Evaluación económica del tratamiento quirúrgico de la obesidad / Economic evaluation of surgical treatment of obesity

INTRODUCCIÓN: La cirugía bariátrica es el mejor tratamiento de la obesidad mórbida a largo plazo. El ahorro generado por la mejoría de las comorbilidades podría justificar el empleo de más recursos sanitarios. MÉTODOS: Estudio observacional, descriptivo, longitudinal y retrospectivo, de pacientes a los que se les realizó un bypass gástrico, en el Hospital Universitario Central de Asturias entre 2003 y 2012. El seguimiento mínimo se estableció en dos años. Calculamos de manera individualizada el coste para cada uno de los pacientes intervenidos (bottom-up), así como según el grupo relacionado por el diagnóstico (GRD) (top-down). RESULTADOS: De los 307 pacientes del estudio, el coste medio del ingreso calculado por GRD fue de 6.545,9€ y el calculado por paciente de 10.572,2€. El GRD 288 representa al 91% de la serie con un valor de 4.631€. El cálculo estimativo del ahorro que supuso en nuestro entorno sanitario la disminución del número de fármacos de 2,86 a 0,78 por paciente medicado, representó 4.433€ por paciente intervenido si padecía todas las comorbilidades analizadas. CONCLUSIONES: El bypass gástrico en el Hospital Universitario Central de Asturias a los dos años de la cirugía, en pacientes con pluripatología consiguió un ahorro solo en fármacos que podría compensar los gastos inherentes al tratamiento quirúrgico. El coste por proceso mediante GRD se mostró insuficiente a la hora de hacer una correcta evaluación económica, por lo que recomendamos un método de evaluación de coste por paciente

INTRODUCTION: Obesity surgery is the best treatment for extreme obesity, with demonstrated long-term positive outcomes. The potential cost-savings generated by the improvement of comorbidities after surgery can justify the allocation of more resources in the surgical treatment of obesity. METHODS: This was an observational, descriptive, longitudinal and retrospective study. Eligible patients underwent Roux-en-Y gastric bypass surgery at the Hospital Universitario Central de Asturias between 2003 and 2012. The established minimum follow-up period was two years. We calculated the individualized cost per patient treated (bottom-up) as well as per Diagnosis-Related Group (DRG) codes (top-down). RESULTS: Our study included 307 patients. The average cost per hospitalization calculated by DRG codes was €6,545.90, and the average cost per patient was €10,572.20. DRG 288 represented 91% of the series, with a value of €4,631. The number of medications also decreased during this period, from 2.86 to 0.78 per medically treated patient, representing a cost reduction of €4,433 per patient with all the obesity-related comorbidities analyzed. CONCLUSIONS: Two years after Roux-en-Y gastric bypass conducted at Hospital Universitario Central de Asturias, the savings in drug costs for patients with multiple pathologies would compensate the inherent costs of the surgical treatment itself. Our results showed that DRG-related costs was insufficient to make a correct economic evaluation, so we recommend an individualized cost calculating method

Economic evaluation of surgical treatment of obesity. / Evaluación económica del tratamiento quirúrgico de la obesidad.

INTRODUCTION: Obesity surgery is the best treatment for extreme obesity, with demonstrated long-term positive outcomes. The potential cost-savings generated by the improvement of comorbidities after surgery can justify the allocation of more resources in the surgical treatment of obesity. METHODS: This was an observational, descriptive, longitudinal and retrospective study. Eligible patients underwent Roux-en-Y gastric bypass surgery at the Hospital Universitario Central de Asturias between 2003 and 2012. The established minimum follow-up period was two years. We calculated the individualized cost per patient treated (bottom-up) as well as per Diagnosis-Related Group (DRG) codes (top-down). RESULTS: Our study included 307 patients. The average cost per hospitalization calculated by DRG codes was €6,545.90, and the average cost per patient was €10,572.20. DRG 288 represented 91% of the series, with a value of €4,631. The number of medications also decreased during this period, from 2.86 to 0.78 per medically treated patient, representing a cost reduction of €4,433 per patient with all the obesity-related comorbidities analyzed. CONCLUSIONS: Two years after Roux-en-Y gastric bypass conducted at Hospital Universitario Central de Asturias, the savings in drug costs for patients with multiple pathologies would compensate the inherent costs of the surgical treatment itself. Our results showed that DRG-related costs was insufficient to make a correct economic evaluation, so we recommend an individualized cost calculating method.

