Implementation of a retinal stroke-code protocol results in visual recovery in patients receiving reperfusion therapies.

INTRODUCTION: Reperfusion therapies represent promising treatments for patients with Central Retinal Artery Occlusion (CRAO), but access is limited due to low incidence and lack of protocols. We aimed to describe the benefit of implementing a Retinal Stroke-Code protocol regarding access to reperfusion, visual acuity and aetiological assessment. PATIENTS AND METHODS: Prospective cohort study performed at a Comprehensive Stroke Centre. Criteria for activation were sudden monocular, painless vision loss within 6 h from onset. Eligible patients received IAT when immediately available and IVT otherwise. All patients were followed by ophthalmologists to assess best-corrected visual acuity (BCVA) and visual complications, and by neurologists for aetiological workup. Visual amelioration was defined as improvement of at least one Early Treatment Diabetic Retinopathy Study (ETDRS) letter from baseline to 1 week. RESULTS: Of 49 patients with CRAO, 15 (30.6%) received reperfusion therapies (12 IVT, 3 IAT). Presentation beyond 6 h was the main contraindication. Patients receiving reperfusion therapies had better rates of visual improvement (33.3% vs 5.9%, p = 0.022). There were no complications related to reperfusion therapies. Rates of neovascular glaucoma were non-significantly lower in patients receiving reperfusion therapies (13.3% vs 20.6%, p = 0.701). Similar rates of atherosclerotic, cardioembolic and undetermined aetiologies were observed, leading to 10 new diagnosed atrial fibrillation and five carotid revascularizations. CONCLUSION: A comprehensive acute management of CRAO is feasible despite low incidence. In our study, reperfusion therapies were safe and associated with higher rates of visual recovery. A similar etiological workup than ischemic stroke led to of high proportion of underlying aetiologies.

Determining the optimal interval between neoadjuvant radiochemotherapy and surgery in rectal cancer: a retrospective cohort study.

INTRODUCTION: In locally advanced rectal cancer, the optimal interval between completion of neoadjuvant radiochemotherapy (RT-ChT) and surgical resection remains unclear due to contradictory data on the benefits of extending this interval. Therefore, the aim of this retrospective study was to determine the impact of this interval on outcomes in patients treated for rectal cancer at our center. METHODS: We retrospectively reviewed 382 consecutive patients treated for stage II/III rectal cancer between October 1, 2012, and December 31, 2017. We evaluated four different cut-off points (56, 63, 70, and 77 days) to determine which had the greatest impact on treatment outcomes. RESULTS: The median time between completion of RT-ChT and surgery was 67.2 days (range, 28-294). Intervals > 8 weeks (56 days) were associated with worse therapeutic outcomes. Specifically, an interval ≥ 77 days was associated with a significant decrease in overall survival (OS; 84% vs. 70%; p = 0.004), which is why we selected this interval for the comparative analysis. Several outcome variables were significantly better in the short interval (< 77 days) group, including margin involvement (5.2% vs. 13.9%; p = 0.01), sphincter preservation (78% vs. 59.3%; p = 0.003), and distant dissemination (22.6% vs. 32.5%; p = 0.04). No significant between-group differences were found in complete/nearly complete response rates (19.2% vs. 24.4%; p = 0.3). Time to surgery was statistically significant on both the univariate and multivariate analyses. CONCLUSIONS: Our findings suggest that surgery should not be delayed more than 8 weeks (56 days) after neoadjuvant treatment. An interval > 8 weeks should only be considered in patients who demonstrate a good response to neoadjuvant RT-ChT.

Preoperative Progressive Pneumoperitoneum in the Treatment of Hernias With Loss of Domain. Our Experience in 50 Cases.

