[Detection of adverse events in thyroid and parathyroid surgery using trigger tool and Minimum Basic Data Set (MBDS)]. / Detección de eventos adversos en la cirugía tiroidea y paratiroidea utilizando la herramienta trigger y el Conjunto Mínimo de Datos Básicos (CMBD).

OBJECTIVES: To compare the ability of the trigger tool) and the Minimum Basic Data Set (MBDS) in detecting adverse events (AE) in hospitalized surgical patients with thyroid and parathyroid disease. METHODS: A descriptive, cross-sectional observational study, retrospective and cross-sectional study was conducted from May 2014 to April 2015 analysing retrospectively data on of patients submitted to thyroidectomy and parathyroidectomy in order to detect AE through the identification of triggers (an event often associated to an AE) and the MBDS. triggers and AE were located by systematic review of clinical documentation. The MBDS was got from the data base. Once an AE was detected, it was characterized. RESULTS: 203 AE were identified in 251 patients, being the 90.04% detected by trigger tool and 10.34% by MBDS. 126 patients had at least one AE (50.2%). Without the cases in which uncontrolled pain was the only AE, the percentage of patients that suffering AE was 38.65%. 187 AE were considered preventable and 16 AE were considered unpreventable. The trigger tool and the MBDS demonstrated a sensitivity of 91.27 and 13.49%, a specificity of 4.8 and 100%, a positive predictive value of 49,15 and 100%, and a negative predictive value of 35.29 and 53.42%, respectively. The triggers with more predictive power in AE detection were «antiemetic administration¼ and «calcium administration¼. CONCLUSIONS: Trigger tool shows higher sensitivity for detecting AE than the MBDS. All the detected AE were considered low severity and most of them were preventable.

Escisión Mesorrectal Total Transanal (Tatme): Aspectos Prácticos De La Técnica Quirúrgica / Transanal Total Mesorectal Excision: Practical Aspects Of Surgical Technique

INTRODUCCIÓN: El cáncer de recto es la séptima neoplasia más frecuente en España con una incidencia de 12570 casos/100.000 hab/año. La supervivencia a 5 años en Europa es del 55-62 % y tiende a aumentar gracias a la introducción de cambios en el tratamiento y nuevas técnicas quirúrgicas. La TaTME permite visualizar directamente el margen distal del tumor, evita las dificultades técnicas que aparecen al introducir las endograpadoras lineales en pelvis estrechas para seccionar el recto y ofrece una visualización directa de las estructuras pélvicas durante la EMT. El objetivo de este estudio es describir la técnica quirúrgica de la TaTME minuciosamente destacando los aspectos más prácticos del procedimiento. MATERIAL Y MÉTODOS: Se ha realizado una búsqueda bibliográfica sistemática en la base de datos Cochrane, MEDLINE y EMBASE mediante los términos "transanal total mesorectal excision". RESULTADOS: Durante la fase transanal se coloca el dispositivo gel-point monopuerto y multicanal transanal para la creación del neumorrecto. La luz del recto se cierra mediante una sutura en bolsa de tabaco. Tras completar la rectotomía se procede a la escisión mesorrectal total. Para la fase abdominal se crea un neumoperitoneo. Los vasos mesentéricos inferiores se seccionan en origen. Una vez que ambos equipos han avanzado en la escisión mesorrectal los campos se comunican abriendo el por el plano anterior. Se pueden construir varios tipos de anastomosis colorrectales. CONCLUSIÓN: La TaTME es un tratamiento quirúrgico del cáncer de recto medio y bajo seguro y factible

