Postoperative Diet with an Oligomeric Hyperproteic Normocaloric Supplement versus a Supplement with Immunonutrients in Colorectal Cancer Surgery: Results of a Multicenter, Double-Blind, Randomized Clinical Trial.

(1) Background: For normo-nourished colorectal cancer patients, the need for immunonutrients after elective surgery is not known. (2) Methods: Multicenter, randomized, double-blind, phase III clinical trial comparing the postoperative diet with 200 mL oligomeric hyperproteic normocaloric (OHN; experimental arm) supplement vs. 200 mL immunonutritional (IN) (active comparator) supplement twice a day for five days in 151 normo-nourished adult colorectal-resection patients following the multimodal rehabilitation ERAS protocol. The proportions of patients with complications (primary outcome) and those who were readmitted, hospitalized for <7 days, had surgical site infections, or died due to surgical complications (secondary outcome) were compared between the two groups until postoperative day 30. Tolerance to both types of supplement and blood parameters was also assessed until day 5. (3) Results: Mean age was 69.2 and 84 (58.7%) were men. Complications were reported in 41 (28.7%) patients and the incidence did not differ between groups (18 (25%) vs. 23 (32.4%) patients with OHN and IN supplement, respectively; p = 0.328). No significant differences were found for the rest of the variables. (4) Conclusions: IN supplement may not be necessary for the postoperative recovery of colorectal cancer patients under the ERAS regimen and with normal nutritional status at the time of surgery.

¿Es la colecistectomía el tratamiento de elección en la colecistitis aguda alitiásica? Revisión sistemática de la literatura / Is cholecystectomy the treatment of choice for acute acalculous cholecystitis? A systematic review of the literature

Introducción y objetivos: actualmente no existe consenso entre colecistectomía o colecistostomía percutánea como elección terapéutica en la colecistitis aguda alitiásica. El objetivo de nuestro trabajo es revisar la evidencia científica acerca del tratamiento en estos pacientes según los hallazgos clínicos y radiológicos. Métodos: revisión sistemática de la literatura desde 2000 hasta 2016. La búsqueda se realizó usando PubMed, Índice Médico Español, Cochrane Library y Embase, siguiendo nuestros criterios de inclusión: idioma de publicación (inglés o español), pacientes adultos, etiología alitiásica y apropiado diseño de estudio. Resultados: se han identificado 1.013 artículos; finalmente, se han seleccionado para la revisión diez artículos que describían los resultados de pacientes tratados con colecistostomía percutánea y colecistectomía urgente, incluyendo cinco estudios observacionales controlados y cinco series de casos. No se han identificado estudios prospectivos o randomizados con los criterios de búsqueda. Los datos de la literatura y el examen de los resultados indicaron que, para la colecistitis aguda alitiásica, la colecistostomía percutánea puede ser un tratamiento definitivo sin requerir una colecistectomía electiva posterior. Conclusiones: la colecistostomía percutánea puede ser la primera opción de tratamiento en pacientes con colecistitis aguda alitiásica salvo en los casos que presenten perforación o gangrena vesicular. Los pacientes con bajo riesgo quirúrgico podrían beneficiarse de una colecistectomía, aunque ambas opciones de tratamiento pueden ser efectivas. La colecistostomía percutánea en pacientes con colecistitis aguda alitiásica puede ser un tratamiento definitivo sin necesidad de una colecistectomía electiva posterior. No obstante, la calidad de los estudios es, en general, baja y hace necesario tomar con cautela las recomendaciones finales (AU)

