Effectiveness of an electronic tool for medication reconciliation in a general surgery department.

BACKGROUND: Medication reconciliation is a key tool in the prevention of adverse drug events. OBJECTIVE: To assess the impact of an electronic reconciliation tool in decreasing unintended discrepancies between medications prescribed after surgery and the patient's usual treatment. SETTING: General Surgery Department of Gregorio Marañón's University General Hospital, Madrid. METHOD: A pre-post intervention study with no equivalent control group was carried out between June 2009 and December 2010. Patients hospitalized in the General Surgery Department for 24 h or more, and whose prescriptions prior to admission included three or more drugs were included in the study. Patients were interviewed to gather information about their usual treatment drugs. Discrepancies between the latter and the drugs prescribed after surgery were assessed before and after the medication reconciliation electronic tool was implemented. MAIN OUTCOME MEASURE: Proportion of patients with at least one unintended discrepancy. RESULTS: A total of 107 patients in the pre-intervention phase and 84 patients in the post-intervention phase were included. We detected 1,678 discrepancies, 167 were found to be unintended. The number of patients with at least one unintended discrepancy was 43 (40.2 %) in the pre-intervention phase, and 38 (38.1 %) in the post-intervention phase, p = 0.885. The percentage of unintended discrepancies over the total amount of drugs reconciled was lower in the post-intervention phase than in the pre-intervention phase (6.6 vs. 10.6 %), p = 0.002. Regarding unintended discrepancies 79.2 % were grade C severity (the error reached the patient but caused no harm), 13.6 % grade D (the error reached the patient and required monitoring or intervention to preclude harm) and 7.1 % grade E (the error may have contributed to or resulted in temporary harm to the patient and required intervention). CONCLUSION: Implementation of an electronic tool facilitated the process of medication reconciliation in a general surgery unit. The proportion of unintended discrepancies over the total amount of drugs reconciled was reduced after the implementation of the reconciliation programme. However, we could not demonstrate a more significant impact due to some methodological limitations.

Factores predictivos de infección de herida en cirugía colorrectal. Estudio observacional multicéntrico de casos y controles / Predictors of wound infection in elective colorectal surgery. Multicenter observational case-control study

INTRODUCCIÓN: El objetivo de este estudio es evaluar la utilidad del material de sutura Vicryl Plus® en reducir la tasa de infección de herida postoperatoria en cirugía colorrectal electiva. MÉTODO: Estudio de casos y controles prospectivo multicéntrico sobre 480 pacientes intervenidos de cirugía colorrectal electiva entre el 2006 y 2007, divididos en 2 grupos de igual tamaño muestral, sometidos a cierre de pared abdominal mediante uso de Vicryl Plus® (grupo 1) y PDS II® (grupo 2). En el estudio participaron 5 centros hospitalarios del Estado Español. La infección de herida fue clasificada en superficial y profunda. Fueron incluidos todos los pacientes diagnosticados de infección de herida durante la estancia hospitalaria y hasta 30 días después del alta. Para el estudio estadístico fueron utilizados el test del Chi-cuadrado y el exacto de Fisher para el análisis bivariante y el modelo de regresión logística para el análisis multivariante. RESULTADOS: La tasa de infección de herida observada fue significativamente inferior en el grupo 1: 14,6 frente al 29,2 del grupo 2. Según el estudio multivariante, el riesgo de infección de herida es superior en los pacientes con neoplasia, enfermedad pulmonar, anemia, tiempo operatorio superior a 2 h, falta de segunda dosis profiláctica intraoperatoria y cierre de laparotomía con sutura de PDS II®. CONCLUSIONES: El uso de material de sutura recubierto de triclosan puede ser una herramienta profiláctica eficaz para disminuir la tasa de infección de herida operatoria en los pacientes intervenidos mediante cirugía colorrectal electiva