INTRODUCTION: Rectal cancer is the seventh most common cancer in Spain with an incidence of 12570 cases/100000 h/year. The 5-year overall survival of rectal cancer in Europe was 55-62% and this rate tends to improve due to new challenges and the development of new surgical techniques. TaTME offers a direct vision of the distal end of tumour, it avoids technical difficulties for in-troducing staplers down a narrow pelvis and it improves a direct visualization of pelvic structures during total mesorectal excision. The aim of this study is to describe the surgical technique for TaTME selecting the most practical aspects of this procedure. MATERIAL AND METHODS: The relevant studies were identified by a search of MEDLINE, EMBASE and Cochrane Oral Health Group Specialized Register using terms transanal total mesorectal excision. RESULTS: During transanal phase pneumorectum is created using Gel Point Path Transanal Access platform. The rectal lumen is closed with a purse.string suture. After a complete rectotomy the total mesorectal excision is performed circumferentially. Pneu-moperitoenum is created for abdominal phase. When transanal and abdominal teams have achieved a complete total mesorectal excision both planes are connected at the anterior plane. Several types of colorectal anastomosis can be performed. CONCLUSIÓN: TaTME is a secure and feasible surgical treatment for low-mid rectal cancer

Bariatric Surgery Waiting Lists in Spain.

Bariatric surgery is one of the most common general surgery procedures in countries that, like Spain, have public healthcare systems, but is also one of the procedures for which patients have to wait the longest. The Spanish Society of Obesity Surgery (SECO) conducted a survey to estimate the situation of bariatric surgery waiting lists in Spain's public hospitals and to gather information on a number of related aspects. METHODS: An online survey was sent to the members of the SECO. The survey received 137 visits, all via the click-through link provided, from 52 health centers (47 public and 5 private). The data collected were included in a database and later analyzed using the SPSS18.0 statistical software package. RESULTS: A total of 4724 patients were on bariatric surgery waiting lists (BWLs), at an average of 100 per public hospital. Sixty-eight percent had been waiting for more than 6 months. The mean delay per patient was 397 days, and the longest wait was 1661 days. A further 46.2% of respondents were able to recall cases of patients who in the past 5 years had suffered cardiovascular events with sequelae while awaiting surgery, and 21.2% recalled at least one fatal cardiovascular event in that time. CONCLUSION: Our data revealed an unacceptably long wait for obesity surgery. Notwithstanding the limitations and potential biases of our research, the long wait for surgery in our context inevitably has serious consequences for a potentially significant number of patients.

Impact on patient outcome of emergency department length of stay prior to ICU admission / Impacto pronóstico de la duración de la estancia en el Servicio de Urgencias antes del ingreso en la UCI

OBJECTIVE: The favorable evolution of critically ill patients is often dependent on time-sensitive care intervention. The timing of transfer to the intensive care unit (ICU) therefore may be an important determinant of outcomes in critically ill patients. The aim of this study was to analyze the impact upon patient outcome of the length of stay in the Emergency Care Department. DESIGN: A single-center ambispective cohort study was carried out. SETTING: A general ICU and Emergency Care Department (ED) of a single University Hospital. PATIENTS: We included 269 patients consecutively transferred to the ICU from the ED over an 18-month period. INTERVENTIONS: Patients were first grouped into different cohorts based on ED length of stay (LOS), and were then divided into two groups: (a) ED LOS ≤5h and (b) ED LOS >5h. VARIABLES: Demographic, diagnostic, length of stay and mortality data were compared among the groups. RESULTS: Median ED LOS was 277min (IQR 129-622). Patients who developed ICU complications had a longer ED LOS compared to those who did not (349min vs. 209min, p < 0.01). A total of 129 patients (48%) had ED LOS >5h. The odds ratio of dying for patients with ED LOS >5h was 2.5 (95% CI 1.3-4.7). Age and sepsis diagnosis were the risk factors associated to prolongation of ED length of stay. CONCLUSIONS: A prolonged ED stay prior to ICU admission is related to the development of time-dependent complications and increased mortality. These findings suggest possible benefit from earlier ICU transfer and the prompt initiation of organ support