Background and objectives: there is currently no consensus with regard to the use of cholecystectomy or percutaneous cholecystostomy as the therapy of choice for acute acalculous cholecystitis. The goal of this study was to review the scientific evidence on the management of these patients according to clinical and radiographic findings. Methods: A systematic review of the literature from 2000 to 2016 was performed. The databases of PubMed, Índice Médico Español, Cochrane Library and Embase were searched according to the following inclusion criteria: publication language (English or Spanish), adult patients, acalculous etiology and appropriate study design. Results: A total of 1,013 articles were identified and ten articles were selected for review. These included five observational controlled studies and five case series which described the outcome of patients treated with percutaneous cholecystostomy and emergency cholecystectomy. No prospective or randomized studies were identified using the search criteria. The data from the literature and analysis of results suggested that percutaneous cholecystostomy may be a definitive therapy for acute acalculous cholecystitis with no need for subsequent elective cholecystectomy. Conclusions: Percutaneous cholecystostomy may be the first treatment option for patients with acute acalculous cholecystitis except in cases with a perforation or gallbladder gangrene. Patients at low surgical risk may benefit from cholecystectomy but both treatment options may be effective. Percutaneous cholecystostomy in patients with acute acalculous cholecystitis may be a definitive therapy with no need for a subsequent elective cholecystectomy. However, the overall quality of studies is low and the final recommendations should be considered with caution (AU)

Is cholecystectomy the treatment of choice for acute acalculous cholecystitis? A systematic review of the literature.

BACKGROUND AND OBJECTIVES: There is currently no consensus with regard to the use of cholecystectomy or percutaneous cholecystostomy as the therapy of choice for acute acalculous cholecystitis. The goal of this study was to review the scientific evidence on the management of these patients according to clinical and radiographic findings. METHODS: A systematic review of the literature from 2000 to 2016 was performed. The databases of PubMed, Índice Médico Español, Cochrane Library and Embase were searched according to the following inclusion criteria: publication language (English or Spanish), adult patients, acalculous etiology and appropriate study design. RESULTS: A total of 1,013 articles were identified and ten articles were selected for review. These included five observational controlled studies and five case series which described the outcome of patients treated with percutaneous cholecystostomy and emergency cholecystectomy. No prospective or randomized studies were identified using the search criteria. The data from the literature and analysis of results suggested that percutaneous cholecystostomy may be a definitive therapy for acute acalculous cholecystitis with no need for subsequent elective cholecystectomy. CONCLUSIONS: Percutaneous cholecystostomy may be the first treatment option for patients with acute acalculous cholecystitis except in cases with a perforation or gallbladder gangrene. Patients at low surgical risk may benefit from cholecystectomy but both treatment options may be effective. Percutaneous cholecystostomy in patients with acute acalculous cholecystitis may be a definitive therapy with no need for a subsequent elective cholecystectomy. However, the overall quality of studies is low and the final recommendations should be considered with caution.

Reduction in inappropriate hospital use based on analysis of the causes.

BACKGROUND: To reduce inappropriate admissions and stays with the application of an improvement cycle in patients admitted to a University Hospital. The secondary objective is to analyze the hospital cost saved by reducing inadequacy after the implementation of measures proposed by the group for improvement. METHODS: Pre- and post-analysis of a sample of clinical histories studied retrospectively, in which the Appropriateness Evaluation Protocol (AEP) was applied to a representative hospital sample of 1350 clinical histories in two phases. In the first phase the AEP was applied retrospectively to 725 admissions and 1350 stays. The factors associated with inappropriateness were analysed together with the causes, and specific measures were implemented in a bid to reduce inappropriateness. In the second phase the AEP was reapplied to a similar group of clinical histories and the results of the two groups were compared. The cost of inappropriate stays was calculated by cost accounting. SETTING: General University Hospital with 426 beds serving a population of 320,000 inhabitants in the centre of Murcia, a city in south-eastern Spain. RESULTS: Inappropriate admissions were reduced significantly: 7.4% in the control group and 3.2% in the intervention group. Likewise, inappropriate stays decreased significantly from 24.6% to 10.4%. The cost of inappropriateness in the study sample fell from 147,044 euros to 66,642 euros. The causes of inappropriateness for which corrective measures were adopted were those that showed the most significant decrease. CONCLUSIONS: It is possible to reduce inadequacy by applying measures based on prior analysis of the situation in each hospital.

