed tendency for in-hospital mortality (IHM). We also analyzed the impact of T2DM on IHM in patients who underwent cholecystectomies. RESULTS: We identified 611 533 cholecystectomies (71.3% laparoscopic) in the patients, in whom 78 227 (12.8%) patients had T2DM. The rates of open cholecystectomies were 3-fold higher (130.0/105 vs 41.1/105) in patients with T2DM than in those without T2DM, and the rate of laparoscopic cholecystectomies was almost 2-fold higher (195.2/105 vs 111.8/105) in patients with T2DM. The annual rate of laparoscopic procedures showed an 11-year relative increase of 88.3% (from 117.0/105 to 220.3/105) in T2DM and 49.2% (from 79.2/105 to 118.2/105) in patients without T2DM (P<0.001), whereas the rate of open procedures showed an 11-year relative decrease of 27.6% in patients with T2DM and 37.9% in those without T2DM (P<0.001). The rate of emergency laparoscopic cholecystectomy was increased in the 11 years, whereas the rate of emergency open cholecystectomies was decreased (both P<0.001). Multivariate analysis revealed that older age, higher comorbidity and emergency cholecystectomy were associated with a higher IHM. Compared with patients without T2DM, patients with T2DM demonstrated a lower IHM after open cholecystectomy [OR=0.82 (0.78-0.87)], but a higher IHM after laparoscopic cholecystectomy [OR=1.18 (1.03-1.35)]. Time-trend analyses showed a significant reduction in IHM in patients with or without T2DM after the two procedures. CONCLUSION: The rate of cholecystectomy was higher in patients with T2DM, and laparoscopic cholecystectomy was popularized in the past 11 years both in selective and emergency cholecystectomies.

Post-chemoradiation intraoperative electron-beam radiation therapy boost in resected locally advanced rectal cancer: long-term results focused on topographic pattern of locoregional relapse.

BACKGROUND: Patients with locally advanced rectal cancer (LARC) have a dismal prognosis. We investigated outcomes and risk factors for locoregional recurrence (LRR) in patients treated with preoperative chemoradiotherapy (CRT), surgery and IOERT. METHODS: A total of 335 patients with LARC [⩾cT3 93% and/or cN+ 69%) were studied. In multivariate analyses, risk factors for LRR, IFLR and OFLR were assessed. RESULTS: Median follow-up was 72.6 months (range, 4-205). In multivariate analysis distal margin distance ⩽10 mm [HR 2.46, p = 0.03], R1 resection [HR 5.06, p = 0.02], tumor regression grade 1-2 [HR 2.63, p = 0.05] and tumor grade 3 [HR 7.79, p < 0.001] were associated with an increased risk of LRR. A risk model was generated to determine a prognostic index for individual patients with LARC. CONCLUSIONS: Overall results after multimodality treatment of LARC are promising. Classification of risk factors for LRR has contributed to propose a prognostic index that could allow us to guide risk-adapted tailored treatment.

Prognostic impact of external beam radiation therapy in patients treated with and without extended surgery and intraoperative electrons for locally recurrent rectal cancer: 16-year experience in a single institution.

PURPOSE: To analyze prognostic factors associated with survival in patients after intraoperative electrons containing resective surgical rescue of locally recurrent rectal cancer (LRRC). METHODS AND MATERIALS: From January 1995 to December 2011, 60 patients with LRRC underwent extended surgery (n=38: multiorgan [43%], bone [28%], soft tissue [38%]) or nonextended (n=22) surgical resection, including a component of intraoperative electron-beam radiation therapy (IOERT) to the pelvic recurrence tumor bed. Twenty-eight (47%) of these patients also received external beam radiation therapy (EBRT) (range, 30.6-50.4 Gy). Survival outcomes were estimated by the Kaplan-Meier method, and risk factors were identified by univariate and multivariate analyses. RESULTS: The median follow-up time was 36 months (range, 2-189 months), and the 1-year, 3-year, and 5-year rates for locoregional control (LRC) and overall survival (OS) were 86%, 52%, and 44%; and 78%, 53%, 43%, respectively. On multivariate analysis, R1 resection, EBRT at the time of pelvic rerecurrence, no tumor fragmentation, and non-lymph node metastasis retained significance with regard to LRR. R1 resection and no tumor fragmentation showed a significant association with OS after adjustment for other covariates. CONCLUSIONS: EBRT treatment integrated for rescue, resection radicality, and not involved fragmented resection specimens are associated with improved LRC in patients with locally recurrent rectal cancer. Additionally, tumor fragmentation could be compensated by EBRT. Present results suggest that a significant group of patients with LRRC may benefit from EBRT treatment integrated with extended surgery and IOERT.