OBJETIVO: La evolución de los pacientes críticos se relaciona con intervenciones que dependen del tiempo. Por tanto, el momento de traslado de los pacientes graves a la UCI puede relacionarse con el pronóstico. El objetivo de este estudio fue analizar el impacto de la duración del ingreso en Urgencias sobre el pronóstico de los pacientes. DISEÑO: Estudio de cohortes ambispectivo de centro único. Ámbito: UCI polivalente y Servicio de Urgencias de un Hospital Universitario. PACIENTES: Un total de 269 pacientes ingresados en la UCI consecutivamente desde urgencias durante 18meses. INTERVENCIONES: Se agrupó a los pacientes en cohortes según la duración del ingreso en urgencias. Después se dividieron en 2 grupos: a)estancia en urgencias ≤5h, y b)estancia en urgencias >5h. VARIABLES: Demográficas, diagnóstico, estancia, mortalidad. RESULTADOS: Mediana de estancia en urgencias de 277min (RIC129-622). Los pacientes que desarrollaron complicaciones en la UCI tuvieron mayor estancia en Urgencias que aquellos sin complicaciones (349 vs. 209min, p < 0,01). Un total de 129 pacientes (48%) tuvieron un ingreso en urgencias >5h. La odds ratio para el fallecimiento hospitalario de los pacientes con un ingreso en urgencias >5h fue de 2,5 (IC del 95%, 1,3 a 4,7). La edad y la sepsis fueron los factores de riesgo asociados a la prolongación del ingreso en urgencias. Conclusiones Una estancia prolongada urgencias antes del ingreso en la UCI se relaciona con el desarrollo de complicaciones que dependen del tiempo y con la mortalidad. Estos hallazgos sugieren un beneficio del ingreso precoz en la UCI y del inicio de soporte orgánico sin retraso

Impact on patient outcome of emergency department length of stay prior to ICU admission.

OBJECTIVE: The favorable evolution of critically ill patients is often dependent on time-sensitive care intervention. The timing of transfer to the intensive care unit (ICU) therefore may be an important determinant of outcomes in critically ill patients. The aim of this study was to analyze the impact upon patient outcome of the length of stay in the Emergency Care Department. DESIGN: A single-center ambispective cohort study was carried out. SETTING: A general ICU and Emergency Care Department (ED) of a single University Hospital. PATIENTS: We included 269 patients consecutively transferred to the ICU from the ED over an 18-month period. INTERVENTIONS: Patients were first grouped into different cohorts based on ED length of stay (LOS), and were then divided into two groups: (a) ED LOS ≤5h and (b) ED LOS >5h. VARIABLES: Demographic, diagnostic, length of stay and mortality data were compared among the groups. RESULTS: Median ED LOS was 277min (IQR 129-622). Patients who developed ICU complications had a longer ED LOS compared to those who did not (349min vs. 209min, p<0.01). A total of 129 patients (48%) had ED LOS >5h. The odds ratio of dying for patients with ED LOS >5h was 2.5 (95% CI 1.3-4.7). Age and sepsis diagnosis were the risk factors associated to prolongation of ED length of stay. CONCLUSIONS: A prolonged ED stay prior to ICU admission is related to the development of time-dependent complications and increased mortality. These findings suggest possible benefit from earlier ICU transfer and the prompt initiation of organ support.

Reservorios venosos subcutáneos tipo port-a-cath. Ventajas del acceso quirúrgico mediante venotomía cefálica / Port-A-Cath implantable venous access system. Advantages ofsurgical access by cephalic venotomy

Introducción: La colocación de dispositivos implantables permanentes ha aumentado exponencialmente debido al aumento de indicaciones. El objetivo de este artículo es demostrar las ventajas de la utilización de la disección de vena cefálica para la colocación de sistemas venosos centrales. Métodos: Estudio longitudinal, descriptivo y retrospectivo, en el cual analizamos 265 pacientes consecutivos, recogidos entre enero de 2010 y octubre de 2013, a los que se les colocó un reservorio venoso subcutáneo mediante venotomía de la vena cefálica en el surco deltopectoral como acceso primario. Se detallan complicaciones intraoperatorias y postoperatorias tempranas y tardías. Resultados: En 253 pacientes se canaliza la vena cefálica, representando una tasa de éxito del 95,5 %. No se asocian complicaciones intraoperatorias como neumotórax o hemotórax. La tasa de complicaciones tempranas es el del 4 %, y tardías del 11,5 %, con un seguimiento mínimo de ocho meses. Se asociaron a retirada del sistema en 14 pacientes. Conclusión: El acceso por vena cefálica en régimen de cirugía mayor ambulatoria es seguro, con una alta tasa de éxito en nuestro estudio, y con una tasa de complicaciones tempranas y tardías bajas igual al acceso mediante punción sin riesgo de neumo-hemotórax (AU)