Telemedicina, telementorización y evaluación telemática en cirugía. ¿Es su momento después de la COVID-19? / Telemedicine, telementoring and telematic evaluation in surgery. Is it your time after COVID-19?

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Ingeniería de diseño en Cirugía. ¿Cómo diseñar, probar y comercializar dispositivos quirúrgicos fabricados con impresión 3D? / Design Engineering in Surgery. How to Design, Test and Market Surgical Devices Made With 3D Printing?

La industria 4.0 ofrece nuevas oportunidades de desarrollo a los cirujanos. El diseño asistido por ordenador y la impresión 3D permiten materializar muchas ideas y conceptos, facilitando la accesibilidad al diseño y la creación de productos, bien como prototipos, bien como productos finales funcionales. Hasta ahora era difícil llegar a la fabricación de nuevos dispositivos. En estos momentos la principal limitación será nuestra creatividad, disponer de espacios que permitan poner a prueba nuestras creaciones y lograr financiación

Industry 4.0 offers new development opportunities for surgeons. Computer-aided design and 3D printing allow for the creation of prototypes and functional end products. Until now, it was difficult for new devices to get to the manufacturing phase. Nowadays, the main limitations are our creativity, available spaces to test our creations and obtaining financing

Design Engineering in Surgery. How to Design, Test and Market Surgical Devices Made With 3D Printing? / Ingeniería de diseño en Cirugía. ¿Cómo diseñar, probar y comercializar dispositivos quirúrgicos fabricados con impresión 3D?

Industry 4.0 offers new development opportunities for surgeons. Computer-aided design and 3D printing allow for the creation of prototypes and functional end products. Until now, it was difficult for new devices to get to the manufacturing phase. Nowadays, the main limitations are our creativity, available spaces to test our creations and obtaining financing.

¿Mejora la incorporación de un simulador virtual las capacidades en cirugía endoscópica adquiridas con simuladores inanimados? / Does the incorporation of a virtual simulator improve abilities in endoscopic surgery acquired with an inanimate simulator?

Se ha generalizado la realización de cursos y programas de formación en cirugía endoscópica en centros de entrenamiento. Además de una adecuada planificación de las actividades, se deben introducir sistemas de simulación para el aprendizaje y monitorizar la progresión. Se valoró la mejor adquisición de capacidades en un programa de formación en cirugía endoscópica al incorporar un simulador virtual a la práctica con cajas de entrenamiento. Material y método Se incluyó a 17 médicos residentes con un registro basal: grupo control. Se constituyeron 2 grupos: el grupo A, con 6h de entrenamiento con simulador inanimado, y el grupo B, con lo mismo más 4h de prácticas con LapSim. Se planificaron ejercicios de movilización-desplazamiento de objetos, corte y sutura-anudado en el simulador simple y en el virtual. Se evaluó el tiempo (medias e intervalos de confianza del 95%) empleado en cada ejercicio sobre el simulador inanimado, antes y después del entrenamiento. ResultadosEjercicio de movilización: el tiempo del grupo control fue de 223,6s, el del grupo A fue de 103,7s y el del grupo B fue de 89,9s (grupo control frente al grupo A, p<0,05). Ejercicio de corte: el tiempo del grupo control fue de 317,72s, el del grupo A fue de 232,8s y el del grupo B fue de 163,6s, (grupo control frente al grupo B, p<0,05). En el ejercicio de sutura todos consiguen dar un punto tras el entrenamiento. El tiempo del grupo control fue de 518,4s, el de A fue de 309,4s y el de B fue de 189,5s (grupo control frente al grupo A, p<0.05).Conclusiones El entrenamiento con simulador inanimado consiguió mejorar tanto el tiempo de movilización como el de sutura-anudado con respecto al grupo control. La incorporación del simulador virtual ha logrado superar los resultados obtenidos, sobre todo en el corte (AU)