Introduction: Surgical planning for repair of giant hernias with loss of domain needs to consider patient comorbidities, potential risks and possible postoperative complications. Some postoperative complications are related to the increase in intra-abdominal pressure caused by the reintroduction of abdominal contents into the peritoneal space. Preoperative progressive pneumoperitoneum (PPP) increases the capacity of abdominal cavity prior to hernia repair and allows for better physiological postoperative adaptation. The aim of this study is to analyze perioperative and intraoperative characteristics as well as outcomes of a cohort of patients treated with PPP prior to giant hernia repair at a single, high volume center. Methods: Prospective, descriptive, observational single-center study including 50 patients undergoing PPP prior to hernia with loss of domain repair between January 2005 and June 2022. We analysed epidemiological, surgical and safety variables. Results: Fifty patients were included: 43 incisional hernias, 6 inguinal hernias and 1 umbilical hernia. Mean age was 66 years (36-85). Median insufflation time was 12 days (4-20) and median insufflated volume of ambient air was 10,036 cc. There were complications during PPP in nine patients: 2 decompensation of chronic respiratory disease and 7 subcutaneous emphysema. PPP was prematurely suspended in patients with respiratory decompensation. All patients with incisional and umbilical hernias underwent open repair with mesh placement. Preperitoneal repair was performed in inguinal hernias. Three cases of hernia recurrence were reported during the follow up. Conclusion: PPP is a safe and effective tool in the preoperative management of patients with giant hernias. It helps to achieve the decrease or absence of abdominal wall tension and can favour the results of complex eventroplasty techniques.

Unidad de Hospitalización a Domicilio del paciente quirúrgico durante la pandemia de la COVID-19 / Home Hospitalization Unit of Surgical Patients During the COVID-19 Pandemic

INTRODUCCIÓN: la pandemia de la COVID-19 ha puesto a prueba sistemas sanitarios a nivel mundial. Desde el servicio de Cirugía General y ante la disminución de camas de hospitalización surgió la necesidad de planificar y organizar una estrategia para la hospitalización y cuidado de pacientes quirúrgicos. La hospitalización a domicilio (HAD) es una modalidad asistencial eficaz en patología médica y quirúrgica donde, por un tiempo limitado, personal sanitario realiza tratamiento y seguimiento de pacientes en su domicilio. OBJETIVO: describir nuestra experiencia de HAD en el paciente quirúrgico durante la pandemia de la COVID-19. MÉTODO: estudio observacional, descriptivo, prospectivo, unicéntrico. 44 pacientes en HAD del 11 de Marzo al 10 de Mayo de 2020. Se incluyeron pacientes sometidos a cirugía urgente, programada y pacientes quirúrgicos con tratamiento conservador o intervencionismo. Se evaluaron variables epidemiológicas, motivo de ingreso, tratamiento, estancia media, tasa de reingresos, complicaciones y mortalidad. RESULTADOS: edad media 64 años ± 16,7 (23-89). 52% hombres y 49% mujeres. 23 pacientes con cirugía urgente o programada, 12 tratamiento conservador, 2 drenaje torácico, 5 drenaje percutáneo y 2 terapia de presión negativa para cura de herida quirúrgica. Estancia media 8,6 días ± 3,6 (1-19). Registradas 5 complicaciones: suboclusión, rectorragia, enfisema subcutáneo, absceso pulmonar e infección por COVID-19. 2 pacientes reingresaron. CONCLUSIONES: La HAD es un modelo seguro y eficaz para disminuir la estancia hospitalaria en pacientes quirúrgicos seleccionados. La combinación de ingreso de corta estancia e ingreso en régimen de HAD podría ser una buena opción en el postoperatorio y recuperación de pacientes quirúrgicos

INTRODUCTION: current COVID-19 pandemic is testing healthcare systems at a global level. From General Surgery Department we decided to provide a practical strategy for surgical patients' hospitalization that allowed to treat them as if they were admitted in hospital. Home Hospitalization is an effective healthcare modality in medical and surgical pathology in which, for a limited time, health practitioners provide active treatment at patient's home. The aim of this study is to describe our experience of home care hospitalization in surgical patients during the covid-19 pandemic. METHOD: Observational, descriptive, prospective, single-center study. 44 patients admitted to surgical home hospitalization unit from March 11 to May 10 2020. Patients with emergency or elective surgery and surgical patients who required conservative medical treatment or interventionism were included. Epidemiological variables, diagnosis, treatment, mean stay, readmissions rate, complications and mortality were evaluated. RESULTS: Mean age 64 years ± 16,7 (23-89). 52% men and 49% women. 23 patients underwent emergency or elective surgery, 12 patients conservative medical treatment, 2 thoracic drainage, 5 percutaneous drainage due to intra-abdominal abscesses and 2 patients with negative pressure therapy for surgical wound healing. Mean hospital stay 8,6 days ± 3,6 (1-19). Five complications were registered: subocclusion, colo-rectal bleeding, subcutaneous emphysema, lung abscess and a COVID-19 infection. Readmissions rate: 4,5%. CONCLUSIONS: Home hospitalization is an effective model to decrease or avoid hospital stay in selected patients. It also appears to be as safe as inpatient hospitalization. Combination of short-stay admission and home admission could be a good therapeutic option in surgical patients

