Weight Loss Analysis According to Different Formulas after Sleeve Gastrectomy With or Without Antral Preservation: a Randomised Study.

BACKGROUND: The measurement of weight loss after bariatric surgery is under constant review in order to obtain the ideal standard for reporting weight loss. Several formulas have been proposed for this purpose. Our goal is to analyse weight loss after sleeve gastrectomy, with or without antrum preservation through different measurement formulas. METHODS: A prospective randomised study of 60 patients (30 patients with initial section at 3 cm from pylorus and 30 patients at 8 cm from the pylorus). We calculate the following variables at 3, 6 and 12 months from surgery: BMI, excess weight loss (%EWL), percentage of excess of BMI loss (%PEBMIL), expected BMI, % PEBMIL corrected by EBMI and percentage of total weight loss (%TWL). RESULTS: Weight evolution is similar in both groups, reaching a mean BMI of 33.62 ± 4.35 and 34.48 ± 4.23 kg/m2 respectively 12 months after surgery, closer to expected BMI. TWL follows the same trend, with losses exceeding 30%, although 3 cm group is above the tables of percentiles made with our series. Regarding PEBMIL, the 3 cm group reaches 67.8% classified as excellent, while 8 cm group reaches 62.8% classified as a good result. EWL situates the best results for 3 cm group. CONCLUSIONS: Group 3 cm obtained a lower percentage of suboptimal results using EWL. %TWL places the 3 cm group in higher percentile than 8 cm group. Through EBMI, both groups are equally effective. It is necessary to have standardised dynamic tables for each surgical technique, becoming essential elements to measure weight loss after surgery.

Usefulness of Baltasar's expected body mass index as an indicator of bariatric weight loss surgery.

INTRODUCTION: Determining the best indicator to report weight loss takes on special relevance following bariatric surgery. Our objective is to apply a method proposed by Baltasar et al. to express weight loss results following bariatric surgery. MATERIALS AND METHODS: Anthropometric data were collected from 265 patients who had undergone Sleeve gastrectomy (SG, n = 172) and Roux-en-Y gastric bypass (RYGBP, n = 93) with a 2-year follow-up period. Initial BMI was calculated as well as BMI 2 years after, percentage of excess BMI loss (PEBMIL), expected BMI (EBMI), and corrected PEBMIL. RESULTS: In SG group, average BMI 2 years after surgery fell within a 95 % CI of expected BMI, with an average BMI of 31.58 ± 4.05 kg/m2 in 35-45 BMI group, an average BMI of 33.62 ± 4.96 kg/m2 in 45-55 BMI group, and an average BMI of 37.40 ± 5.93 kg/m2 in 55-65 BMI group. In RYGBP group, average BMI 2 years after the surgery was below than average expected BMI (28.76 ± 3.20 kg/m2 in 35-45 BMI group and 29.71 ± 3.30 kg/m2 in 45-55 BMI group). Results are considered excellent for the group with an initial BMI of above 45 kg/m2. CONCLUSIONS: EBMI is a good weight loss indicator, mainly when 95 % CI is taken into account. EBMI is consistent with the results obtained 2 years after surgery in our patients who underwent SG and RYGBP. Corrected PEBMIL is a good indicator for expressing the percentage of BMI loss and offers more realistic values than conventional formula with a cut-off point of 25 points.

Duodeno-jejunal tube placement in an experimental model of obesity: effects on food behaviour and basal energy expenditure.

BACKGROUND: Metabolic surgery can modulate weight as well as food intake and basal energy expenditure. In this study, we evaluate the effectiveness of duodenal exclusion by analysing anthropometric results, intake variations, food behaviour and calorimetric parameters. METHODS: This is an experimental study with 8-week-old Sprague-Dawley male rats. The sequences used are as follows: Cafeteria diet for 3 weeks, followed by surgery and sacrifice at 4 weeks. Four experimental groups are as follows: two non-obese groups (n = 15; surgery = 10, sham = 5) and two obese groups by cafeteria diet (n = 15; surgery = 10, sham = 5). Surgery performed was duodenal exclusion with physical barrier. Weight, intake, glycaemia and basal energy expenditure by indirect calorimetry were monitored before and after surgery. RESULTS: Weight changes in groups that underwent intervention were significant. The reduction in calorie consumption after surgery was significant in the obese intervention group despite an increased standard feed consumption (161 ± 11 vs 139 ± 13 Kcal/day, p < 0.05; due to a lower consumption of cafeteria diet). In non-obese animals, changes were transient. Basal energy expenditure decreased in both intervention groups: 6.2 ± 0.5 vs 5.5 ± 0.4 Kcal/kg/h in non-obese animals and 5.6 ± 0.3 vs 4.7 ± 0.3 Kcal/kg/h in obese animals (p < 0.05). CONCLUSIONS: Duodeno-jejunal tube placement stops weight gain in obese and non-obese animals. In obese animals, there is an important qualitative change in appetite towards standard feed with a significant decrease in caloric intake. In non-obese animals, changes in quantitative intake are transient. This surgery decreases basal energy expenditure in obese animals. This may be attributed to an enhanced thermogenic effect of food and a slowing in the animal's weight gain.

