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.

Usefulness of Clinical Signs and Diagnostic Tests for Suspected Leaks in Bariatric Surgery.

BACKGROUND: The early diagnosis of leakage poses a challenge to bariatric surgeons, who need to suspect and treat it promptly. The aim of this study is to determine the value of clinical signs and complementary tests in its detection. METHODS: Between January 2007 and 2012, 200 patients underwent surgery for pathological obesity. Perioperative variables were collected prospectively, and univariate and multivariate analyses were conducted to study the factors related to leak occurrence and the predictive value of the tests performed. RESULTS: The study includes 172 proximal gastric bypasses and 28 sleeve gastrectomies. Nine patients (4.5 %) had leaks in the immediate postoperative period. Multivariate analyses found that age over 48 years and preoperative BMI > 48 kg/m(2) were the patient-related variables associated with a higher risk of leakage. The clinical variables significantly related to postoperative leaks were heart rate over 100 bpm, leukocytes over 15,000/mm(3) and systolic arterial pressure below 100 mmHg. In patients with a clinical suspicion of leakage (n = 19), 7.7 % of abdominal CT scans returned false negatives, versus 28.6 % for oral methylene blue and 22.2 % for upper gastrointestinal (UGI) Gastrografin swallow [Corrected]. CONCLUSIONS: Bariatric surgery proved to be a safe technique at our medical centre. Patient-related variables associated with a higher risk of leakage were age and BMI. Early clinical signs of leakage were tachycardia, leukocytosis and hypotension. The most reliable diagnostic test was the abdominal CT scan.

Frequency of abnormal esophageal acid exposure in patients eligible for bariatric surgery.

BACKGROUND: Obesity and gastroesophageal reflux disease (GERD) are both high-prevalence diseases in developed nations. Obesity has been identified as an important risk factor in the development of GERD. The objective of this study was to determine the frequency of abnormal esophageal acid exposure in patients candidate for bariatric surgery and its relationship with any clinical and endoscopic findings before surgery. METHODS: Data collected from a group of 88 patients awaiting bariatric surgery included a series of demographic variables and symptoms typical of GERD. The tests patients underwent included manometry, pH monitoring, and upper gastrointestinal endoscopy. Univariate and multivariate analyses were conducted on the variables related to the onset of reflux. RESULTS: Esophageal pH monitoring tests were positive in 65% of the patients. Manometries showed lower esophageal sphincter hypotonia in 46%, while 20% returned abnormal upper endoscopy results. Out of the 45% of patients who were asymptomatic or returned normal endoscopies, half returned positive esophageal pH tests. In turn, among the 55% of patients who had symptoms or an abnormal upper endoscopy, three quarters had pH tests that diagnosed reflux. pH tests were also positive in 80% of symptomatic patients and 100% of patients with esophagitis (P<.042). No statistically significant relationship was found between body mass index, sex, age, manometry, or hiatus hernia and the positive pH monitoring. CONCLUSION: Frequency of abnormal esophageal acid exposure among obese patients is high. There is a relationship between the presence of symptoms and reflux. But the absence of symptoms does not rule out the presence of abnormal esophageal function tests.

Armas eléctricas: ¿qué sabemos? ¿qué ignoramos? / Electronic control devices: what is known? what is unknown?

Las armas eléctricas se introdujeron como una alternativa a las armas de fuego en la policía, aunque también están siendo utilizadas fuera del marco de la ley. Mediante las descargas eléctricas que producen, se inmoviliza a la víctima como consecuencia de una contracción muscular tetánica dolorosa. La utilización de estas armas es controvertida, ya que se les han atribuido algunas muertes en custodia en Estados Unidos. Revisamos la literatura médica sobre este tema y concluimos que algunas veces pueden ser letales, y que es necesario analizar factores de riesgo potencial asociados para confirmar o descartar una verdadera relación causa-efecto en estos casos (AU)

Conducted energy devices are used as a non-lethal weapons by law enforcement personal internationally to subdue potentially violent or combative subjects. The victim is immobilized as a result of painful tetanic contraction of the muscles. However, controversy exists about these weapons, because they have been implicated in some deaths in custody in the United States. We review medical literature related on this topic and conclude that they are not always non lethal and that all potential associated factors must be analyzed to be able to confirm or disprove a true causal relationship (AU)

Mycobacterium africanum, an emerging disease in high-income countries?

