Morbidity following thyroid surgery: does surgeon volume matter?

PURPOSE: The aim of our study was to analyze the relationship between surgeon volume and morbidity in patients operated on by surgeons with endocrine specialization (EndS group) and those operated on by general surgeons (GenS group) in a single tertiary institution. METHODS: We present the results of a prospective cohort study of all patients undergoing thyroid surgery in our institution between January 2008 and January 2010, all of whom attended for follow-up for at least 12 months. We assessed pre- and postoperative recurrent laryngeal nerve (RLN) function by laryngoscopy. We monitored serum calcium concentrations in all patients until these values were normal without vitamin D and oral calcium supplementation. RESULTS: We studied 225 patients: 30 in the GenS group (six surgeons performing <5 procedures per surgeon per year) and 195 in the EndS group (two surgeons performing >40 procedures per surgeon per year). The total number of exposed RLN was 46 and 325, respectively. The incidence of RLN palsy persisting beyond 12 months was higher in the GenS group (2/46 vs. 1/325 exposed RLNs, p = 0.04). The incidence of hypocalcaemia persisting beyond 12 months (bilateral procedures) was also higher in the GenS group (3/16 vs. 3/130 patients, p = 0.028). CONCLUSIONS: Morbidity in terms of permanent RLN palsy and hypocalcaemia was less frequent among patients operated on by endocrine-dedicated surgeons. Differences in surgical volume and specialized training in neck endocrine surgery may explain these variations in morbidity.

Uso potencial de ciertas lectinas para el seguimiento del estado de salud de pacientes operados de cáncer colorrectal / Potential use of certain lectins for the follow-up of patients operated for colorectal cancer

The reactivity of 15 lectins or their derivatives (commercially available) were determined in blood serum of a control group of 13 apparently healthy humans in comparison with: (I) a group of 28 patients of colorectal cancer, explored 1 day before surgical exeresis; (II) another group of 15 subjects analysed 4-7 days after surgery; and (III) 27 subjects investigated 7-9 months after their operation. The lectins or their derivatives were selected taking into consideration the peculiarities of their specificities for the glycoconjugate ligands in the sera. A very different reactivity was found. Results pointed to certain variability for the pathological sera analysed. In addition, differences in the lectin reactivity depending on the time of surgical exeresis (4-7 days in comparison to 7-9 months) were detected. The usefulness of the assays with certain lectins (SNA = Sambucus nigra, LEL = Licopersicon esculentum and LTL = Lotus tetragonolobus) in the follow-up of the health status of patients operated for colorectal cancer is discussed (AU)

Se ha determinado la especificidad de la reacción de 15 lectinas o sus derivados (disponibles comercialmente) con glicoconjugados de sueros sanguíneos de un grupo control de 13 humanos aparentemente sanos, en comparación con: (I) un grupo de 28 pacientes de cáncer colorrectal, explorados 1 día antes de la intervención quirúrgica; (II) otro grupo de 15 sujetos analizados 4-7 días después de dicha intervención; y (III) con 27 sujetos investigados 7-9 meses después de la operación (en estado satisfactorio de salud). Las lectinas o sus derivados fueron seleccionados tomando en consideración las peculiaridades de sus respectivas especificidades en relación con los ligandos de naturaleza glicoconjugada de los sueros analizados. Se halló reactividad diferente según los sueros. Así, se detectaron diferencias en la intensidad de la reacción, dependiendo del tiempo transcurrido desde la intervención quirúrgica (4-7 días en comparación con 7-9 meses). Por último, se discute la utilidad de las determinaciones con ciertas lectinas (las de SNA = Sambucus nigra, LEL = Licopersicon esculentum y LTL = Lotus tetragonolobus) en el seguimiento del estado de salud de personas operadas de cáncer colorrectal, como valoraciones complementarias de las habituales empleadas con esta finalidad (AU)

Microorganismos y cáncer: evidencias científicas y nuevas hipótesis / Microorganisms and cancer: Scientific evidence and new hypotheses

La implicación de los microorganismos en el cáncer humano se conoce desde hace más de un siglo y diferentes tipos de parásitos, bacterias y virus se han relacionado con procesos oncogénicos. Dentro de las bacterias, la primera reconocida como carcinogénica fue Helicobacter pylori, que causa cáncer gástrico y podría estar relacionada con cánceres extragástricos en el hombre. Helicobacter hepaticus se ha relacionado con cánceres hepáticos utilizando modelos animales. Otras bacterias, como Chlamydia psitacii, Borrelia burgdorferi y Streptococcus bovis, se han relacionado con cánceres oculares, de piel y colorrectal, respectivamente. Además, una bacteria comensal del intestino humano, Bacteroides fragilis, se ha vinculado muy recientemente con el cáncer colorrectal utilizando modelos animales (AU)

Microorganism involvement in cancer has been known for over a century, and different types of parasites, bacteria and viruses have been associated with oncogenic processes. Among the bacteria, the first recognised was Helicobacter pylori which causes gastric cancer and might be related to extra-gastric cancer in humans. Helicobacter hepaticus has been associated with liver cancers using animal models. Other bacteria such as, Chlamydia psitacii, Borrelia burgdorferi and Streptococcus bovis have been associated with ocular, skin and colorectal cancers, respectively. Also, a commensal bacterium in the human intestine, Bacteroides fragilis, has been linked, very recently, with colorectal cancer using animal models (AU)

[Microorganisms and cancer: scientific evidence and new hypotheses]. / Microorganismos y cáncer: evidencias científicas y nuevas hipótesis.