Evaluación de las habilidades quirúrgicas durante el pregrado mediante la introducción de un simulador virtual / Evaluation of surgical skills in medical students using a virtual simulator

Introducción Durante el pregrado, la utilización de los simuladores virtuales junto con las prácticas hospitalarias puede mejorar las aptitudes quirúrgicas básicas, e incluso ser un eje motivacional importante. El objetivo del trabajo es determinar el grado de habilidad endoscópica y su curva en 3 etapas dentro del grado de Medicina (segundo, cuarto y sexto curso) mediante un simulador virtual. Material y métodos Se ha utilizado el simulador Lapsim® con 7 ejercicios del módulo básico. Se somete a 24 alumnos (8 de segundo, 8 de cuarto y 8 de sexto curso) a un programa de entrenamiento (prueba basal más 3 sesiones) y a un examen a los 30 días. Un grupo control de cada curso (n=24)ha sido sometido a 2 exámenes con un intervalo de 30 días. Resultados Todos los grupos mejoran significativamente después del entrenamiento y se mantienen después del periodo de lavado de 30 días, y en todos los ejercicios. Los ejercicios «Cutting» y «Lifting and grasping», considerados de nivel intermedio, destacan sobre los demás por el bajo score basal que tienen todos los grupos. Después del proceso de entrenamiento, en cambio, son los únicos ejercicios en los que los alumnos de sexto se muestran claramente superiores respecto a los demás cursos: «Cutting» (94,5%±11 vs 81%±7) (p<0,05), «Lifting and grasping» (88,1%±13 vs 68%±11) (p<0,001).Conclusiones La utilidad del simulador virtual parece mayor para aquellos alumnos de cursos superiores con una mayor experiencia clínica, existiendo un proceso de discriminación ya durante este periodo. Las competencias quirúrgicas durante esta fase deberían reforzarse mediante nuevas apuestas docentes como los programas de simulación en el marco de los laboratorios de habilidades (AU)

Introduction The use of virtual simulators together with hospital practicals during undergraduate training can improve basic surgical skills, and may even be an important motivating focal point. The aim of this work is to determine the endoscopy skill level and its learning curve in three stages within the Medical degree (second, fourth, and sixth year) using a virtual simulator. Material and methods The Lapsim® simulator with 7 basic modular exercises was used. Twenty four students (8 second, 8 fourth, and 8 sixth year) were subjected to a training program (basic test plus 3 sessions), and an examination at 30 days. A control group (n=24) from each year were subjected to 2 examinations with an interval of 30 days. Results All the groups improved significantly after training, and this was maintained in all the exercises after a “wash out” period of 30 days. All the groups achieved lower baseline scores in the “Cutting” and “Lifting and grasping” exercises, considered of intermediate level than any of the others. However, after the training process, they were the only exercises that the sixth year students demonstrated that they were clearly superior to the rest of the years: “Cutting” (94.5%±11 vs 81%±7) (P<.05), “Lifting and grasping” (88.1%±13 vs 68%±11) (P<.001).Conclusions The virtual simulator appears to be of greater use for those students in higher years with more clinical experience, there already being a discrimination process during this period. Surgical skills during this phase should be reinforced by means of new teaching challenges, such as simulation programs in the framework of skills laboratories (AU)

[Evaluation of surgical skills in medical students using a virtual simulator]. / Evaluación de las habilidades quirúrgicas durante el pregrado mediante la introducción de un simulador virtual.