Clinical experience with ertapenem in the treatment of infections of the biliary tract in daily practice in five Spanish hospitals.

Efficacy of ertapenem in biliary tract infections in daily practice was retrospectively analyzed. Records of patients admitted to five Spanish hospitals (January 2007/February 2011) with biliary infections (cholecystitis/cholangitis) treated with ertapenem for ≥72 hours were reviewed. A total of 187 patients (mean 63.8±19.3 years, 52.9% males) were identified. Up to 96 (51.3%) were operated, with cholecystectomy (97.9%) and primary laparoscopy approach (75%) as most frequent intervention. Non-operated patients presented higher age (71.0±17.5 vs 56.9±18.5 years; P<0.001), heart insufficiency (11.0 vs 3.1%; P = 0.044) and the Mortality in Emergency Department Sepsis score (2.99±2.26 vs 1.94±2.34; P<0.001); and longer length of stay (10.3±6.6 vs 9.1±7.0; P = 0.005). Mean duration of treatment was 6.89±3.38 days. Overall favourable response was 87.7% (95% CI = 83.0-92.4) at the end of treatment. In the multivariate analysis (P<0.001, R² Cox = 0.10), non-favourable response was associated with Charlson index≥5 (OR = 18.71; 95% CI: 1.26-278.55; P = 0.034), pericholecystic abscess (OR = 5.30; 95% CI: 1.26-22.37; P = 0.023) and >3 days from symptoms start to admission (OR = 3.02; 95% CI: 1.13-8.04; P = 0.027).

Randomized prospective trial on the occurrence of laparoscopic trocar site hernias.

INTRODUCTION: Laparoscopy has become the gold standard in an increasing number of procedures. We analyze the incidence of trocar site hernias (TSH) and determine whether closure of the external fascia prevents onset of TSH and possible complications. METHODS: We performed a simple-blind randomized trial with two groups, one in which all the orifices were closed by suturing the external fascia of the abdominal wall (group A), and another in which the orifices were left open, closing only the skin (group B). Monitoring for TSH lasted 2 years from the intervention. The trial has been registered at www.clinicaltrials.gov with the clinicaltrials.gov identifier number: NCT01240434. RESULTS: A total of 195 patients were randomized. Thirty-three were removed from the study after conversion to open surgery, early open reoperation, or loss to follow-up. The remaining 162 patients comprised the study population, 80 in group A and 82 in group B. We found no differences between the groups regarding basic demographic data, kind of surgery, or topographic distribution of the trocars. Five TSH were diagnosed-four in group A and one in group B (P=.176)-and there was no relation between TSH and trocar size (11 or 12 mm) or location. We found 10 wound infections, 7 in group A and 3 in group B (P=.154). CONCLUSION: Our study suggests that the onset of TSH does not depend on trocar size or location. There is no evidence that suture of the fascial defect prevents the onset of TSH. In addition, we found a trend toward a higher incidence of wound infection among patients in whom the fascia had been sutured.