BACKGROUND: Mycobacterium africanum is a cause of tuberculosis (TB) that has mainly been described in Africa, but immigration and travel patterns have contributed to the spread of the disease to other countries. METHODS: We retrospectively reviewed TB cases due to M. africanum during 2000-2010 in seven Spanish hospitals. Selected clinical charts were reviewed using a predefined protocol that included demographical, clinical and microbiological data and outcome. RESULTS: Although 57 cases were diagnosed, only 36 clinical charts were available for review: 82.8% were men and the mean age was 31.6 years (range 12-81). Forty-four cases were from Africa, 1 from the Philippines, 1 from India, and 4 from Spain, while the country of origin was unknown in 7 cases. The most frequent site of infection was the lung (58.3%). Four cases (6.9%) were resistant to at least one first-line anti-tuberculosis drug. CONCLUSIONS: Disease due to M. africanum in industrialised countries is mainly associated with immigration from endemic areas, although some cases also occur among native-born populations.

Suspended particles in wastewater: their optical, sedimentation and acoustical characterization and modeling.

Wastewater regulation and treatment is still a major concern in planetary pollution management. Some pollutants, referred to as particulate matter, consist of very small particles just suspended in the water. Various techniques are used for the suspended particles survey. Few of them are able to provide real-time data. The development of new, real time instruments needs the confrontation with real wastewater. Due its instability, the modeling of wastewater in terms of suspended solids was explored. Knowing the description of real wastewater, we tried to produce a synthetic mixture made of basic organic ingredients. A good agreement in terms of turbidity and settling velocity was observed between the artificial wastewater matrix and the real one. The investigation of the individual contribution of the different compounds to the acoustical signal showed a more complex dependence. Thus the modeling of wastewater with reference to turbidity and settling velocity is not sufficient to describe it acoustically. Further studies should lead to a good comparison of the acoustical and turbidity behavior of wastewater.

Ultrasonic device for real-time sewage velocity and suspended particles concentration measurements.

In the frame of a technological research and innovation network in water and environment technologies (RITEAU, Réseau de Recherche et d'Innovation Technologique Eau et Environnement), our research group, in collaboration with industrial partners and other research institutions, has been in charge of the development of a suitable flowmeter: an ultrasonic device measuring simultaneously the water flow and the concentration of size classes of suspended particles. Working on the pulsed ultrasound principle, our multi-frequency device (1 to 14 MHz) allows flow velocity and water height measurement and estimation of suspended solids concentration. Velocity measurements rely on the coherent Doppler principle. A self developed frequency estimator, so called Spectral Identification method, was used and compared to the classical Pulse-Pair method. Several measurements campaigns on one wastewater collector of the French city of Strasbourg gave very satisfactory results and showed smaller standard deviation values for the Doppler frequency extracted by the Spectral Identification method. A specific algorithm was also developed for the water height measurements. It relies on the water surface acoustic impedance rupture and its peak localisation and behaviour in the collected backscattering data. This algorithm was positively tested on long time measurements on the same wastewater collector. A large part of the article is devoted to the measurements of the suspended solids concentrations. Our data analysis consists in the adaptation of the well described acoustic behaviour of sand to the behaviour of wastewater particles. Both acoustic attenuation and acoustic backscattering data over multiple frequencies are analyzed for the extrapolation of size classes and respective concentrations. Under dry weather conditions, the massic backscattering coefficient and the overall size distribution showed similar evolution whatever the measurement site was and were suggesting a global wastewater particles behaviour. By comparison to sampling data, our data analysis lead to the characterization of two particle groups: the ones occurring during rain events and the ones typical of wastewater under dry weather conditions. Even with already encouraging results on the several weeks of data recorded on several wastewater collectors, the validation of our data inversion method is still under progress.

Obstruction of the bypassed stomach treated with percutaneous drainage: an alternative treatment for selected cases.