INTRODUCTION: The use of virtual simulators together with hospital practicals during undergraduate training can improve basic surgical skills, and may even be an important motivating focal point. The aim of this work is to determine the endoscopy skill level and its learning curve in three stages within the Medical degree (second, fourth, and sixth year) using a virtual simulator. MATERIAL AND METHODS: The Lapsim simulator with 7 basic modular exercises was used. Twenty four students (8 second, 8 fourth, and 8 sixth year) were subjected to a training program (basic test plus 3 sessions), and an examination at 30 days. A control group (n=24) from each year were subjected to 2 examinations with an interval of 30 days. RESULTS: All the groups improved significantly after training, and this was maintained in all the exercises after a "wash out" period of 30 days. All the groups achieved lower baseline scores in the "Cutting" and "Lifting and grasping" exercises, considered of intermediate level than any of the others. However, after the training process, they were the only exercises that the sixth year students demonstrated that they were clearly superior to the rest of the years: "Cutting" (94.5%±11 vs 81%±7) (P<.05), "Lifting and grasping" (88.1%±13 vs 68%±11) (P<.001). CONCLUSIONS: The virtual simulator appears to be of greater use for those students in higher years with more clinical experience, there already being a discrimination process during this period. Surgical skills during this phase should be reinforced by means of new teaching challenges, such as simulation programs in the framework of skills laboratories.

Gastric volvulus after sleeve gastrectomy for morbid obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy in morbid obesity has proved to be a safe and reproducible technique. Sleeve gastrectomy, however, is not free of complications. On the other hand, gastric volvulus is reported in those subjects where, either because of laxity of the gastric anatomical fixations or incorrect position of the stomach, rotation or turning is facilitated. CASE: We report the case of a patient with morbid obesity (Bone mass index / BMI 63 Kg/m2), who in the post-operative period immediately following a sleeve gastrectomy, presented early symptoms of upper gastrointestinal occlusion indicative of gastric volvulus of the gastric sleeve. RESULTS: The patient developed a partial obstruction secondary to a mixed volvulus mechanism (organo-axial and partially mesenteric-axial) after sleeve gastrectomy. We performed a laparoscopic antrectomy of the gastric sleeve and then a gastroileal anastomosis, a form of biliopancreatic diversion, with a common channel of 80 cm and alimentary limb of 160 cm). 18 months after, the patient has a BMI of 28 kg/m2 and enjoys a good quality of life. CONCLUSION: Sleeve gastrectomy leaves the stomach with no fixations along the entire greater curvature, which may predispose to volvulus. This complication is a rare finding and not reported to date following this intervention, but still needs to be considered in this type of patient.

Experimental metabolic surgery: justification and technical aspects.

BACKGROUND: Metabolic surgery is a surgical strategy which has shown great potential in the treatment of diseases which may be associated with morbid obesity. It must be developed on the basis of both animal and clinical research. The objective of this study is to set out the various options in experimentation animals and the technical characteristics in operations, and the specific animal care undertaken by our group. METHODS: We identified and reviewed the key points to be considered in animal handling during interventions such as sleeve gastrectomy, Roux-en-Y gastric bypass, ileal transposition and duodenal exclusion. RESULTS: The technical variations found at experimental level are due to the pouch capacity for the Roux-en-Y gastric bypass. Intestinal anastomosis is the variable with the greatest differences found between the various working groups. Ileal transposition is a technique that is undergoing constant review, and the results differ substantially depending on the animal model chosen, and are also metabolically effective in animals with a normal weight. Duodenal exclusion by means of a physical barrier has not been studied sufficiently but could be a pre-operative support for weight loss. CONCLUSIONS: There are experimental technical discrepancies and further studies are necessary to ascertain their efficiency. Metabolic surgery currently complements bariatric surgery and justifies the appearance of new experimental studies. The animal models chosen are very important as only very specific study models will be used in cases in which the technique is sufficiently validated by the research team, as the results to be assessed depend on this.