Gangrena de Fournier: análisis de una serie de 34 casos / Fournier´s gangrene: analysis of a series of 34 cases

Introducción. La gangrena de Fournier es la fasciítis necrosante genital y perineal. El objetivo del estudio fue analizar nuestra experiencia hospitalaria en su manejo.Materiales y métodos. Estudio descriptivo retrospectivo de los pacientes atendidos con gangrena de Fournier en el Servicio de Urgenciasdel Hospital General Universitario Gregorio Marañón, entre 1998 y 2008.Resultados. Se incluyeron 34 pacientes, 30 hombres y 4 mujeres, con una mediana de edad de 69 años, con algún factor de riesgo en 30 de ellos, el másfrecuente de los cuales fue la hipertensión arterial (n=18). La etiología más frecuente fue la colorrectal (n=18). La presentación clínica más común fue el dolor perineal (n=21) y el eritema perineal (n=19).Los datos analíticos alterados más importantes fueron: hemoglobina, 11,8 g/dl; hematocrito, 32,7%; leucocitos, 17.300/mm3 (88,2% neutrófilos); INR(International Normalized Ratio) 1,3 y urea 73,5 mg/dl. El tratamiento se basó en el desbridamiento quirúrgico y, como tratamientos complementarios, sepracticaron cistostomía (3), colostomía (7) y orquidectomía (2). Los gérmenes más aislados fueron Escherichia coli (63%), Bacteroides spp. (55%) yPeptostreptococcus spp. (42%). La terapia antibiótica empírica más empleada fue el imipenem (44%),seguida de la combinación penicilina másgentamicina más metronidazol (26%). Fallecieron nueve pacientes (26%).Discusión. En nuestro medio, la gangrena de Fournier tuvo una baja incidencia. Su causa más frecuente fue la colorrectal y su diagnóstico fuefundamentalmente clínico. El tratamiento fue multidisciplinario, con soporte hemodinámico, cirugía y terapia antibiótica de amplio espectro. La tasa de mortalidad fue elevada.

Introduction: Fournier’s gangrene the of necrotizing fasciitis perineum and genital. The objetive of this study was to analyze our institution experience in the management of this pathology.Materials and methods: Descriptive and retrospective study of the patients with Fournier’s gangrene treated in the Emergency Department of the Hospital General Universitario Gregorio Marañón between 1998 and 2008. Results: 34 patients were evaluated, 30 males and 4 females with a median age of 69 years. 30 patients suffered some predisposing factors, and the most common was arterial hypertension (n=18). Colorectal etiology were the most frequent (n=18). The most common clinical presentation were perineum pain (n=21) and erythema (n=19). Main laboratory results were hemoglobin 11.8 gr/dl, hematocrit 32,7%, white blood cells 17.300/mm3 (88,2% neutrophiles), INR 1,3 and urea 73,5 mg/dl. Surgical debridement is the main treatment but complementary treatment such as cistostomy (n=3), colostomy (n=7) and orchiectomy (n=2)were needed. Microbiological cultures revealed Escherichia coli (63%), Bacteroides (55%) andPeptostreptococcus (42%). Imipenem (44%) and combination of penicillin, gentamicin and metronidazole (26%) were the most common empiric antibiotic therapy. Mortality was registered in 9 patients (26%).Conclusions: Fournier’s gangrene exhibits low incidence at our institution. Colorectal etiology was the most common. The diagnosis was mainly clinic. Multidisciplinary treatment seems to be the best approach and includes hemodinamic support, surgery and broad-spectrum antibiotic therapy. The mortality rate was high.

Lesiones inadvertidas en el politraumatizado: análisis de un registro de trauma / Missed injuries in patients with multiple trauma: analysis of a trauma registry