Introduction The carrying out of training courses in surgical endoscopy for surgeons in training centres, is becoming more common. In addition to adequately planning activities, simulation systems are used to improve learning and monitor progression. Inanimate models and virtual reality programs increase psychomotor skills and assessment of performance. In this work we tried to improve our training program, basically in training boxes by introducing a virtual simulator. Material and method Seventeen surgical residents, with a basic training were chosen as the control group. Two additional groups were established, group A: with 6 hours of training with inanimate simulator. Group B: the same training system plus 4h of practice with LapSim. Exercises in the endotrainer and virtual simulator with moving-replacing objects, cutting and suturing-knotting were planned. End-point was time (mean with 95% confidence interval) in every exercise in box trainer, before and after the training period. Results Movement exercises: Time in control group was 223.6s, A:103.7s, and B:89.9s (Control vs. A, p<0,05). Cutting exercises: Time in control group was 317.7s, group A: 232.8s and in the B: 163.6s, (Control vs. B, p<0.05). In the suture/knot exercise everyone was able to carry out a stitch after the training period. Time in control group was 518.4s, in group A: 309.4s, p<0.05, and in B:189.5s (Control vs. A, p<0.05).Conclusions Training in inanimate boxes was able to improve the skills of students, particularly for moving and suture/knots. The incorporation of a virtual simulator increased the learning capabilities, mainly in cutting exercises (AU)

[Does the incorporation of a virtual simulator improve abilities in endoscopic surgery acquired with an inanimate simulator?]. / ¿Mejora la incorporación de un simulador virtual las capacidades en cirugía endoscópica adquiridas con simuladores inanimados?

INTRODUCTION: The carrying out of training courses in surgical endoscopy for surgeons in training centres, is becoming more common. In addition to adequately planning activities, simulation systems are used to improve learning and monitor progression. Inanimate models and virtual reality programs increase psychomotor skills and assessment of performance. In this work we tried to improve our training program, basically in training boxes by introducing a virtual simulator. MATERIAL AND METHOD: Seventeen surgical residents, with a basic training were chosen as the control group. Two additional groups were established, group A: with 6 hours of training with inanimate simulator. Group B: the same training system plus 4h of practice with LapSim. Exercises in the endotrainer and virtual simulator with moving-replacing objects, cutting and suturing-knotting were planned. End-point was time (mean with 95% confidence interval) in every exercise in box trainer, before and after the training period. RESULTS: Movement exercises: Time in control group was 223.6s, A:103.7s, and B:89.9s (Control vs. A, P < 0.05). Cutting exercises: Time in control group was 317.7s, group A: 232.8s and in the B: 163.6s, (Control vs. B, P < 0.05). In the suture/knot exercise everyone was able to carry out a stitch after the training period. Time in control group was 518.4s, in group A: 309.4s, P < 0.05, and in B:189.5s (Control vs. A, P < 0.05). CONCLUSIONS: Training in inanimate boxes was able to improve the skills of students, particularly for moving and suture/knots. The incorporation of a virtual simulator increased the learning capabilities, mainly in cutting exercises.

Cirugía en el cáncer de colon complicado / Rupture of a splenic artery aneurism

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[Integral management of the process of laparoscopic cholecystectomy]. / Gestión integral del proceso de colecistectomía laparoscópica.

INTRODUCTION: One of the most important objectives of public healthcare services is to guarantee integral healthcare to patients; activity is currently focussed on process management. Analysis of a "key" process could have health, social and economic effects if measures to improve the results are designed. The aim of the present study was to evaluate the process of laparoscopic cholecystectomy in our hospital in order to determine its strong and weak points. MATERIAL AND METHOD: We performed a prospective observational study of the laparoscopic cholecystectomy (LC) process in the Jarrio Hospital between January 2001 and December 2002. A working group was formed and a process flowchart was designed by consensus. The different steps of the process were evaluated through the main indicators of quality: accessibility, efficiency, and effectiveness, including cost, the convalescence period, and patient satisfaction. The results were compared with the standards defined by the Andalusian Health Council, bibliographic sources, and hospital commissions. The statistical analysis was performed with 95% confidence intervals of the main results. RESULTS: A series of 86 patients who underwent LC was evaluated. The results for accessibility showed wide variability in delays for specialist consultations, the waiting list for surgery, and urgent diagnostic tests, often exceeding the standards. The laparoscopic approach was more frequent than open cholecystectomy; morbidity and mortality with LC were below the reference standards and compliance with established prophylaxis protocols was close. The efficiency markers showed that the length of hospital stay for elective LC was close to the standard; however, for cholecystitis preoperative length of stay was longer than the standard. Overall patient satisfaction with medical care and non-medical services was high. CONCLUSIONS: Quality analysis of a process allowed us to identify strong points such as the high rate of laparoscopic cholecystectomy -showing good effectiveness and efficiency- the quality of informed consent, and patient satisfaction. Required improvements consisted of shortening preoperative length of stay in acute cholecystitis and waiting lists, informing patients about the length of the convalesce period, eliminating routine type and screen, and admitting patients on the day of surgery.