Biliopancreatic limb obstruction in Roux-en-Y gastric bypass is an infrequent complication that should be recognized early to avoid the risk of peritonitis and death. In this manuscript, we report a case of acute gastric remnant dilatation secondary to intraabdominal hematoma provoked by trocar injury that was compressing the second portion of duodenum lumen. To treat this problem, we decided on a less invasive treatment consisting of percutaneous decompression of the stomach. The procedure was performed using sonographic guidance with local anesthesia, thus, avoiding a new surgical procedure. In this selected case, percutaneous radiological catheter placement provided an effective decompression of the excluded gastric remnant until spontaneous resolution of the obstruction.

Carcinoid syndrome misdiagnosed as a malabsorptive syndrome after biliopancreatic diversion.

A case is reported of a woman who developed untreatable diarrhea after a prior biliopancreatic diversion (BPD), attributed to the malabsorptive component. Abdominal ultrasound incidentally found focal liver lesions. On fine needle aspiration biopsy, atypia was found, and these hepatic lesions were resected with free margins. The specimen showed liver metastases of an aggressive malignant neuroendocrine neoplasm. The primary site was subsequently identified to be in the pancreas. The physician and surgeon must realize that non-related diseases can develop after bariatric surgery, as in the general population.

[Mesenteric panniculitis: experience in our center]. / Paniculitis mesentérica: experiencia en nuestro centro.

Although several etiological factors have been associated with mesenteric panniculitis, the exact etiology in some cases remains unknown. Herein, we present a retrospective analysis of 8 patients affected with this disorder performed between May 2000 and December 2006. In our series the mean age at which patients presented was 63 years. The majority of the patients were male (with a male: female ratio of 3:1). The most common clinical manifestations were abdominal pain (n = 4) and asthenia (n = 4). Three cases presented with obstructive symptoms and three had a history of abdominal surgery. Notably, seven had a background of tobacco use (five smokers and two ex-smokers) and one patient developed follicular lymphoma. A literature research was carried out to analyze our results and formulate a new hypothesis. In our opinion, we believe that the study of causal factors such as tobacco and its components is required due to the strong association found in this study.

Paniculitis mesentérica: experiencia en nuestro centro / Mesenteric panniculitis: experience in our center

A pesar de que se han reconocido distintos factores precipitantes en la paniculitis mesentérica, su etiología en determinados casos es incierta. Presentamos un análisis retrospectivo de 8 pacientes afectados de paniculitis mesentérica en un periodo comprendido entre mayo 2000 hasta diciembre 2006. En nuestra serie la edad media de presentación fue 63 años, siendo la mayoría de pacientes varones (proporción 3:1). Las manifestaciones clínicas más frecuentes fueron el dolor abdominal (n = 4) y la astenia (n = 4). Tres casos se presentaron como cuadro de obstrucción y tres casos presentaron antecedentes de cirugía abdominal. El antecedente más común fue el tabaquismo (5 casos eran fumadores activos y 2 exfumadores) y hubo un paciente que desarrolló un linfoma folicular en el seguimiento. Revisamos la literatura para analizar nuestros resultados y formular una hipótesis. En nuestra opinión, pensamos que debe ser analizada de forma más exhaustiva la relación entre el tabaco y sus componentes con la aparición de la enfermedad debido a la fuerte asociación encontrada en este estudio

Although several etiological factors have been associated with mesenteric panniculitis, the exact etiology in some cases remains unknown. Herein, we present a retrospective analysis of 8 patients affected with this disorder performed between May 2000 and December 2006. In our series the mean age at which patients presented was 63 years. The majority of the patients were male (with a male: female ratio of 3:1). The most common clinical manifestations were abdominal pain (n = 4) and asthenia (n = 4). Three cases presented with obstructive symptoms and three had a history of abdominal surgery. Notably, seven had a background of tobacco use (five smokers and two ex-smokers) and one patient developed follicular lymphoma. A literature research was carried out to analyze our results and formulate a new hypothesis. In our opinion, we believe that the study of causal factors such as tobacco and its components is required due to the strong association found in this study

Restorative proctocolectomy with an ileoanal pouch: the role of laparoscopy.

