Proyecto nacional para la gestión clínica de procesos asistenciales. Tratamiento quirúrgico de la hernia inguinal / National project for the management of clinical processes. Surgical treatment of inguinal hernia

Introducción. La alta prevalencia del tratamiento quirúrgico de la hernia inguinal (procedimiento más frecuente en cirugía general) ha llevado a la Asociación Española de Cirujanos (AEC) a realizar un estudio a escala nacional dirigido a conocer los indicado-res más importantes. Objetivo. Análisis de la calidad asistencial en el tratamiento quirúrgico programado de la hernia inguinal, en el que se evalúa la calidad cientificotécnica, la eficiencia, la efectividad y la satisfacción del paciente. Material y métodos. Estudio prospectivo, longitudinal y descriptivo, desde el diagnóstico de la enfermedad hasta el seguimiento posterior. Se incluyó a pacientes intervenidos por hernia inguinal uni o bilateral, primarias o recidivas. Los criterios de exclusión fueron cirugía urgente y procedimientos quirúrgicos asociados. Se seleccionaron indicadores clínicos tras revisar la bibliografía científica. Resultados. Participaron 46 hospitales correspondientes a 16 comunidades autónomas que proporcionaron en total 386 casos. El seguimiento medio fue de 18 meses. La edad media de los pacientes fue de 56,33 años, el 88,3% varones. El 50,1% eran ASA I (grado marcado por la American Society of Anathesiologists). El 95,6% no cumplió las pautas del protocolo de pruebas preoperatorias de la AEC. Se empleó profilaxis antibiótica en el 75,39% y tromboembólica en el 40,04%. El 33,6% se intervino en régimen de (..) (AU)

Introduction. The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators. Objective. To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientifictechnical quality, efficiency, effectiveness, and patient satisfaction. Material and methods. A prospective, longitudinal, descriptive study from diagnosis to postoperative fo-llow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review. Results. Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was (..) (AU)

Variación del valor pronóstico de la proteína p53 en relación con el estadio tumoral en pacientes con adenocarcinoma colorrectal / Variation in the prognostic value of p53 protein in relation to tumoral stage in patients with colorectal adenocarcinoma

Objetivo. Analizar el valor pronóstico que posee la proteína p53 en cada estadio tumoral, como indicador de riesgo de recidiva. Pacientes y método. Estudio prospectivo de una cohorte de 288 pacientes intervenidos por adenocarcinoma colorrectal. Cuarenta y dos pacientes (14,6%) se encontraban en estadio I de la clasificación TNM (tu-mor-nodo-metástasis); 144 (50%), en estadio II, y 102 (35,4%), en estadio III. Se analizaron, en muestras tu-morales fijadas en formol y parafinadas, variables histopatológicas y se determinaron mediante inmunohistoquímica las proteínas p53 (anticuerpo DO7) y PCNA (proliferative cell nuclear antigen) (anticuerpo PC10). Se analizaron los resultados de p53 en cada una de las categorías de las variables clínicas e histopatológicas. Se calculó la supervivencia sin recidiva mediante el método de Kaplan-Meier. Se analizó el valor de cada variable como indicador predictivo de aparición de recidiva tumoral mediante análisis de regresión de Cox. Se calcularon las hazard ratio y los intervalos de confianza (IC) del 95%, como indicadores del riesgo relativo. El análisis se aplicó en toda la cohorte de pacientes y, posteriormente, fue repetido en cada estadio tumoral TNM por separado. Resultados. Los tumores con sobreexpresión de proteína p53 desarrollaron con mayor frecuencia recidiva tumoral y presentaron menor supervivencia sin recurrencia a los 5 años de seguimiento. Sin embargo, únicamente en los tumores en estadio III la asociación entre expresión de p53 y evolución postoperatoria alcanzó significación estadística. En este subgrupo de pacientes, la supervivencia sin recidiva a los 60 meses de seguimiento fue del 60% en los tumores con p53 negativo y del 26% en aquellos con p53 positivo (p = 0,010). En el análisis multivariante, p53 se mostró como un factor pronóstico independiente asociado a un riesgo elevado de recidiva en tumores en estadio III (hazard ratio = 2,76; IC del 95%, 1,29-5,9; p = 0,009). La sobreexpresión de p53 aportó valor pronóstico como indicador de riesgo elevado de recidiva en forma de metástasis (hazard ratio = 2,23; IC del 95%, 1,04-4,75) y no como factor pronóstico de recidiva locorregional. No se observó relación entre el estado de la proteína p53 y el efecto de la quimioterapia adyuvante postoperatoria. Conclusión. La proteína p53 no posee el mismo valor como factor pronóstico en todos los estadios tu-morales. Esta proteína únicamente posee valor predictivo indicativo de riesgo elevado de recidiva en el subgrupo de pacientes con tumores en estadio III (AU)