Ways to perform an endoscopic tattoo. Prospective and randomized study in patients with colorectal neoplasm.

BACKGROUND AND AIMS: intraoperative identification of colonic lesions previously detected via colonoscopy may be difficult. Endoscopic tattooing facilitates identification, but there is no evidence regarding which is the best tattoo technique. The goal of the study was to describe the efficacy and safety of endoscopic tattooing and to detect technical and clinical factors associated with its efficacy. PATIENTS AND METHODS: a prospective and randomized study was performed. All tattoo candidate patients were included prior to surgery and randomized into four groups; tattoo at two or three injection points and with a volume of 1 or 1.5 ml of labeling. Multiple variables were registered. RESULTS: one hundred and ninety-five patients were included with an endoscopic tattoo and who subsequently underwent a surgical intervention, the mean age was 70.1 years and 67.2 % were male. The laparoscopic approach was applied in 57.9 % of cases. The intraoperative visibility of the endoscopic tattoo was 89.7 % and 30 % of rectal lesions were not visible. Excluding the rectum, the marking was visible intraoperatively in 92 % of patients, without significant differences according to the surgical approach, the type of marking or any of the variables collected. The tattoo was safe in 92.3 % of the cases. The adverse effect rate was 7.7 % and none of the complications were clinically significant. There were no significant differences between any variables collected in relation to adverse effects. CONCLUSIONS: endoscopic colon tattoo is safe and effective regardless of the technique used. We recommend the technique of two injection points and 1 ml of marking volume for its simplicity, efficiency and safety.

Democratizing wildfire strategies. Do you realize what it means? Insights from a participatory process in the Montseny region (Catalonia, Spain).

Participatory planning networks made of government agencies, stakeholders, citizens and scientists are receiving attention as a potential pathway to build resilient landscapes in the face of increased wildfire impacts due to suppression policies and land-use and climate changes. A key challenge for these networks lies in incorporating local knowledge and social values about landscape into operational wildfire management strategies. As large wildfires overcome the suppression capacity of the fire departments, such strategies entail difficult decisions about intervention priorities among different regions, values and socioeconomic interests. Therefore there is increasing interest in developing tools that facilitate decision-making during emergencies. In this paper we present a method to democratize wildfire strategies by incorporating social values about landscape in both suppression and prevention planning. We do so by reporting and critically reflecting on the experience from a pilot participatory process conducted in a region of Catalonia (Spain). There, we built a network of researchers, practitioners and citizens across spatial and governance scales. We combined knowledge on expected wildfires, landscape co-valuation by relevant actors, and citizen participation sessions to design a wildfire strategy that minimized the loss of social values. Drawing on insights from political ecology and transformation science, we discuss what the attempt to democratize wildfire strategies entails in terms of power relationships and potential for social-ecological transformation. Based on our experience, we suggest a trade-off between current wildfire risk levels and democratic management in the fire-prone regions of many western countries. In turn, the political negotiation about the landscape effects of wildfire expert knowledge is shown as a potential transformation pathway towards lower risk landscapes that can re-define agency over landscape and foster community re-learning on fire. We conclude that democratizing wildfire strategies ultimately entails co-shaping the landscapes and societies of the future.

³Cat-3/MOTS Nanosatellite Mission for Optical Multispectral and GNSS-R Earth Observation: Concept and Analysis.