Simulador de bajo coste para el entrenamiento de habilidades laparoscópicas básicas / Low cost simulator for acquiring basic laparoscopic skills

Introducción La cirugía laparoscópica requiere el conocimiento y tratamiento de un equipo e instrumental diferente al de la cirugía abierta. El objetivo de este estudio es observar si el entrenamiento con un simulador de bajo coste es de utilidad para adquirir habilidades en técnicas laparoscópicas básicas. Material y métodos Estudio aleatorizado en el que participaron 48 sujetos (32 estudiantes y 16 cirujanos). Se diseñaron 2 ejercicios, uno de prensión y otro de corte. Los estudiantes se dividieron en 2 grupos (n=8), el primer grupo realizó los ejercicios en quirófano con la cámara de laparoscopia habitual y el segundo en un aula con una microcámara de bajo coste. Ambos grupos realizaron una primera evaluación, varias sesiones de entrenamiento y una segunda evaluación. Se utilizaron 2 grupos control con estudiantes (n=8) que realizaron las 2 evaluaciones sin entrenamiento. Los cirujanos se dividieron en 2 grupos y realizaron una evaluación, un grupo en quirófano y otro en el aula. Resultados En los grupos con entrenamiento, la mejoría entre la primera evaluación y la segunda para el primer ejercicio fue significativamente mayor que en los grupos sin entrenamiento (p<0,001). Los cirujanos presentaron una puntuación significativamente mejor que los estudiantes en su primera evaluación (p<0,001).Conclusiones El entrenamiento con este simulador de bajo coste ha demostrado ser de utilidad, de forma similar al entrenamiento en el simulador con un sistema de laparoscopia convencional, para adquirir habilidades laparoscópicas básicas. Este sistema de entrenamiento fue capaz de discriminar entre los sujetos con y sin experiencia en cirugía laparoscópica (AU)

Introduction Laparoscopic surgery requires a different set of skills than conventional surgery. The aim of this study was to evaluate the usefulness of a low-cost simulator and camera for the acquisition of basic laparoscopic skills. Material and Methods This randomised trial involved 48 subjects (32 students and 16 surgeons). Two exercises were used, object transfer and cutting. Students were divided into two groups (n=8). One group performed the exercises in the operating theatre with the conventional laparoscopic camera. The second group performed the exercises in a classroom with a low cost micro-camera. Both groups were evaluated before and after five training sessions. Two groups of students were used as controls (n=8), and were evaluated two times without training. The surgeons were divided in two groups (n=8), one was evaluated in the theatre and the other one in the classroom. Results The trained groups showed significant improvements in the first exercise (P <0.001) compared with non-trained groups. There were no differences in scores between the groups with different cameras. The surgeons had better scores than students (P <0.001).Conclusions The improvements in laparoscopic skills on this simulator with a low-cost camera were not significantly different from those gained using the simulator with the conventional laparoscopic camera. This simulator was able to differentiate between experienced and inexperienced subjects (AU)

[Low cost simulator for acquiring basic laparoscopic skills]. / Simulador de bajo coste para el entrenamiento de habilidades laparoscópicas básicas.

INTRODUCTION: Laparoscopic surgery requires a different set of skills than conventional surgery. The aim of this study was to evaluate the usefulness of a low-cost simulator and camera for the acquisition of basic laparoscopic skills. MATERIAL AND METHODS: This randomised trial involved 48 subjects (32 students and 16 surgeons). Two exercises were used, object transfer and cutting. Students were divided into two groups (n=8). One group performed the exercises in the operating theatre with the conventional laparoscopic camera. The second group performed the exercises in a classroom with a low cost micro-camera. Both groups were evaluated before and after five training sessions. Two groups of students were used as controls (n=8), and were evaluated two times without training. The surgeons were divided in two groups (n=8), one was evaluated in the theatre and the other one in the classroom. RESULTS: The trained groups showed significant improvements in the first exercise (P <0.001) compared with non-trained groups. There were no differences in scores between the groups with different cameras. The surgeons had better scores than students (P <0.001). CONCLUSIONS: The improvements in laparoscopic skills on this simulator with a low-cost camera were not significantly different from those gained using the simulator with the conventional laparoscopic camera. This simulator was able to differentiate between experienced and inexperienced subjects.