Introduction: The use of totally implantable access ports has increased exponentially due to the increase of indications. The objective of this article is to demonstrate the advantages of using surgical venous cutdowns of the cefalic vein to place central venous systems. Patients and methods: Longitudinal, descriptive and retrospective study, which analyzed 265 consecutive patients, collected between January 2010 and October 2013. In these patients a subcutaneous venous reservoir was placed by opening the cephalic vein in the deltopectoral groove as primary access. Intraoperative and postoperative early and late complications were documented in detail. Results: The primary success rate was 95.5 % for the venous cutdowns. No intraoperative complications such as pneumothorax or haemothorax were associated. The early complication rate is 4 %; late complications rate is 11.5 %, with a minimum follow-up of eight months. In 14 cases the complications were associated with the removal of the system. Conclusion: The surgical venous cutdown in ambulatory surgery is safe, with a high success rate in our study, and a rate of early and late complications like puncture of the subclavian vein approach, without risk of pneumo-haemothorax (AU)

Impacto de los métodos de diagnóstico por imagen en la apendicectomía de urgencia / Impact of imaging tests on the negative appendectomy rate

Introducción. Las apendicectomías negativas y gangrenadas son indicadores de calidad en cirugía general. Los objetivos de este estudio son analizar las apendicectomías de urgencia en relación con el uso de pruebas de imagen y revisar la bibliografía para analizar la calidad del proceso diagnóstico en la apendicitis aguda. Material y métodos. Estudio retrospectivo en el que se incluyeron todos los pacientes a los que se les realizó apendicectomía de urgencia por sospecha de apendicitis aguda en el Hospital Universitario 12 de Octubre de Madrid durante el año 2007. Los datos se obtuvieron de los informes de anatomía patológica y de las pruebas de imagen realizadas. Se analizaron la histología, las pruebas de imagen empleadas y su utilidad diagnóstica. Se compararon con los niveles de calidad publicados en la literatura médica internacional. Resultados. Se incluyeron en el estudio 394 pacientes. La tasa de apendicectomías negativas fue del 9,6%. Se le realizó ecografía (ECO) abdominal al 54,6% de los pacientes y tomografía axial computarizada (TAC) abdominal al 10,2% de los pacientes (TAC+ECO: 4,2%). El valor predictivo positivo de la ECO fue del 92,2% y el de la TAC fue del 97,5%. Conclusión. Las apendicectomías negativas (9,6%) muestran valores inferiores a los publicados históricamente, pero son más elevados que los publicados recientemente en EE. UU. El uso de técnicas de imagen en nuestro medio es inferior al publicado en EE. UU., aunque similar al de otros países europeos(AU)

Introduction. Negative appendectomies and perforated appendectomies have traditionally been quality indicators in surgery. The aim of this study is to analyze the emergency appendectomies in our hospital regarding the use of imaging tests and a review of the literature to analyze the quality of diagnosis in acute appendicitis. Material and methods. Retrospective study including all patients operated on for suspected acute appendicitis at a single institution for one year (2007). Data gathered from histology and imaging tests reports. Analysis of the histology results, imaging test used and its diagnostic accuracy. Comparison with quality levels published in the international literature. Results. A total of 394 patients were included in the study, the overall rate of negative appendectomy was 9.6%. Abdominal ultrasound (AU) was performed on 54.6% of patients and abdominal CT-scan on 10.2% of them, and 4.2% of the patients had both tests. AU positive predictive value was 82%. CT-scan positive predictive value was 97%. Conclusion. The negative appendectomy rate (9.6%) in our centre shows values lower than the published ones in historical series but superior to the one published recently in the USA. The use of imaging tests in our hospital is lower than the one published in the USA, although similar to data reported in other European countries(AU)

[Impact of imaging tests on the negative appendectomy rate]. / Impacto de los métodos de diagnóstico por imagen en la apendicectomía de urgencia.