Gestión integral del proceso de colecistectomía laparoscópica / Integral management of the process of laparoscopic cholecystectomy

Introducción. Entre los objetivos básicos de la sanidad pública está garantizar la atención integral al paciente, y centrar la actividad en la gestión por procesos. El análisis de un proceso "clave" podría tener un efecto tanto desde el punto de vista sanitario como social y económico si se desarrollan medidas encaminadas a mejorar los resultados. El objetivo de este trabajo es el análisis del proceso de colecistectomía laparoscópica (CL) en nuestro hospital para determinar sus puntos fuertes y sus posibilidades de mejora. Material y método. Se realiza un estudio observacional y prospectivo del proceso de CL durante el período enero 2001-diciembre 2002. Mediante consenso de un grupo de trabajo se elaboró un diagrama de flujo y se realizó la evaluación de la gestión median-te indicadores de calidad: accesibilidad, eficiencia, efectividad, incluyendo el coste, la baja laboral y la satisfacción del paciente. Se consideraron como estándares los definidos por la Consejería de Salud de la Junta de Andalucía, los aceptados en bases bibliográficas y técnicas de grupo. Se exponen los intervalos de confianza del 95% de los resultados más relevantes. Resultados. Se evaluó a 86 pacientes intervenidos mediante CL. Existe variabilidad en la espera para la consulta, para la realización de cirugía y pruebas diagnósticas de urgencia, que exceden los estándares. La CL ha predominado sobre la cirugía abierta con tasas de morbimortalidad por debajo de los estándares y elevada adhesión a los protocolos de profilaxis. La estancia de la CL programada se aproxima mucho al objetivo, mientras que en la urgente las estancias preoperatorias son más elevadas de lo aceptable. En la satisfacción del paciente la puntuación global ha sido alta en los aspectos médicos y no médicos. Conclusiones. Destacan como puntos fuertes el elevado índice de cirugía laparoscópica, con una alta efectividad y eficiencia, la calidad del consentimiento informado y la satisfacción global de los pacientes. Como posibilidades de mejora: la demora en la cirugía de la colecistitis aguda, la priorización de las listas de espera, la orientación sobre el tiempo de baja laboral, suprimir el type-screen y la implantación del ingreso en el día (AU)

Introduction. One of the most important objectives of public healthcare services is to guarantee integral healthcare to patients; activity is currently focussed on process management. Analysis of a "key" process could have health, social and economic effects if measures to improve the results are designed. The aim of the present study was to evaluate the process of laparoscopic cholecystectomy in our hospital in order to determine its strong and weak points. Material and method. We performed a prospective observational study of the laparoscopic cholecystectomy (LC) process in the Jarrio Hospital between January 2001 and December 2002. A working group was formed and a process flowchart was designed by consensus. The different steps of the process were evaluated through the main indicators of quality: accessibility, efficiency, and effectiveness, including cost, the convalescence period, and patient satisfaction. The results were compared with the standards defined by the Andalusian Health Council, bibliographic sources, and hospital commissions. The statistical analysis was performed with 95% confidence intervals of the main results. Results. A series of 86 patients who underwent LC was evaluated. The results for accessibility showed wide variability in delays for specialist consultations, the waiting list for surgery, and urgent diagnostic tests, often exceeding the standards. The laparoscopic approach was more frequent than open cholecystectomy; morbidity and mortality with LC were below the reference standards and compliance with established prophylaxis protocols was close. The efficiency markers showed that the length of hospital stay for elective LC was close to the standard; however, for cholecystitis preoperative length of stay was longer than the standard. Overall patient satisfaction with medical care and non-medical services was high. Conclusions. Quality analysis of a process allowed us to identify strong points such as the high rate of laparoscopic cholecystectomy ­showing good effectiveness and efficiency­ the quality of informed consent, and patient satisfaction. Required improvements consisted of shortening preoperative length of stay in acute cholecystitis and waiting lists, informing patients about the length of the convalesce period, eliminating routine type and screen, and admitting patients on the day of surg (AU)

[Surgical training with simulators in training centers]. / Formación quirúrgica con simuladores en centros de entrenamiento.