Microorganism involvement in cancer has been known for over a century, and different types of parasites, bacteria and viruses have been associated with oncogenic processes. Among the bacteria, the first recognised was Helicobacter pylori which causes gastric cancer and might be related to extra-gastric cancer in humans. Helicobacter hepaticus has been associated with liver cancers using animal models. Other bacteria, such as Chlamydia psitacii, Borrelia burgdorferi and Streptococcus bovis, have been associated with ocular, skin and colorectal cancers, respectively. Also, a commensal bacterium in the human intestine, Bacteroides fragilis, has been linked, very recently, with colorectal cancer using animal models.

Open and endovascular treatment for pseudoaneurysms of the superior mesenteric artery.

BACKGROUND: Pseudoaneurysms of the superior mesenteric artery are rare, and their natural history is characterized by their tendency to rupture, thereby leading to a high mortality rate. Compared with classic surgical techniques (open), in recent years the possibility of endovascular treatment has increased. RESULTS: We report the cases of two patients with a pseudoaneurysm of the superior mesenteric artery. Each case was successfully treated in a different way: open and endovascular surgery. CONCLUSION: Despite the advantages (less risk for the patient) and good results obtained with endovascular surgery, this cannot completely replace open surgery. The choice of the most appropriate therapeutic option for pseudoaneurysms of the superior mesenteric artery depends on the state of the patient and the characteristics of the lesion. Open and endovascular surgical techniques are complementary, not mutually exclusive, techniques.

Respuesta de los autores: «Estadio» y «estadío» / Author’s reply: «Estadio» and «estadío»

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Trocar y trócar, estadio y estadío / Trocar and trócar, estadio and estadío

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Proyecto de programa de la especialidad de cirugía general y del aparato digestivo / Update on the residency training program in the Specialty of General and Digestive Surgery

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Bacterial translocation as a source of Dacron-graft contamination in experimental aortic operation: the importance of controlling SIRS.

BACKGROUND: Several experimental studies have shown the beneficial effects of nitric oxide (NO) in the modulation of the systemic inflammatory response syndrome (SIRS). Nitric oxide is involved in and affects almost all stages in the development of inflammation. We have attempted to ascertain whether the nitric oxide donor molsidomine prevents aortic graft contamination through control of the SIRS and a decrease in bacterial translocation (BT). METHODS: Twenty-four mini-pigs were divided into 4 groups. The animals were subjected to suprarenal aortic/iliac cross-clamping (for 30 minutes) and by-pass with a Dacron-collagen prosthetic graft impregnated in rifampicin. Groups: 1) sham (aortic dissection alone); 2) cross-clamping and bypass; 3) hemorrhage of 40% of total blood volume before cross-clamping and by-pass; and 4) the same as in group 3 but also including the administration of the NO donor molsidomine (4 mg/kg) 5 minutes before cross-clamping. VARIABLES: 1) bacteriology of mesenteric lymph nodes (MLN), kidney, blood, and prosthesis; 2) serum TNF-alpha (ELISA); and 3) iNOS expression in kidney and liver (Western blot). RESULTS: Aortic cross-clamping with or without hemorrhage was associated with BT in 80% and 100% of the animals, respectively. About 86% of the bacteria isolated in the graft were also present in MLN. This contamination coincided with an increase in TNF-alpha and with a greater expression of iNOS. Molsidomine administration decreased TNF-alpha and iNOS, decreased BT (from 100% to 20% of the animals), and decreased graft contamination (from 83% to 20%). CONCLUSIONS: The present model induces high levels of BT and SIRS, both acted as sources of contamination for the implanted Dacron graft. Molsidomine administration decreased the presence of bacteria in the graft by controlling BT and modulating SIRS.

[Surgical access routes in enteral nutrition]. / Vías de acceso quirúrgico en nutrición enteral.

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last < or = 6 weeks, nasoenteral tubes are the best option. In NE > or = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 +/- 21.9 days, and 72 double lumen nasojejunal tubes.