Evaluation of a clinical pathway to improve colorectal cancer outcomes.

The aims of this preintervention and postintervention study were to monitor and evaluate the clinical pathway (CP) for colorectal cancer (CRC) over a 5-year period and to compare 2 groups of patients (before and after the intervention) with regard to different variables of effectiveness. Group I comprised 68 patients who underwent planned surgery between January 2002 and January 2003. Group II comprised a sample of 202 patients who underwent surgery between January 2004 and December 2008. No significant differences were found in the majority of the parameters measured: postoperative stay, compliance with antibiotic prophylaxis, compliance with the staging study, mortality, rate of infection, and reoperations. The mean length of stay (±standard deviation) for patients without complications was reduced significantly (9.2 ± 3.6 in group I versus 7.7 ± 1.7 in group II, P = .031). The CP for CRC did not achieve most of the objectives for which it was designed.

Associated factors and cost of inappropriate hospital admissions and stays in a second-level hospital.

The objective of this study was to analyze the variables related to inappropriate admissions and hospital stays and their financial repercussions. This was a descriptive retrospective study in which the Appropriateness Evaluation Protocol (AEP) was applied to a representative sample of 725 hospital admissions and 1350 hospital stays. The cost of inappropriate stays was calculated by cost accounting. The study found that 7.4% of admissions and 24.6% of stays were inappropriate. Inappropriate admissions were significantly related to medical specialties and younger patient age. Inappropriate stays were related to these factors, plus patients being outside their corresponding areas, nonurgent admissions, and low occupancy rate. The cost of the inappropriate admissions and stays was 147 044 euros. Extrapolated to the hospital as a whole this would represent 2125638 euros per year. Steps must be taken to reduce inappropriate admissions and stays to lower health care costs and to reserve hospital resources for patients who genuinely need them.

Evaluation and monitoring of the clinical pathway for thyroidectomy.

The aim of this study is to present the evaluation and monitoring of a clinical pathway for thyroidectomy 1 year after its implementation and after 4 years' follow up. We compare the results of an evaluation and monitoring indicators series before and after the establishment of the clinical pathway for thyroidectomy in the Surgery Department of Morales Meseguer Hospital, a general university hospital in Murcia, Spain. Implementation of the clinical pathway led to a reduction in length of hospital stay for all the surgery patients (4.8 +/- 2.1 and 3.6 +/- 1.9 days before and after pathway implementation, respectively; P < 0.001). Implementation of the clinical pathway led to a reduction in cost in all the operated patients (3357 +/- 966 and 2695 +/- 970 US$ before and after implementing the clinical pathway, respectively; P < 0.001). Evolution of the mean hospital cost according to year of study shows a reduction from 2000 (3400 +/- 1056 US$) to 2004 (2404 +/- 666 US$) with a slight increase during 2005 (2721 +/- 1335 US$) (P < 0.001). Implementation of the clinical pathway for thyroidectomy has successfully reduced clinical variation and therefore the length of hospital stay and mean cost of the process. In subsequent years, no such major improvements have been made with regard to hospital stay, although they are still clearly better than those before pathway implementation.

Evaluación de la vía clínica de la colecistectomía laparoscópica / Evaluation of a clinical pathway for laparoscopic cholecystectomy