INTRODUCTION: The aim of this study is to evaluate the usefulness of Vicryl Plus® suture in reducing the rate of postoperative wound infection in elective colorectal surgery. METHODS: A prospective case-control multicenter study with 480 patients undergoing elective colorectal surgery was performed between 2006 and 2007. Patients were divided in 2 groups of equal sample size: group 1, closure of the abdominal wall using Vicryl Plus® and group 2 where PDS II® was used. The study involved 5 hospitals in the Spanish State. Wound infection was classified into superficial and deep. All patients diagnosed of wound infection during the hospital stay and up to 30 days after discharge were studied. For the statistical analysis Chi-square test and Fisher exact were used for bivariate analysis and logistic regression model for multivariate analysis. Results Wound infection rates were significantly lower in group 1: 14.6 vs 29.2. Multivariate analysis showed that risk of wound infection was higher in patients with cancer, lung disease, anemia, operative time greater than 2 h, lack of second dose intra-operative prophylactic antibiotic and laparotomy closure with PDS suture II®. CONCLUSIONS: The use of suture coated with triclosan can be an effective prophylactic tool in reducing wound infection rate in patients undergoing elective colorectal surgery

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.

Predictors of wound infection in elective colorectal surgery. Multicenter observational case-control study.

INTRODUCTION: The aim of this study is to evaluate the usefulness of Vicryl Plus(®) suture in reducing the rate of postoperative wound infection in elective colorectal surgery. METHODS: A prospective case-control multicenter study with 480 patients undergoing elective colorectal surgery was performed between 2006 and 2007. Patients were divided in 2 groups of equal sample size: group 1, closure of the abdominal wall using Vicryl Plus(®) and group 2 where PDS II(®) was used. The study involved 5 hospitals in the Spanish State. Wound infection was classified into superficial and deep. All patients diagnosed of wound infection during the hospital stay and up to 30 days after discharge were studied. For the statistical analysis Chi-square test and Fisher exact were used for bivariate analysis and logistic regression model for multivariate analysis. RESULTS: Wound infection rates were significantly lower in group 1: 14.6 vs. 29.2. Multivariate analysis showed that risk of wound infection was higher in patients with cancer, lung disease, anemia, operative time greater than 2 h, lack of second dose intra-operative prophylactic antibiotic and laparotomy closure with PDS suture II(®). CONCLUSIONS: The use of suture coated with triclosan can be an effective prophylactic tool in reducing wound infection rate in patients undergoing elective colorectal surgery.

Postchemoradiation laparoscopic resection and intraoperative electron-beam radiation boost in locally advanced rectal cancer: long-term outcomes.

BACKGROUND: In selected patients with rectal cancer, laparoscopic surgery is as safe as open surgery, with similar resection margins and completeness of resection. In addition, recovery is faster after laparoscopic surgery. We analyzed long-term outcomes in a group of patients with locally advanced rectal cancer (LARC) treated with preoperative therapy followed by laparoscopic surgery and intraoperative electron-beam radiotherapy (IOERT). METHODS AND MATERIALS: From June 2005 to December 2010, 125 LARC patients were treated with 2 induction courses of FOLFOX-4 (oxaliplatin 85 mg/m(2)/d1, intravenous leucovorin at 200 mg/m(2)/d1-2, and an intravenous bolus of 5-fluorouracil 400 mg/m(2)/d1-2) and preoperative chemoradiation (4,500-5,040 cGy) followed by total mesorectal excision (laparoscopic, 35 %; open surgery, 65 %) and a presacral boost with IOERT. RESULTS: Patients in the laparoscopic surgery group lost less blood (median 200 vs 350 mL, p < 0.01) and had a shorter hospital stay (7 vs 11 days; p = 0.02) than those in the open surgery group. Laparoscopic procedures were shorter than open surgery procedures (270 vs 302 min; p = 0.67). Postoperative morbidity (32 vs 44 %; p = 0.65), RTOG grade ≥3 acute toxicity (25 vs 25 %; p = 0.97), and RTOG grade ≥3 chronic toxicity (7 vs 9 %; p = 0.48) were similar in the laparoscopy and open surgery groups. The median follow-up time for the entire cohort of patients was 59.5 months (range 7.8-90); no significant differences were observed between the groups in locoregional control (HR 0.91, p = 0.89), disease-free survival (HR 0.80, p = 0.65), and overall survival (HR 0.67, p = 0.52). CONCLUSIONS: Postchemoradiation laparoscopically assisted IOERT is feasible, with an acceptable risk of postoperative complications, shorter hospital stay, and similar long-term outcomes when compared to the open surgery approach.