Objective. To analyze the prognostic value of p53 protein as a marker of recurrence risk in each tumoral stage. Patients and method. A prospective study of a cohort of 288 patients who underwent surgery for colo-rectal adenocarcinoma was performed. Stage 1 of the tumor-node-metastasis (TNM) classification was found in 42 patients (14.6%), stage II in 144 (50%) and stage III in 102 (35.4%). Histopathological variables were examined in tumor samples fixed in formol and embedded in paraffin and p53 (DO7 antibody) and proliferative cell nuclear antigen (PC-10 antibody) proteins were determined using immunohistochemistry. The results of p53 were analyzed in each of the categories of clinical and histopathological variables. Recurrence-free survival was calculated using the Kaplan-Meier method. The value of each variable as a predictive marker for tumoral recurrence was analyzed using Cox regression analysis. Hazard ratios and 95% confidence intervals were calculated as indicators of relative risk. The analysis was applied to the whole cohort and was subsequently repeated in each TNM tumoral stage separately. Results. Tumors with p53 protein overexpression more frequently recurred and showed lower recurren-ce-free survival at 5 years. However, the association between p53 expression and postoperative outcome was statistically significant in stage III tumors only. In this subgroup of patients, recurrence-free survival at 60 months was 60% in p53-negative tumors and was 26% in p53-positive tumors (p = 0.010). In the multivariate analysis, p53 was an independent prognostic factor associated with a high risk of recurrence in stage III tumors (hazard ratio = 2.76; 95% CI, 1.29-5.9; p = 0.009). Overexpression of p53 showed prognostic value as a marker of high risk of recurrence in the form of metastases (hazard ratio = 2.23; 95% CI, 1.04-4.75), but not as a prognostic marker of locoregional recurrence. No relationship was found between the state of p53 protein and the effect of postoperative adjuvant therapy. Conclusion. The p53 protein does not have the same prognostic value in all tumoral stages. This protein is only predictive of high recurrence risk in the subgroup of patients with stage III tumors (AU)

[National project for the management of clinical processes. Surgical treatment of inguinal hernia]. / Proyecto nacional para la gestión clínica de procesos asistenciales. Tratamiento quirúrgico de la hernia inguina.

INTRODUCTION: The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators. OBJECTIVE: To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientific-technical quality, efficiency, effectiveness, and patient satisfaction. MATERIAL AND METHODS: A prospective, longitudinal, descriptive study from diagnosis to postoperative follow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review. RESULTS: Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was performed in 33.6%. Local anesthesia and sedation only were used in 16.36% of the patients. The most frequently used surgical procedures involved mesh repair (Lichtenstein 50%, Rutkow-Robbins 17.1%), laparoscopy was used in 5.2% of the patients, and the Shouldice technique was used in 8.5%. The mean length of hospital stay was 47.5 hours in inpatients and was 11.65 hours in patients who underwent ambulatory surgery. Notable among the complications was hematoma in 11.6%. Ninety-six percent of the patients were satisfied or highly satisfied. The most highly scored items in the satisfaction survey were those related to information, personal dealings with staff, and the staffs kindness. The lowest scored items dealt with punctuality and accessibility. Follow-up at 18 months showed a recurrence rate of 4.11% with a total recovery time estimated by patients of 7.26 weeks. CONCLUSIONS: Analysis of the process revealed areas for improvement and strong points. Strong points consisted of up-to-date choice of surgical technique. The most frequently used techniques were tension-free procedures and the Shouldice technique. The following areas for improvement were identified: adherence to protocols for preoperative evaluation, increased use of ambulatory surgery, local anesthesia and sedation, appropriate use of antibiotic and thromboembolic prophylaxis in selected patients and a reduction in the length of hospital stay in inpatients. Patient satisfaction with the treatment was acceptable.

[Variation in the prognostic value of p53 protein in relation to tumoral stage in patients with colorectal adenocarcinoma]. / Variación del valor pronóstico de la proteína p53 en relación con el estadio tumoral en pacientes con adenocarcinoma colorrectal.

OBJECTIVE: To analyze the prognostic value of p53 protein as a marker of recurrence risk in each tumoral stage. PATIENTS AND METHOD: A prospective study of a cohort of 288 patients who underwent surgery for colorectal adenocarcinoma was performed. Stage 1 of the tumor-node-metastasis (TNM) classification was found in 42 patients (14.6%), stage II in 144 (50%) and stage III in 102 (35.4%). Histopathological variables were examined in tumor samples fixed in formol and embedded in paraffin and p53 (DO7 antibody) and proliferative cell nuclear antigen (PC-10 antibody) proteins were determined using immunohistochemistry. The results of p53 were analyzed in each of the categories of clinical and histopathological variables. Recurrence-free survival was calculated using the Kaplan-Meier method. The value of each variable as a predictive marker for tumoral recurrence was analyzed using Cox regression analysis. Hazard ratios and 95% confidence intervals were calculated as indicators of relative risk. The analysis was applied to the whole cohort and was subsequently repeated in each TNM tumoral stage separately. RESULTS: Tumors with p53 protein overexpression more frequently recurred and showed lower recurrence-free survival at 5 years. However, the association between p53 expression and postoperative outcome was statistically significant in stage III tumors only. In this subgroup of patients, recurrence-free survival at 60 months was 60% in p53-negative tumors and was 26% in p53-positive tumors (p=0.010). In the multivariate analysis, p53 was an independent prognostic factor associated with a high risk of recurrence in stage III tumors (hazard ratio=2.76; 95% CI, 1.29-5.9; p=0.009). Overexpression of p53 showed prognostic value as a marker of high risk of recurrence in the form of metastases (hazard ratio=2.23; 95% CI, 1.04-4.75), but not as a prognostic marker of locoregional recurrence. No relationship was found between the state of p53 protein and the effect of postoperative adjuvant therapy. CONCLUSION: The p53 protein does not have the same prognostic value in all tumoral stages. This protein is only predictive of high recurrence risk in the subgroup of patients with stage III tumors.