Efectos de la transposición ileal, el bypass gastroyeyunal y la gastroplastia vertical en la regulación de la ingesta en un modelo experimental de obesidad relacionada con diabetes mellitus tipo 2 / The effects of ileal transposition, gastrojejunal bypass and vertical gastroplasty on the regulation of ingestion in an experimental obesity model associated with diabetes mellitus type 2

Introducción: En el marco de la cirugía metabólica, este estudio pretende valorar la transposición ileal como tratamiento quirúrgico de la obesidad mórbida relacionada con la diabetes mellitus no insulinodependiente gracias a la acción del péptido GLP-1, en relación con el bypass gástrico y la gastroplastia vertical. También determinar las concentraciones de grelina y su contribución a la pérdida de peso para cada técnica. Material y métodos: Animales de experimentación del tipo Zucker Diabetic Fatty, ratas obesas y modelo de diabetes tipo 2. Tres grupos de 10 animales cada uno: a) transposición ileal; b) bypass gastroyeyunal, y c) gastroplastia vertical. Parámetros determinados: pérdida de peso, cambios en la ingesta, valores de glucemia, GLP-1, insulina y grelina en sangre de cada uno de los animales una semana antes de la intervención quirúrgica y a los 15 días de la cirugía. Resultados: La intervención que produce una mayor pérdida de peso es el bypass gastroyeyunal. Hay una disminución de la ingesta calórica significativa para los tres tipos de intervención. No se consigue corregir el estado de hiperglucemia intensa en los tres grupos, aunque en el grupo de la transposición se logra frenar el estado de cetosis. El aumento de GLP-1 es sólo significativo en la transposición ileal. Conclusiones: En la respuesta metabólica a la cirugía no sólo se modifica una única hormona, sino que se establece un estado de regulación y contrarregulación como traducción de una determinada acción quirúrgica. Los animales obesos, cuyo exceso de peso es de causa exógena, pueden ser un buen modelo para otros estudios en esta dirección (AU)

Aim: The continual advances in our knowledge of the pathogenesis and hormonal disorders of morbid obesity lead to new studies in experimental animals and the development of new technical options. The aim is to asses whether ileal transposition can be a good treatment of morbid obesity associated with diabetes mellitus due to the action of intestinal peptide Glp-1 (enteroglucagon) compared to gastric bypass and vertical gastroplasty (VGB). Material and methods: Trial enviroment: experimental animals ZDF rats (Zucker Diabetic Fatty rats). Subjects of the study: three groups of 10 animals each one divided as: a) ileal tranposition; b) gastro-jejunal bypass; c) vertical gastroplasty. Parameters to determine: weight loss, levels of glycaemia, enteroglucagon, insulin and ghrelin in blood, one week before the operation as a baseline control, and 15 days after the surgical procedure. Results: Gastrojejunal bypass produces the most significant weight loss. There is a significant decrease in intake in all groups. Hyperinsulinaemia and hyperglycaemia tend to decrease after surgery in all groups, but in ileal transposition there is better control of ketosis. After gastrojejunal bypass and ileal transposition, we observed an increase in GLP-1 levels but were only significant in ileal transposition. Conclusions: Ileal transposition produces a decrease in plasma glucose and better control of diabetes mellitus, which could benefit patients affected by morbid obesity and poor metabolic control. More studies are needed on other models of obesity. A model of exogenous and reversible obesity could be a good option to study the real benefits of the interventions (AU)

[The effects of ileal transposition, gastrojejunal bypass and vertical gastroplasty on the regulation of ingestion in an experimental obesity model associated with diabetes mellitus type 2]. / Efectos de la transposición ileal, el bypass gastroyeyunal y la gastroplastia vertical en la regulación de la ingesta en un modelo experimental de obesidad relacionada con diabetes mellitus tipo 2.

AIM: The continual advances in our knowledge of the pathogenesis and hormonal disorders of morbid obesity lead to new studies in experimental animals and the development of new technical options. The aim is to asses whether ileal transposition can be a good treatment of morbid obesity associated with diabetes mellitus due to the action of intestinal peptide Glp-1 (enteroglucagon) compared to gastric bypass and vertical gastroplasty (VGB). MATERIAL AND METHODS: Trial environment: experimental animals ZDF rats (Zucker Diabetic Fatty rats). Subjects of the study: three groups of 10 animals each one divided as: a) ileal tranposition; b) gastro-jejunal bypass; c) vertical gastroplasty. Parameters to determine: weight loss, levels of glycaemia, enteroglucagon, insulin and ghrelin in blood, one week before the operation as a baseline control, and 15 days after the surgical procedure. RESULTS: Gastrojejunal bypass produces the most significant weight loss. There is a significant decrease in intake in all groups. Hyperinsulinaemia and hyperglycaemia tend to decrease after surgery in all groups, but in ileal transposition there is better control of ketosis. After gastrojejunal bypass and ileal transposition, we observed an increase in GLP-1 levels but were only significant in ileal transposition. CONCLUSIONS: Ileal transposition produces a decrease in plasma glucose and better control of diabetes mellitus, which could benefit patients affected by morbid obesity and poor metabolic control. More studies are needed on other models of obesity. A model of exogenous and reversible obesity could be a good option to study the real benefits of the interventions.