Vías de acceso quirúrgico en nutrición enteral / Surgical access routes in enteral nutrition

Son múltiples las vías de acceso al tubo digestivo para la nutrición enteral (NE) que conocemos y que en los últimos años ha experimentado importantes avances. Igualmente han avanzado considerablemente tanto las técnicas de administración como los productos nutricionales. La colocación de estos sistemas puede ser temporal o permanente. Sus indicaciones a menudo se superponen. Si es factible, siempre la vía enteral es la preferida respecto de la parenteral. Si ésta es necesaria durante 6 semanas o menos, las sondas nasoenterales son la mejor opción, por el contrario, las sondas de enterostomía serían las indicadas en la NE que supere las 6 semanas y la gastrostomía endoscópica percutánea (PEG) es el procedimiento de elección. El acceso pospilórico debe considerarse en pacientes con alto riesgo de aspiración. Finalmente, la yeyunostomía con catéter fino en el curso de una intervención quirúrgica del tracto gastrointestinal superior es la técnica ideal para iniciar la NE precoz. Todas las técnicas continúan teniendo alguna vigencia y sólo la situación clínica del enfermo y la experiencia del equipo que los atiende determinarán su uso. Este trabajo consta de dos partes. En la primera se analizan las técnicas de acceso quirúrgico en NE, sus indicaciones, contraindicaciones y las complicaciones más frecuentes relacionadas con la técnica, con el cuidado del estoma y con el material de intubación. En la segunda se aportan datos de nuestra experiencia en el tema, con las diversas técnicas que hemos realizado, en qué pacientes y con qué resultados y complicaciones. En total, 287 procedimientos: 48 gastrostomías quirúrgicas, 40 según la técnica de Fontan o Stamm y 8 gastrostomías de Janeway, 27 de ellas permanentes; 169 catéteres de yeyunostomía con una permanencia media de 29,05 ± 21,9 días y 72 sondas nasoyeyunales de doble luz (AU)

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 ± 21.9 days, and 72 double lumen nasojejunal tubes (AU)

Supresión de la mucosa residual vesicular tras la colecistectomía parcial / Suppression of residual mucosa after partial cholecystectomy

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Application of horizontal staircase electrophoresis in agarose minigels to the random intergenic spacer analysis of clinical samples.

The random intergenic spacer analysis is a recently developed technique for the study of microbial populations. The bacterial intergenic spacer (ITS) is located between 16S rRNA and 23S rRNA genes and presents different length and sequence among bacterial species. Therefore, the amplicons can be separated by electrophoresis commonly performed at low voltage during several hours. Although this technique is especially useful for unculturable microorganisms, it has not been applied before to clinical sample analysis. As these samples have a limited number of bacterial species, the size of the gels may be reduced to facilitate their handling and to reduce the running time. To obtain maximum separation among the ITS bands, we analysed in this work different electrophoretical conditions including staircase electrophoresis, a technique based on the application of several voltage steps. The results obtained showed a different behaviour of the electrical resistance during the performance of submarine horizontal and vertical staircase electrophoresis. In the first case the resistance decreased during most of the running time whereas in the second case it increased. Here, we show that the performance of horizontal staircase electrophoresis reduces the running time more than 80% with respect to conventional electrophoresis at low voltages. This procedure was applied to the separation of ITS bands from bacterial DNA present in a tissue from a vocal cord biopsy. The sequencing of these bands allowed their identification. This new procedure may be very useful in the rapid diagnosis of bacteria present in human, animal and plant tissues.

Postoperative evolution of inflammatory response in a model of suprarenal aortic cross-clamping with and without hemorrhagic shock. Systemic and local reactions.

Surgery of the abdominal aorta generates a systemic inflammatory response (SIR), a source of operative morbidity-mortality. In the present work we attempted to evaluate the evolution of SIR in an experimental model that simulates elective and urgent surgery on the abdominal aorta. Fifteen mini-pigs divided into three groups were used. The animals were subjected to suprarenal aortic/iliac clamping and bypass with a Dacron-collagen prosthetic graft. Groups were as follows: (1) sham (only aortic dissection); (2) clamping and bypass; (3) hemorrhage of 40%, pre-clamping, and bypass. Determinations included (1) tumor necrosis factor-alpha (TNF-alpha) interleukin (IL)-1beta, IL-6, IL-10, interferon-gamma; (2) myeloperoxidase (MPO), superoxide anion (SOA), superoxide dismutase (SOD), and malondialdehyde (MDA); (3) nitrites; (4) iNOS, (5) cell adhesion molecules (ICAM-1, VCAM-1) at 24 hours, 48 hours, and on day 7; and (6) NFkappaB at 48 hours. Our results point to an increase in all inflammatory variables, corroborated by their molecular regulators such as the expression of CAMs, iNOS, and NFkappaB. The alterations tended to normalize by day 7, after reperfusion. The results point to the great importance of SIR at all levels (molecular, nuclear, cellular, and systemic) in situations such as elective and urgent abdominal aorta surgery and the role that control of this response could represent for the future of vascular surgery.