INTRODUCTION: Negative appendectomies and perforated appendectomies have traditionally been quality indicators in surgery. The aim of this study is to analyze the emergency appendectomies in our hospital regarding the use of imaging tests and a review of the literature to analyze the quality of diagnosis in acute appendicitis. MATERIAL AND METHODS: Retrospective study including all patients operated on for suspected acute appendicitis at a single institution for one year (2007). Data gathered from histology and imaging tests reports. Analysis of the histology results, imaging test used and its diagnostic accuracy. Comparison with quality levels published in the international literature. RESULTS: A total of 394 patients were included in the study, the overall rate of negative appendectomy was 9.6%. Abdominal ultrasound (AU) was performed on 54.6% of patients and abdominal CT-scan on 10.2% of them, and 4.2% of the patients had both tests. AU positive predictive value was 82%. CT-scan positive predictive value was 97%. CONCLUSION: The negative appendectomy rate (9.6%) in our centre shows values lower than the published ones in historical series but superior to the one published recently in the USA. The use of imaging tests in our hospital is lower than the one published in the USA, although similar to data reported in other European countries.

Chronic intestinal pseudo-obstruction: a diagnosis to be considered.

Chronic intestinal pseudoobstruction (CIPO) is a rare entity characterized by recurrent clinical episodes of intestinal obstruction in which no mechanical cause is identified. There are multiple causes for this syndrome but two main groups can be distinguished: a) secondary to a systemic non-gastrointestinal disease; and b) primary or idiopathic originated from alterations in the components of the intestinal wall. The latter forms are the most uncommon and their diagnosis is generally difficult. In the present article, we describe nine patients with CIPO that were diagnosed in our center over the last six years. Four of them were diagnosed with primary or idiopathic form of CIPO and another four were clearly secondary to a systemic disease. The ninth case, which was initially diagnosed as secondary, is probably also a primary form of the disease. The number of patients diagnosed in our center, even thought small, makes us to hypothesize that the prevalence of CIPO is probably greater than is generally believed and that the reasons of its rarity are the incomplete understanding of its physiopathology and the difficulties to achieve a correct diagnosis.

Chronic intestinal pseudo-obstruction: a diagnosis to be considered

Chronic intestinal pseudoobstruction (CIPO) is a rare entitycharacterized by recurrent clinical episodes of intestinal obstructionin which no mechanical cause is identified. There are multiplecauses for this syndrome but two main groups can be distinguished:a) secondary to a systemic non-gastrointestinal disease;and b) primary or idiopathic originated from alterations in thecomponents of the intestinal wall. The latter forms are the mostuncommon and their diagnosis is generally difficult. In the presentarticle, we describe nine patients with CIPO that were diagnosedin our center over the last six years. Four of them were diagnosedwith primary or idiopathic form of CIPO and another four wereclearly secondary to a systemic disease. The ninth case, whichwas initially diagnosed as secondary, is probably also a primaryform of the disease. The number of patients diagnosed in our center,even thought small, makes us to hypothesize that the prevalenceof CIPO is probably greater than is generally believed andthat the reasons of its rarity are the incomplete understanding ofits physiopathology and the difficulties to achieve a correct diagnosis(AU)

Pancreatitis aguda, adenopatías mesentéricas y diarrea / No disponible

No disponible

Enteritis grave por radiación: ¿es la nutrición parenteral domiciliaria la mejor solución? / Severe radiation-related enteritis: is home-based parenteral nutrition the best solution?

No disponible

No disponible

Marjolin's ulcer arising from a laparostomy scar.

Marjolin's ulcer is the malignant transformation of a scar, usually as a squamous cell carcinoma. An uncommon presentation form is from a laparostomy scar. A 49-year-old patient that had a laparostomy during the treatment of a necrohemorrhagic pancreatitis in 1987 complained 13 years later of a 20-cm ulcer on the laparostomy scar. A resection of the abdominal wall including the ulcer and a segmental transverse colectomy were performed because of infiltration by an invasive squamous cell carcinoma. Ten months later, axillary lymphadenectomy was performed because of lymph node metastasis. Currently, the patient is free of disease. Lymph node infiltration is frequent in squamous cell carcinoma on Marjolin's ulcer and survival is not good. Prophylaxis of this disease includes meticulous care of wounds, with early skin grafts when required and treatment of infections.