OBJECTIVES: The Aim of this retrospective study was to evaluate early experience with laparoscopic restorative proctocolectomy by analyzing the perioperative results of surgical treatment. PATIENTS AND METHODS: Seven major surgeries were performed in six patients with familial adenomatous polyposis and ulcerative colitis. All procedures were performed under laparoscopy at our third-level hospital from June 2003 to October 2004. RESULTS: Mean surgical time was 287.5 +/- 80.7 min, and median blood loss was 300 +/- 249.0 cc. There were no conversions; return of peristalsis began at 32 +/- 12.4 h; average time to first oral intake was 64.0 +/- 32.8 h, and mean duration of hospital stay was 9.3 +/- 1.2 days. There was one case of perineal sepsis due to ileal pouch-anal anastomotic leakage, which was successfully treated with oral intake restriction, parenteral nutrition, and intra-rectal drainage. The most common postoperative complication was postoperative ileus. CONCLUSIONS: We believe that the laparoscopic approach to restorative proctocolectomy may be considerably improved in our center. Particular aspects for improvement include efforts to achieve lower operating and hospitalization times to equate our results with those reported by multicenter studies for laparoscopic colon cancer surgery. In our opinion, learning and further training opportunities should be encouraged to improve surgeon experience in the field of laparoscopy, preferably at centers specializing in restorative proctocolectomy.

Invaginación intestinal asociada a metástasis de melanoma maligno / Small-bowel intussusception secondary to metastatic melanoma

No disponible

Recurrence of inflammatory pseudotumor in the distal bile duct: lessons learned from a single case and reported cases.

Inflammatory myofibroblastic tumors (IMTs) or inflammatory pseudotumors (IPs) have been extensively discussed in the literature. They are usually found in the lung and upper respiratory tract. However, reporting of cases involving the biliopancreatic region has increased over recent years. Immunohistochemical study of these lesions limited to the pancreatic head or distal bile duct seems to be compatible with those observed in a new entity called autoimmune pancreatitis, but usually intense fibrotic reaction (zonation) predominates producing a mass. When this condition is limited to the pancreatic head, the common bile duct might be involved by the inflammatory process and jaundice may occur often resembling adenocarcinoma of the pancreas. We have previously reported a case of IMT arising from the bile duct associated with autoimmune pancreatitis which is an extremely rare entity. Four years after Kaush-Whipple resection, radiological examination on routine follow-up revealed a tumor mass, suggesting local recurrence. Ultrasound-guided FNA confirmed our suspicious diagnosis. This present case, as others, suggests that persistent follow-up is necessary in order to prevent irreversible liver damage at this specific location.

[Cost of quality in Intensive Medicine. Guidelines for clinical management]. / Costes de la calidad en Medicina Intensiva. Guía para gestores clínicos.

OBJECTIVE: This article reviews the utility and applicability of available systems in order to calculate general and quality costs in clinical services settings. METHODS: Review of techniques to calculate costs in Intensive Care Units (ICUs) according to analytical accounting approaches. RESULTS: The methodological development is complemented with the results of its application in the ICU of the Miracle's Hospital showing the structure of costs and the results obtained with this methodology when analyzing the costs of activities related to quality improvement. CONCLUSIONS: The effort to implement systems focused to analyze general and quality costs will result in a benefit of those participating in the healthcare system: citizens, professionals, managers, and "financials" since that which is only a legitimate demand today will be a inexcuseable commitment of the healthcare professionals from the society tomorrow.

Proctocolectomía restauradora con reservorio ileoanal: el papel de la laparoscopia / Restorative proctocolectomy with an ileoanal pouch: the role of laparoscopy