Subfascial endoscopic perforator vein surgery (SEPS) modified technique: subaponeurotic approach without balloon.

Subfascial Endoscopic Perforator Vein Surgery (SEPS) is one of the best procedures and a minimally invasive option for treating chronic venous insufficiency. We explain our experience with SEPS, which has been turned into a subaponeurotic approach without balloon, and assess the possible advantages of this technique. The subaponeurotic space was entered using the Visiport Plus (Autusuture, Tyco Healthcare) video-assisted technique, which shows how the trocar enters through the subcutaneous tissue and superficial aponeurosis of the leg. A blunt retractor was inserted which, together with CO2 insufflation (20 mm Hg), enabled the veins to be dissected. Ligation was performed using tripolar sealing. In no case was a balloon used. There were no incidents such as haemorrhage or subcutaneous emphysema during the procedure. The patients (n = 206) remained in the hospital for less than 24 hours and suffered no post-surgical complications. Active ulcers were cured, with no relapses, in 100% of cases. This is a very effective method for treating advanced chronic insufficiency because it prevents local damage and the rate of post-surgical complications is low. Technically it has more advantages because the fact that it does not use a balloon means that it exerts less pressure on the tissues.

Tumor sólido seudopapilar del páncreas / Solid pseudopapillar tumour of the pancreas

No disponible

Hernia diafragmática incarcerada de origen traumático como causa rara de abdomen agudo / Incarcerated traumatic diaphragmatic hernia as an uncommon cause of acute abdomen

No disponible

The evolution of experimental surgery in the field of morbid obesity.

BACKGROUND: We reviewed the experimental surgery, related to bariatric surgery in laboratory animals, to consider new lines of research. METHODS: The literature on experimental surgery for morbid obesity since the mid-20th century was reviewed, focusing on existing techniques (malabsorptive, restrictive, mixed and experimental) and their associated metabolic component. RESULTS: In the field of laparoscopy, there is a clear tendency for large laboratory animals such as pigs to be used. These are useful for developing and perfecting techniques. A second area of animal experimentation concentrates on the relationship between metabolism and surgery in order to find improvements in the co-morbidities associated with morbid obesity. A third area of research focuses on manipulating intake via central and vagal control. CONCLUSION: Further studies are needed to combine traditional and recently developed techniques of experimental surgery with the mechanisms that determine the physiopathology, metabolism and regulation of intake of morbidly obese patients. To accurately determine metabolic behavior and avoid drawing conclusions that are not very significant, these studies should be carried out on obese animals and focus on the co-morbidities associated with morbid obesity.

Seguimiento postoperatorio de la obesidad mórbida: aspectos quirúrgicos y nutricionales / Postoperative follow of morbid obesity: surgical and nutritional issues

La cirugía de la obesidad mórbida como entidad propia y diferenciada requiere un seguimiento postoperatorio muy estricto, tanto desde el punto de vista quirúrgico, como nutricional y dietético. Se recomienda una actuación multidisciplinaria en el seguimiento postoperatorio del paciente para el control integral de esta enfermedad. Es preciso diferenciar los controles posquirúrgicos generales de toda intervención y los controles posquirúrgicos específicos de cada técnica bariátrica. Así, se determina el seguimiento de la banda ajustable por laparoscopia, del bypass gástrico en "Y" de Roux y del bypass biliopancreático. También se concretan los aspectos nutricionales y dietéticos que se deben tener en cuenta en cada técnica y se detallan los mecanismos de prevención y correcto tratamiento de los principales problemas nutricionales observados. Por último, es importante destacar el papel que desempeña establecer de forma coordinada un régimen de visitas y los controles periódicos ambulatorios a corto y a largo plazo, todo ello con el fin de asegurar el buen resultado global del tratamiento (AU)