Introducción. Las vías clínicas son planes asistenciales integrales y sistematizados para determinados procesos. En marzo de 2002 se implantó en nuestro servicio la vía clínica de la colecistectomía laparoscópica. El objetivo de este trabajo es presentar la evaluación de la vía clínica de dicho proceso tras 1 año de implantación. Metodología. Se ha estudiado a todos los pacientes incluidos en la vía clínica desde su implantación. Los criterios de evaluación incluyen el grado de cumplimiento, los indicadores de efectividad en la atención clínica, el impacto económico y los indicadores de satisfacción basados en una encuesta. Los resultados se comparan con la serie de pacientes intervenidos durante el año previo a la implantación de la vía clínica. En nuestro hospital se realiza gestión analítica y hemos analizado el gasto medio por proceso antes y después de la implantación de la vía clínica. Resultados. Se ha evaluado una serie de 160 pacientes consecutivos intervenidos durante 1 año previo a la elaboración de la vía clínica que cumplieran los criterios de inclusión aceptados, con una estancia media de 3,27 días. El gasto medio por proceso antes de la implantación de la vía fue de 2.149 ± 768 euros. Tras la implantación de la vía clínica y después de 1 año se ha incluido a 140 pacientes, con un porcentaje de inclusión del 100%. La estancia media de los pacientes incluidos en la vía clínica fue de 2,2 días. El grado de cumplimiento de las estancias ha sido del 66,7%. Las causas más frecuentes de incumplimiento han sido las dependientes del personal, seguidas de las dependientes del paciente (intolerancia oral, dolor, etc.). El gasto medio en la serie de pacientes incluidos en la vía clínica ha sido de 1.845 ± 618 euros. Conclusiones. La colecistectomía laparoscópica es un proceso idóneo para iniciar la sistematización de las vías clínicas. Los resultados evidencian que se ha conseguido disminuir de forma significativa la estancia hospitalaria y el gasto medio por proceso sin aumentar la morbilidad y con un alto grado de satisfacción de los pacientes (AU)

Introduction. Clinical pathways are standardized plans for the integral care of specific processes. In March 2002, a clinical pathway for laparoscopic cholecystectomy was introduced in our service. The aim of the present study was to evaluate this pathway 1 year after its implementation. Methodology. All patients included in the clinical pathway since its introduction were studied. Evaluation criteria included compliance, indicators of the effectiveness of clinical care, economic impact and indicators of satisfaction based on a survey. The results were compared with those in a series of patients who underwent surgery in the year before the introduction of the clinical pathway. Our hospital uses analytical accounting and the mean cost per process before and after the introduction of the clinical pathway was analyzed. Results. A series of 160 consecutive patients who underwent surgery during the year prior to the creation of the clinical pathway and who fulfilled the accepted inclusion criteria was evaluated. The mean length of hospital stay was 3.27 days. The mean cost per process before the introduction of the pathway was 2149 (± 768) euros. During the first year after the introduction of the pathway, 140 patients were included with an inclusion rate of 100%. The mean length of hospital stay in patients included in the clinical pathway was 2.2 days. The degree of compliance with length of hospital stay was 66.7%. The most frequent causes of breach were staff-related, followed by patient-related (oral intolerance, pain, etc.). The mean cost in patients included in the clinical pathway was 1845 (± 618) euros. Conclusions. Laparoscopic cholecystectomy is a suitable process with which to initiate systematization of clinical pathways. The results show that length of hospital stay has been significantly reduced without increasing morbidity. Patient satisfaction has been high (AU)

[Evaluation of a clinical pathway for laparoscopic cholecystectomy]. / Evaluación de la vía clínica de la colecistectomía laparoscópica.

INTRODUCTION: Clinical pathways are standardized plans for the integral care of specific processes. In March 2002, a clinical pathway for laparoscopic cholecystectomy was introduced in our service. The aim of the present study was to evaluate this pathway 1 year after its implementation. METHODOLOGY: All patients included in the clinical pathway since its introduction were studied. Evaluation criteria included compliance, indicators of the effectiveness of clinical care, economic impact and indicators of satisfaction based on a survey. The results were compared with those in a series of patients who underwent surgery in the year before the introduction of the clinical pathway. Our hospital uses analytical accounting and the mean cost per process before and after the introduction of the clinical pathway was analyzed. RESULTS: A series of 160 consecutive patients who underwent surgery during the year prior to the creation of the clinical pathway and who fulfilled the accepted inclusion criteria was evaluated. The mean length of hospital stay was 3.27 days. The mean cost per process before the introduction of the pathway was 2149 (+/- 768) euros. During the first year after the introduction of the pathway, 140 patients were included with an inclusion rate of 100%. The mean length of hospital stay in patients included in the clinical pathway was 2.2 days. The degree of compliance with length of hospital stay was 66.7%. The most frequent causes of breach were staff-related, followed by patient-related (oral intolerance, pain, etc.). The mean cost in patients included in the clinical pathway was 1845 (+/- 618) euros. CONCLUSIONS: Laparoscopic cholecystectomy is a suitable process with which to initiate systematization of clinical pathways. The results show that length of hospital stay has been significantly reduced without increasing morbidity. Patient satisfaction has been high.