La anatomía patológica como factor pronóstico en el carcinoma lobulillar invasivo de la mama / Invasive lobular carcinoma of the breast : histopathology as a prognostic factor

Propósito: El carcinoma lobulillar invasivo de la mama presenta características únicas que lo diferencian del carcinoma ductal, como los hallazgos frecuentes de multicentricidad, bilateralidad, afectación de la mama contralateral, la positividad de los márgenes de la pieza y un teórico mayor porcentaje de afectación a nivel regional, que podrían influir en el pronóstico de la enfermedad. Material y métodos: Con el ánimo de evaluar las características definitorias del pronóstico en este tipo tumoral, se han estudiado ciertos factores de la anatomía patológica, como lo son el tamaño tumoral, el nivel de afectación axilar, el grado de malignidad tumoral, la afectación de los márgenes de la pieza, la muticentridad y la positividad de los receptores tumorales, para relacionarlos con la supervivencia a largo plazo en una población de 390 casos de carcinoma lobulillar invasivo de la mama en un estudio multicéntrico que refiere los resultados del período 1980-1997. Resultados y conclusiones: En conclusión, se observa que el pronóstico del carcinoma lobulillar se determina por el nivel de afectación regional, el tamaño tumoral y el grado de malignidad tumoral principalmente; la afectación axilar demuestra esta influencia en períodos avanzados del seguimiento de la paciente la positividad de los márgenes tumorales y la multicentricidad no se relacionan significativamente con el pronóstico (AU)

[Intraoperative serum parathyroid hormone measurement in the surgical treatment of hyperparathyroidism]. / Utilidad de las determinaciones intraoperatorias de la parathormona plasmática en la cirugía del hiperparatiroidismo.

BACKGROUND: PTH(1-84) short half life permits us to monitor parathyroidectomy efficacy, confirming complete resection after unilateral surgical approach in some cases of primary hyperparathyroidism. Nevertheless, this utility has been tested in controlled clinical trials and there is no agreement regarding the extraction of samples, their processing and interpretation of results. PATIENTS AND METHODS: In 18 consecutive patients operated on for primary or secondary hyperparathyroidism, serum PTH(1-84) concentrations were assessed at different times before, during and after partial (in 11 patients with multiglandular illness) and total resections. RESULTS: Initial PTH(1-84) concentrations very largely in different pre-resection samples, and these variations significantly affect post-resection percentage reduction. Plasmatic clearance of PTH(1-84) after incomplete resection follows a decreasing exponential curve towards new equilibrium concentrations. The difference is significant comparing with concentrations following complete resection only 5 minutes after, but the 95% intervals with a confidence level of 90% of confidence are exclusive only for determinations after 120 minutes. CONCLUSIONS: The decrement of serum PTH(1-84) concentrations to 20% of the preresection levels 120 minutes after an adenomectomy confirms the complete removal of all pathologic parathyroid tissue. A less sharp decrement must be investigated and may justify an early surgical revision.

Pathologic intrathyroidal parathyroid glands.

BACKGROUND: Parathyroid glands originate from the third and fourth branchial pouches and migrate caudally to their final positions. Aberrations during migration result in anomalous locations. Intrathyroidal location is not common. METHODS: We reviewed cervical explorations performed from 1974 to 1993 in hyperparathyroidism patients. RESULTS: We found pathological intrathyroidal glands in six patients. Three patients had adenomas (left superior, left inferior and right inferior glands). The hyperplastic glands were left inferior in one patient and right inferior in the remaining two. Intraoperative diagnosis was made in three cases in which palpation of the thyroid gland showed a nodule that was suspected to be the parathyroid missing gland. In three patients it was a finding in thyroidectomy or hemithyroidectomy specimens, two of them with associated thyroid nodular disease. CONCLUSIONS: Ipsilateral thyroidotomy on the side of a palpable thyroid mass or blind hemithyroidectomy are justified if a presumably pathological intrathyroidal gland is suspected, when all other sites in the neck have been excluded.