Introducción. La frecuencia de lesiones inadvertidas en pacientes con traumatismos oscila entre el 0,5 y el 38%, según los diferentes estudios y sus criterios de inclusión. En nuestro trabajo hemos evaluado la incidencia, los factores contribuyentes y la relevancia clínica de estas lesiones a partir del Registro de Trauma grave de nuestro centro. Pacientes y métodos. Se analiza de manera retrospectiva un registro de 912 traumatizados graves, recogidos de forma prospectiva. De éstos, 19 pacientes presentaron una lesión inadvertida (2%). Se comparan variables demográficas (edad y sexo) y clínicas (escalas de gravedad y mecanismo lesivo), y se evalúan los factores contribuyentes evitables, así como las lesiones inadvertidas clínicamente relevantes. Resultados. De los 19 pacientes con lesiones inadvertidas, el 58% sufrió traumatismos cerrados. En ninguna de las variables estudiadas se encontró diferencia estadística, aunque las lesiones penetrantes fueron claramente más frecuentes en los pacientes con lesiones inadvertidas que en el grupo sin ellas. El 47% fueron osteoarticulares, el 26% viscerales y el 21% vasculares. Las lesiones potencialmente evitables fueron el 63%, y el motivo más frecuente fue una incorrecta evaluación clínica. La mortalidad por lesiones diagnosticadas de manera tardía alcanzó el 21%. Conclusiones. Una incorrecta evaluación clínica es el factor evitable que más impacto tiene a la hora de disminuir el número de lesiones inadvertidas. Otro factor que claramente contribuye a la reducción es la adecuada interpretación de las imágenes radiológicas, en el contexto de una revisión terciaria. Todos los equipos que tratan a estos pacientes deberían conocer sus resultados e incidir en las fases diagnósticas donde reside el error (AU)

Introduction. The frequency of missed injuries (MI) in patients with trauma oscillates between 0.5 and 38%, depending on the distinct studies and their inclusion criteria. In the present study, we evaluated the incidence, contributory factors and clinical relevance of these lesions, based on the Severe Trauma Registry of our center. Patients and methods. We retrospectively analyzed a registry of 912 cases of severe trauma, which were prospectively gathered. Of these, 19 patients had a MI (2%). Demographic (age and sex) and clinical variables (severity scales and mechanism of injury) were compared and avoidable contributory factors and clinically relevant MI were evaluated. Results. Of the 19 patients with a MI, 58% had closed injuries. No statistically significant differences were found in any of the variables studied, although penetrating injuries were clearly more frequent in patients with MI than in those without. Forty-seven percent of MI were musculoskeletal, 26% were visceral and 21% were vascular. Sixty-three percent of contributory factors were potentially avoidable and the most frequent reason for MI was incorrect clinical evaluation. Mortality due to lesions with a delayed diagnosis was 21%.Conclusions. Incorrect clinical evaluation was the avoidable factor that would have the greatest impact on reducing the number of MI. Another factor that clearly contributes to reduction of MI is appropriate interpretation of radiological images in the context of a tertiary survey. All teams treating these patients should periodically evaluate their results and intervene in the factors contributing to missed diagnoses (AU)

[Missed injuries in patients with multiple trauma: analysis of a trauma registry]. / Lesiones inadvertidas en el politraumatizado: análisis de un registro de trauma.

INTRODUCTION: The frequency of missed injuries (MI) in patients with trauma oscillates between 0.5 and 38%, depending on the distinct studies and their inclusion criteria. In the present study, we evaluated the incidence, contributory factors and clinical relevance of these lesions, based on the Severe Trauma Registry of our center. PATIENTS AND METHODS: We retrospectively analyzed a registry of 912 cases of severe trauma, which were prospectively gathered. Of these, 19 patients had a MI (2%). Demographic (age and sex) and clinical variables (severity scales and mechanism of injury) were compared and avoidable contributory factors and clinically relevant MI were evaluated. RESULTS: Of the 19 patients with a MI, 58% had closed injuries. No statistically significant differences were found in any of the variables studied, although penetrating injuries were clearly more frequent in patients with MI than in those without. Forty-seven percent of MI were musculoskeletal, 26% were visceral and 21% were vascular. Sixty-three percent of contributory factors were potentially avoidable and the most frequent reason for MI was incorrect clinical evaluation. Mortality due to lesions with a delayed diagnosis was 21%. CONCLUSIONS: Incorrect clinical evaluation was the avoidable factor that would have the greatest impact on reducing the number of MI. Another factor that clearly contributes to reduction of MI is appropriate interpretation of radiological images in the context of a tertiary survey. All teams treating these patients should periodically evaluate their results and intervene in the factors contributing to missed diagnoses.

Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure.

PURPOSE: To compare the outcomes of embolotherapy and surgery as salvage therapy after therapeutic endoscopy failure in the treatment of upper gastrointestinal peptic ulcer bleeding. MATERIALS AND METHODS: Retrospective analysis of 70 cases of refractory peptic upper gastrointestinal hemorrhage was performed. Thirty-one cases were managed with embolotherapy and 39 were managed surgically. Demographic variables, underlying conditions, clinical findings, endoscopic treatment, transfusion requirements before and after alternative therapeutic approach, length of hospital stay, and outcomes including recurrent bleeding, need for surgery after initial alternative treatment, and in-hospital death were recorded. RESULTS: Patients who received embolotherapy were older (75.2 years +/- 10.9 vs 63.3 years +/- 14.5; P <.001) and had greater incidences of heart disease (67.7% vs 20.5%; P <.001) and previous anticoagulation treatment (25.8% vs 5.1%; P =.018). There were no differences in the rest of the pretreatment variables. No differences were found between the embolotherapy and surgery groups in the incidence of recurrent bleeding (29% vs 23.1%), need for additional surgery (16.1% vs 30.8%), or death (25.8% vs 20.5). CONCLUSIONS: The lack of differences between these two treatment alternatives, despite the more advanced age and greater prevalence of heart disease in the embolotherapy group, provides support for future prospective randomized studies aimed to evaluate the role of embolotherapy in the management of refractory peptic ulcer bleeding.

New approach to improving endothelial preservation in cryopreserved arterial substitutes.

The endothelial loss provoked by the methods of vascular cryopreservation used at most human vessel banks is one of the main factors leading to the failure of grafting procedures performed using cryopreserved vessel substitutes. This study evaluates the effects of the storage temperature and thawing protocol on the endothelial cell loss suffered by cryopreserved vessels, and optimises the thawing temperature and protocol for cryopreserving arterial grafts in terms of that producing least endothelial loss. Segments of the common iliac artery of the minipig (n = 20) were frozen at a temperature reduction rate of 1 degrees C/min in a biological freezer. After storing the arterial fragments for 30 days, study groups were established according to the storage temperature (-80, -145 or -196 degrees C) and subsequent thawing procedure (slow or rapid thawing). Fresh vessel segments served as the control group. Once thawed, the specimens were examined by light, transmission, and scanning electron microscopy. The covered endothelial surface was determined by image analysis. Data for the different groups were compared by one way ANOVA. When cryopreservation at each of the storage temperatures was followed by slow thawing, the endothelial cells showed improved morphological features and viability over those of specimens subjected to rapid thawing. Rapidly thawed endothelial cells showed irreversible ultrastructural damage such as mitochondrial dilation and rupture, reticular fragmentation, and peripheral nuclear condensation. In contrast, slow thawing gave rise to changes compatible with reversible damage in a large proportion of the endothelial cells: general swelling, reticular dilation, mitochondrial swelling, and nuclear chromatin condensation. Gradually thawed cryopreserved arteries showed a lower proportion of damaged cells identified by the TUNEL method compared to the corresponding rapidly thawed specimens (p < 0.05, for all temperatures). In all the groups in which vessels underwent rapid thawing (except at -145 degrees C), significant differences (p < 0.05) in endothelial cover values were recorded with respect to control groups. Storage of cryopreserved vessels at -80 degrees C followed by rapid thawing led to greatest endothelial cell loss (61.36+/-9.06% covered endothelial surface), while a temperature of -145 degrees C followed by slow thawing was best at preserving the endothelium of the vessel wall (89.38+/-16.67% surface cover). In conclusion, storage at a temperature of -145 degrees C in nitrogen vapour followed by gradual automated thawing seems to be the best way of preserving the endothelial surface of the arterial cryograft. This method gives rise to best endothelial cell viability and cover values, with obvious benefits for subsequent grafting.