Evaluación de la vía clínica de la hemitiroidectomía y tiroidectomía total en un hospital de segundo nivel / Evaluation of a clinical pathway for hemithyroidectomy and total thyroidectomy in a level II hospital

Introducción. Las vías clínicas son herramientas que facilitan la atención sistemática y multidisciplinaria del paciente. Son especialmente útiles en procesos frecuentes y con un curso clínico predecible, en los que encontramos una elevada variabilidad en su asistencia. El objetivo de este trabajo es presentar los resultados de la evaluación de la vía clínica de la tiroidectomía tras 5 meses de implantación. Pacientes y método. Entre octubre de 2001 y marzo de 2002 fueron intervenidos 44 pacientes por enfermedad tiroidea (35 tiroidectomías totales y nueve hemitiroidectomías). Los resultados se comparan con una serie obtenida de un muestreo aleatorio estratificado de 56 pacientes operados previamente a la implantación de la vía clínica. La vía contempla una estancia media de 2 días en la hemitiroidectomía, y de 3, en la tiroidectomía total. Se incorpora a la vía clínica un protocolo de tratamiento de reposición de calcio asociado con la tiroidectomía total. Se establecen como indicadores: la estancia hospitalaria, los efectos adversos y los resultados de la encuesta de satisfacción a los pacientes. Resultados. La estancia media de los pacientes con hemitiroidectomía fue de 3,3 días antes de la implantación de la vía clínica y de 2,4 tras ésta, y la de los pacientes con tiroidectomía total fue de 4,3 días antes de la vía clínica y de 3,4 días después de ésta, con diferencias estadísticamente significativas en ambos procesos. No hubo diferencias en cuanto a efectos adversos antes o después de la implantación de la vía clínica. Al 93,2 por ciento de los pacientes le pareció adecuado el tiempo de ingreso en el hospital. Conclusiones. La implantación de la vía clínica de la tiroidectomía ha conseguido disminuir la variabilidad clínica y, con ello, acortar la estancia hospitalaria, todo ello sin aumentar las complicaciones y con un alto grado de satisfacción de los pacientes (AU)

Obstrucción intestinal por una hernia de Bochdaleck en el adulto / Intestinal obstruction due to Bochdaleck´s hernia in an adult

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Hematoma de la vaina de los rectos. Las pruebas de imagen evitan laparotomías innecesarias / Rectus sheath hematoma. Imaging studies avoid unnecessary laparotomies

Introducción. El hematoma de la vaina de los rectos es una causa poco frecuente de dolor abdominal. Si se diagnostica correctamente, la cirugía suele ser innecesaria en la mayoría de los casos. Este estudio evalúa el papel de la ecografía y la tomografía axial computarizada (TAC) en el diagnóstico del hematoma de la vaina de los rectos. Método. Se revisan 12 casos de hematoma de la vaina de los rectos en un período de 15 meses. Resultados. La ecografía fue diagnóstica en 11 de los 12 pacientes. La TAC diagnosticó correctamente a los 3 pacientes en los que se practicó. Conclusión. La cirugía puede evitarse en la mayoría de pacientes con hematoma de la vaina de los rectos si se diagnostica correctamente mediante pruebas de imagen (AU)