Objetivos: el objetivo de este estudio restrospectivo es evaluarla experiencia inicial en la proctocolectomía restauradora laparoscópica,analizando los resultados perioperatorios obtenidos durantela fase de introducción de la técnica.Pacientes y métodos: entre junio de 2003 y octubre 2004,realizamos siete intervenciones mayores en seis pacientes afectosde poliposis colónica familiar y colitis ulcerosa mediante abordajelaparoscópico.Resultados: el tiempo medio quirúrgico fue: 287,5 ± 80,7min y las pérdidas hemáticas: 300 ± 249,0 cc. No hubo conversiones;el inicio del peristaltismo fue: 32 ± 12,4 h; el tiempo mediode reintroducción de la alimentación: 64,0 ± 32,8 h; el tiempomedio de estancia hospitalaria: 9,3 ± 1,2 días. Hubo un casode dehiscencia del reservorio ileoanal con sepsis perineal tratadasatisfactoriamente con dieta absoluta, nutrición parenteral y drenajedel mismo mediante punción intrarrectal. La complicaciónpostoperatoria más frecuente fue la presencia de íleo postoperatorio.Conclusiones: creemos que la proctocolectomía restauradoralaparoscópica aún debe mejorar. Estas mejoras deberían reducirlos tiempos operatorios y la estancia hospitalaria para que la laparoscopiaen este campo iguale los resultados tan favorables obte-nidos en estudios multicéntricos en la cirugía oncológica del colon.En nuestra opinión, estos cambios deberían producirse con elaprendizaje y formación de los cirujanos en laparoscopia colorrectaly siempre en centros dedicados especialmente a este tipo de cirugía

Objectives: the aim of this retrospective study was to evaluateearly experience with laparoscopic restorative proctocolectomy byanalyzing the perioperative results of surgical treatment.Patients and methods: seven major surgeries were performedin six patients with familial adenomatous polyposis and ulcerativecolitis. All procedures were performed under laparoscopyat our third-level hospital from June 2003 to October 2004.Results: mean surgical time was 287.5 ± 80.7 min, and medianblood loss was 300 ± 249.0 cc. There were no conversions;return of peristalsis began at 32 ± 12.4 h; average time to firstoral intake was 64.0 ± 32.8 h, and mean duration of hospital staywas 9.3 ± 1.2 days. There was one case of perineal sepsis due toileal pouch-anal anastomotic leakage, which was successfullytreated with oral intake restriction, parenteral nutrition, and intrarectaldrainage. The most common postoperative complicationwas postoperative ileus.Conclusions: we believe that the laparoscopic approach torestorative proctocolectomy may be considerably improved in ourcenter. Particular aspects for improvement include efforts toachieve lower operating and hospitalization times to equate ourresults with those reported by multicenter studies for laparoscopiccolon cancer surgery. In our opinion, learning and further trainingopportunities should be encouraged to improve surgeon experiencein the field of laparoscopy, preferably at centers specializingin restorative proctocolectomy

Costes de la calidad en Medicina Intensiva. Guía para gestores clínicos / Cost of quality in Intensive Medicine. Guidelines for clinical management

Objetivo. Este artículo revisa la utilidad y aplicabilidad de los sistemas disponibles para calcular los costes generales y los costes de la calidad de los servicios clínicos hospitalarios. Métodos. Revisión de técnicas para calcular los costes en las Unidades de Cuidados Intensivos (UCI) mediante diferentes enfoques de la contabilidad analítica para tal fin. Resultados. El desarrollo metodológico se complementa con los resultados de aplicación en la UCI del Hospital del Milagro presentándose su estructura de costes y los datos obtenidos con esta metodología al analizar los costes resultantes de las actividades de mejora de la calidad en la UCI del Hospital del Milagro. Conclusiones. El esfuerzo para implementar sistemas de análisis de los costes en general y de los costes de la calidad en particular redundará en beneficio de los actores del sistema sanitario: ciudadanos, profesionales, gestores y financiadores, ya que lo que hoy sólo son legítimas demandas más o menos en ciernes, mañana será un compromiso ineludible de los profesionales asistenciales ante la sociedad

Objective. This article reviews the utility and applicability of available systems in order to calculate general and quality costs in clinical services settings. Methods. Review of techniques to calculate costs in Intensive Care Units (ICUs) according to analytical accounting approaches. Results. The methodological development is complemented with the results of its application in the ICU of the Miracle's Hospital showing the structure of costs and the results obtained with this methodology when analyzing the costs of activities related to quality improvement. Conclusions. The effort to implement systems focused to analyze general and quality costs will result in a benefit of those participating in the healthcare system: citizens, professionals, managers, and financials since that which is only a legitimate demand today will be a inexcusable commitment of the healthcare professionals from the society tomorrow