The ³Cat-3/MOTS (3: Cube, Cat: Catalunya, 3: 3rd CubeSat mission/Missió Observació Terra Satèl·lit) mission is a joint initiative between the Institut Cartogràfic i Geològic de Catalunya (ICGC) and the Universitat Politècnica de Catalunya-BarcelonaTech (UPC) to foster innovative Earth Observation (EO) techniques based on data fusion of Global Navigation Satellite Systems Reflectometry (GNSS-R) and optical payloads. It is based on a 6U CubeSat platform, roughly a 10 cm × 20 cm × 30 cm parallelepiped. Since 2012, there has been a fast growing trend to use small satellites, especially nanosatellites, and in particular those following the CubeSat form factor. Small satellites possess intrinsic advantages over larger platforms in terms of cost, flexibility, and scalability, and may also enable constellations, trains, federations, or fractionated satellites or payloads based on a large number of individual satellites at an affordable cost. This work summarizes the mission analysis of ³Cat-3/MOTS, including its payload results, power budget (PB), thermal budget (TB), and data budget (DB). This mission analysis is addressed to transform EO data into territorial climate variables (soil moisture and land cover change) at the best possible achievable spatio-temporal resolution.

Preoperative management of colorectal cancer-induced iron deficiency anemia in clinical practice: data from a large observational cohort.

BACKGROUND: Preoperative anemia prevalence among colorectal cancer (CRC) patients is high and may adversely influence postoperative outcome. This study assesses the efficacy of a preoperative anemia managing protocol in CRC. STUDY DESIGN AND METHODS: This was a retrospective analysis of consecutive CRC resections at two Spanish centers (January 2012 to December 2013). Preoperative anemia was defined as a hemoglobin (Hb) level of less than 13 g/dL and treated with intravenous iron (IVI) or standard care (oral iron or no iron). Red blood cell transfusion (RBCT) requirements was the primary outcome variable. Postoperative infection rate and length of hospital stay (LOS) were secondary outcome variables. Patients were managed with a restrictive transfusion trigger (Hb < 8 g/dL). Infection was diagnosed clinically and confirmed by laboratory, microbiologic, and/or radiologic evidence. RESULTS: Overall, 322 of 571 patients (56%) presented with anemia: 232 received IVI and 90 standard care. There were differences in RBCT rate between no anemia and anemia (2% vs. 16%; p < 0.01), but not in postoperative infections (19% vs. 22%; p = NS) or LOS. Compared to those on standard care, anemic patients on IVI presented with lower Hb (10.8 g/dL vs. 12.0 g/dL; p < 0.001) at baseline, but similar Hb on day of surgery and Postoperative Day 30. There were no between-group differences in RBCT rates (16% vs. 17%; p = NS), but infection rates were lower among IVI-treated patients (18% vs. 29%; p < 0.05). No relevant IVI-related side effects were recorded. CONCLUSION: Compared to standard care, IVI was more effective in treating preoperative anemia in CRC patients and appeared to reduce infection rate, although it did not reduce postoperative RBCT.

Retinal vein occlusion and paroxysmal nocturnal hemoglobinuria.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder associated with increased risk for thrombosis and reduced life expectancy. Retinal vein occlusion (RVO) is a frequent cause of vision loss but its relationship with PNH has not been studied systematically. Patients followed up for RVO in our ophthalmology department were screened for the presence of a PNH clone in peripheral blood by means of flow cytometry. The presence of other well-documented risk factors for RVO was also analyzed. In a series of 110 patients (54 males, median age of 67) we found no evidence of PNH. Most patients (97/110) had cardiovascular risk factors and/or hyperhomocysteinemia (67/110). Inherited thrombophilias were rare (three confirmed cases). Therefore, PNH does not appear to play a role in the development of RVO. However, this finding does not necessarily apply to young patients and/or those with no conventional risk factors for RVO, due to the low number of patients in these subgroups in our population.

Displasia neuronal intestinal en paciente con pseudoobstrucción colónica crónica / Intestinal neuronal dysplasia in a patient with chronic colonic pseudo-obstruction

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Colonoscopic perforation: useful parameters for early diagnosis and conservative treatment.