The development of new endoscopic procedures and minimally-invasive surgical interventions has led the methodology used to date to be questioned. Greater demand for safety by patients, the growth of the health budget and the reduced time available for training have led to the proliferation of centers with accredited personnel in which the knowledge and surgical skills necessary for the controlled incorporation of these techniques can be acquired. Simulators are available for the learning of both digestive endoscopy and laparoscopic techniques. These simulators are more or less dynamic, virtual, with viscera or mixed; even live animals can be used. Thus, the various techniques can be incorporated into clinical practice safely and effectively and at a reasonable cost. Simulators also allow evaluation and follow-up of the skills acquired.

Formación quirúrgica con simuladores en centros de entrenamiento / Surgical training with simulators in training centers

El desarrollo de nuevos procedimientos endoscópicos e intervenciones quirúrgicas mínimamente invasivas cuestiona los medios y la metodología utilizada hasta el momento. Las mayores exigencias de seguridad por parte del paciente, el crecimiento del gasto sanitario y la reducción del tiempo disponible para la formación justifican la proliferación de centros con personal acreditado en los que se puedan adquirir los conocimientos y las habilidades quirúrgicas necesarias para la incorporación controlada de estas técnicas. Tanto para el aprendizaje de la endoscopia digestiva como para las técnicas con abordaje laparoscópico hay disponibles en el mercado modelos de simuladores más o menos dinámicos, virtuales, con vísceras, mixtos e incluso se puede recurrir a animales vivos. Así se consigue incorporar a la actividad clínica las diferentes técnicas con eficacia, seguridad y coste razonable, además de permitir una evaluación y un seguimiento de las capacidades adquiridas (AU)

The development of new endoscopic procedures and minimally-invasive surgical interventions has led the methodology used to date to be questioned. Greater demand for safety by patients, the growth of the health budget and the reduced time available for training have led to the proliferation of centers with accredited personnel in which the knowledge and surgical skills necessary for the controlled incorporation of these techniques can be acquired. Simulators are available for the learning of both digestive endoscopy and laparoscopic techniques. These simulators are more or less dynamic, virtual, with viscera or mixed; even live animals can be used. Thus, the various techniques can be incorporated into clinical practice safely and effectively and at a reasonable cost. Simulators also allow evaluation and follow-up of the skills acquired (AU)

Sistemas de cobertura quirúrgica estériles y desechables / Comparison of sterile, disposable surgical drapes

Introducción. Se estudian el cumplimiento de las características del material de cobertura estéril y desechable en el bloque quirúrgico, las incidencias relacionadas con su uso, la opinión del personal y la influencia sobre las tasas de infección de herida quirúrgica en una unidad clínica. Material y método. Se analizaron los equipos desechables utilizados en 88 intervenciones quirúrgicas de cirugía general, se hizo una encuesta a 41 profesionales y se analizó la variación del porcentaje de infecciones en 396 intervenciones del año anterior a la implantación y 421 del año posterior a la introducción del nuevo material, tras 6 meses de adaptación al mismo. Resultados. En el 92 por ciento de los equipos se mantuvo la impermeabilidad, y en el 87,5 por ciento, la resistencia a la rotura o desgarro de los paños del campo. Se garantizó el aislamiento en el 68,2 por ciento de las intervenciones. Se produjo arrancamiento del vello, sobre todo pectoral y púbico, en el 62,5 por ciento de los casos, e interferencias con placas electroquirúrgicas en el 42 por ciento. El 68,2 por ciento de los entrevistados consideran la incorporación del material como una mejora de la calidad. El porcentaje de infecciones de herida quirúrgica del total de intervenciones del ámbito de cirugía general pasó de 4,5 por ciento al 7,3 por ciento en el primer año de utilización del nuevo material (intervalo de confianza del 95 por ciento de la diferencia entre proporciones -7,6-0,4 por ciento). Conclusiones. Se mantuvieron la impermeabilidad y la resistencia. Falló el aislamiento. El adhesivo produjo arrancamiento del vello, sobre todo en los varones e interferencias con los elementos de monitorización. La mayor parte del personal considera la introducción del nuevo material como una mejora de la calidad aunque durante el primer año evaluado se asoció a un incremento de las infecciones no significativo (AU)