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.

Adenocarcinoma colorrectal en la enfermedad de Crohn / Colorectal adenocarcinoma in Crohn's disease

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Resultados de la cirugía con tratamiento neoadyuvante del cáncer de recto / Results of surgery with neoadjuvant treatment in rectal cancer

Objetivo. El tratamiento neoadyuvante en el cáncer de recto está cada vez más establecido como la forma más adecuada de complementar la resección quirúrgica en lesiones localmente avanzadas. Los centros con especial interés en el tratamiento multidisciplinario del cáncer de recto evalúan diversas modalidades de tratamiento adyuvante preoperatorio. El presente trabajo es una revisión crítica de las diversas formas de tratamiento empleadas. Resultados. La adyuvancia preoperatoria se tolera de forma aceptable, controla la progresión de la enfermedad, facilita la resección de lesiones grandes y, en las localizadas en el tercio inferior, ayuda a la preservación esfinteriana. Mejora las cifras de recidiva local y aumenta la tasa de supervivencia libre de enfermedad. La tendencia actual es asociar quimioterapia durante la radioterapia, aun cuando el beneficio de esta asociación debe ser validado por estudios aleatorizados que están pendientes de resultados. Este tratamiento no está exento de efectos secundarios, tales como alteración de la función anorrectal y sexual, por lo que debe seleccionarse a los pacientes que se beneficiarán de este esquema terapéutico. Conclusiones. El tratamiento neoadyuvante es de elección en los pacientes con tumores en estadios II y III. En el futuro, nuevos esquemas y agentes quimioterápicos, y sistemas que sean capaces de identificar a los pacientes con tumores que sean respondedores a estas formas de tratamiento complementario, harán posible un mejor uso de estas opciones terapéuticas. (AU)

Ganglio centinela en el melanoma cutáneo: nuevas perspectivas en el drenaje linfático / Sentinel lymph node in cutaneous melanoma: new perspectives in lymphatic drainage

Introducción. La biopsia del ganglio centinela permite realizar la indicación de linfadenectomías en estadios iniciales de tumores como el melanoma maligno cutáneo (MM). La necesidad de un adecuado conocimiento del drenaje linfático de la lesión, obtenido mediante linfogammagrafía preoperatoria, ha llevado a un cambio en el conocimiento de las vías de drenaje del organismo. Pacientes y método. Durante 3 años se ha llevado a cabo biopsia del ganglio centinela a 77 pacientes que presentaron 78 melanomas en estadios I y II, la mayoría de ellos incluidos en estadios de Breslow intermedios. A todos los pacientes se les inyectó el nanocoloide de tecnecio perilesional para, a continuación, llevar a cabo el estudio dinámico y, con posterioridad, imágenes tardías por medio de la linfogammagrafía. La identificación intraoperatoria se realizó por medio de una sonda detectora de rayos gamma (Navigator).Resultados. Se identifican 90 regiones linfáticas, en las que se localizan 87 ganglios centinelas (96,6 por ciento). Se aprecia una gran variabilidad en las vías de drenaje de las lesiones cutáneas, en especial en la cabeza, el cuello y el tronco. En este último, más concretamente inferior a la región umbilical, la posibilidad de drenar tanto en la axila como en la ingle se hace patente incluso de forma contralateral. Un total de 12 melanomas presentaron drenaje múltiple, siendo uno de ellos triple. En la región del tronco anteroinferior se localizó un mayor número de melanomas malignos con drenaje múltiple. Conclusiones. El conocimiento de la posibilidad de utilizar patrones de drenaje linfático poco habituales a la hora de llevar a cabo la biopsia del ganglio centinela permitirá una mayor efectividad en esta técnica. De la misma forma, se destaca la importancia del uso de la linfogammagrafía preoperatoria para la identificación adecuada del ganglio centinela (AU)