OBJECTIVE: The purpose of this study is to determine useful parameters for the early diagnosis of colonoscopic perforation and to select those who would require surgical treatment. METHODS: We retrospectively reviewed the demographics, clinical and colonoscopic data, diagnostic-surgical interval, operative findings, complications, and hospital stay of patients who developed postcolonoscopy iatrogenic colonic perforation between January 2002 and December 2008. RESULTS: A retrospective multicentric study of patients diagnosed of colonoscopic perforation was performed. Fifty-four patients were found for final analysis (mean age, 71 years (26-91 years). Thirty-four were diagnostic and 20 were therapeutic colonoscopies. Most patients in whom the perforation was noticed during colonoscopy were treated surgically (p = 0.032) within 24 h (p = 0.004) and had a lesser degree of surgical peritonitis (p = 0.033). Those with deficient bowel preparation had more interventions (p < 0.05), ostomies (p = 0.015), and complications (p = 0.023) as well as major clinical (p < 0.001) and surgical peritonitis (p = 0.031). Patients with nonoperative management had fewer complications (p = 0.011) and lower hospital stay (p < 0.048). Surgical treatment within 24 h resulted in a lesser degree of surgical peritonitis (p < 0.001), fewer intestinal resections (p < 0.001), ostomies (p = 0.002) and complications (p < 0.047), and shorter hospital stay (p < 0.05). CONCLUSIONS: We recommend a conservative treatment for patients with the following conditions: good general health, unnoticed perforation during endoscopy, early diagnosis, no signs of diffuse peritonitis, proper colonic preparation, and a different injury mechanism to traction. Patients treated surgically after the first 24 h are likely to have a greater degree of peritonitis and more intestinal resections, ostomies, and complications.

Perforación endoscópica iatrogénica del colon: ¿es posible una opción conservadora? / Iatrogenic perforation of the colon: could it be a conservative option?

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[Perforated duodenal diverticulum]. / Divertículo duodenal perforado.

Diverticular disease of the duodenum is uncommon. Perforation is the least frequent complication. Diagnosis and treatment are not well defined as the presentation and symptomatology are nonspecific. Diagnostic delay carries high rates of postoperative mortality (30%). Early diagnosis is essential to reduce morbidity and mortality. We present the case of a male patient with perforated duodenal diverticulum. This case suggests that computed tomography can be highly useful in the preoperative diagnosis of this entity. Treatment consisted of duodenal exclusion and retroperitoneal drainage.

Divertículo duodenal perforado / Perforated duodenal diverticulum

La enfermedad diverticular del duodeno es una entidad clínica poco frecuente. La perforación es la complicación menos habitual. La secuencia diagnóstica y terapéutica no está definida debido a que su forma de presentación y sus síntomas son muy inespecíficos. La demora diagnóstica comporta tasas de mortalidad operatoria elevadas (30%). El diagnóstico precoz es fundamental para reducir la morbimortalidad. Se presenta el caso de un paciente con un divertículo duodenal perforado. Este caso indica que la tomografía computarizada es de gran utilidad en el diagnóstico preoperatorio. El tratamiento consistió en la exclusión duodenal y el drenaje del retroperitoneo (AU)

Diverticular disease of the duodenum is uncommon. Perforation is the least frequent complication. Diagnosis and treatment are not well defined as the presentation and symptomatology are nonspecific. Diagnostic delay carries high rates of postoperative mortality (30%). Early diagnosis is essential to reduce morbidity and mortality. We present the case of a male patient with perforated duodenal diverticulum. This case suggests that computed tomography can be highly useful in the preoperative diagnosis of this entity. Treatment consisted of duodenal exclusion and retroperitoneal drainage (AU)

Vía clínica de cirugía electiva colorrectal en un hospital general básico.Experiencia y resultados / Clinical pathway in elective colorectal surgery in a basic general hospital. Experience and results

Introducción. La práctica clínica habitual nos muestra la gran variabilidad existente en las formas de tratar una misma patología, así como en los recursos utilizados y resultados obtenidos. Las vías clínicas constituyen una herramienta útil para disminuir dicha variabilidad, ajustar los recursos y aumentar la calidad en la atención de los pacientes. En el presente estudio presentamos nuestra experiencia y resultados de la implantación de la vía clínica para cirugía colorrectal electiva diseñada con el fin de aplicarla en un hospital general básico. Pacientes y métodos. Un total de 43 pacientes fueron intervenidos de forma programada de patología colorrectal durante el período de febrero a diciembre de 2002. Los objetivos del presente estudio fueron: 1) elaboración e implantación de la vía clínica de cirugía colorrectal electiva a todos los pacientes susceptibles; 2) definición de criterios, indicadores, estándares de calidad y su evaluación, y 3) mejora de la información al paciente. Resultados. Se incluyó el 100 por ciento de los pacientes susceptibles de entrar en la vía clínica para cirugía colorrectal electiva. La aparición de complicaciones (28 por ciento; estándar < 20 por ciento) durante el postoperatorio obligó a la salida de la vía clínica a un total de 12 pacientes. La sonda nasogástrica no se colocó o bien pudo ser retirada antes de las 48 h en el 60 por ciento de los pacientes (estándar, 80 por ciento). De éstos, un 92 por ciento pudo iniciar la ingesta de líquidos con buena tolerancia (estándar, 90 por ciento). La estancia hospitalaria igual o inferior a 10 días ha sido discretamente inferior al estándar (el 70 frente al 80 por ciento), si bien hemos conseguido disminuir en 2 días nuestra media global de estancia hospitalaria. La densidad de variaciones de la vía clínica (11 por ciento) se ha adecuado al estándar (10 por ciento). La analgesia postoperatoria se ha adaptado a la marcada para la vía clínica en casi todos los pacientes (98 por ciento; estándar, 100 por ciento) con una eficacia (82 por ciento) discretamente inferior al estándar establecido (90 por ciento). La entrega por parte de enfermería de la hoja informativa gráfica dirigida al paciente sobre la vía clínica se ha realizado tan sólo en un 72 por ciento (estándar, 100 por ciento). Se realizó medición de la escala visual analógica (EVA) a un 65 por ciento de los pacientes (estándar, 100 por ciento). En el 93 por ciento de las encuestas para la valoración de la información del paciente, la puntuación ha sido superior a 11 (estándar, 100 por ciento). Conclusiones. Las vías clínicas constituyen un compromiso multidisciplinario pero de costosa implantación en los actuales sistemas sanitarios de atención al paciente. A pesar de las dificultades en su implantación, estamos convencidos de que constituyen un sistema de control de calidad de dicha atención, disminuyendo la variabilidad de la práctica clínica, y aumentando la atención personalizada y la información al paciente sobre su enfermedad. La mayor parte de los indicadores analizados en la vía clínica se han aproximado a los estándares fijados previamente. Creemos necesario mejorar el porcentaje de entrega de hojas informativas gráficas al paciente, la medición de EVA, así como el porcentaje de EVA inferior a 4 como criterio de eficacia analgésica. (AU)

Cáncer colorrectal y gástrico. Cómo informamos a nuestros enfermos / Gastric and colorectal cancer. How we inform our patients

Introducción. El diagnóstico de cáncer es de los peores hallazgos que se pueden encontrar durante la atención al paciente; además, hay que explicarle el fruto de nuestras exploraciones, así que la tarea para tener una correcta relación médico-paciente se complica. El objetivo de este estudio es analizar el grado de adecuación de la información que han recibido los pacientes intervenidos quirúrgicamente por cáncer colorrectal y gástrico Pacientes y métodos. Analizamos una muestra de 66 pacientes, intervenidos de cáncer gástrico, colon y recto, en nuestro hospital en los últimos 5 años. Quedan incluidos 40, para efectuar un estudio mediante cuestionario de 10 preguntas, que evalúa la información recibida durante la asistencia. Resultados. Los enfermos dicen saber que han sido diagnosticados de cáncer en un 57 por ciento de los casos, mientras que un 85 por ciento de los enfermos manifiesta que desearía conocer que padecen cáncer y un 90 por ciento de los pacientes está de acuerdo con el documento de consentimiento informado. Conclusiones. La información que hemos proporcionado a nuestros enfermos no alcanzaría plenamente sus expectativas, en lo que se refiere a la revelación del diagnóstico. Hay que saber qué considera el enfermo una información adecuada a su enfermedad y, además, adecuada a su persona (AU)