Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico / Stoma reversal after surgery for complicated acute diverticulitis: A multicentre retrospective study

INTRODUCCIÓN: El objetivo del estudio es analizar la tasa de reconstrucción del estoma tras cirugía por diverticulitis aguda complicada (DAC), su demora, factibilidad, complicaciones y factores de riesgo de mantenerlo. MÉTODOS: Estudio retrospectivo multicéntrico de pacientes intervenidos mediante cirugía urgente por DAC con realización de un estoma en 10 hospitales durante 6 años. Se analiza la frecuencia de reconstrucción del estoma, fundamentalmente de los terminales, y el tiempo en que se produce, así como los factores relacionados con ella. RESULTADOS: De 385 pacientes intervenidos por DAC, a 312 (81%) se les realizó un estoma: 292 fueron colostomías terminales y 20 estomas derivativos. Durante el seguimiento, en 161 (51,6%), se intentó el cierre a una mediana de 9 meses. Las causas más frecuentes de no efectuarlo fueron la comorbilidad y el fallecimiento del paciente. La edad más avanzada se mostró factor adverso en el análisis multivariante y la tasa actuarial de reconstrucción fue mayor en hombres y en quienes no se realizó un Hartmann. La cirugía pudo completarse en todos menos en un paciente y en 4 se asoció un estoma derivativo. La morbimortalidad fue del 35,7 y 1,9%, respectivamente. Hubo un 8,4% de reintervenciones y un 6% de fallos de sutura, quedando 12 pacientes (7,9%) con un estoma tras el intento de reconstrucción. CONCLUSIONES: La cirugía de la DAC se asocia muy frecuentemente a la construcción de un estoma terminal, que en casi un 50% no se reconstruirá. Además, la intervención de reconstrucción tiene una demora notable y está asociada a una morbimortalidad nada despreciable

INTRODUCTION: The aim was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS: A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS: Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmann's operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS: Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality

Stoma reversal after surgery for complicated acute diverticulitis: A multicentre retrospective study. / Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico.

INTRODUCTION THE AIM: was to analyse the stoma reversal rate after surgery for complicated acute diverticulitis (CAD), and more specifically the end-stoma-reversal, as well as the delay, feasibility, complications and risk factors for stoma maintenance. METHODS: A multicentre retrospective study of patients who had undergone urgent surgery for CAD with stoma formation in ten hospitals during a period of 6 years. The frequency of reversal over time and the factors affecting the decision for reversal were analysed. RESULTS: Out of 385 patients operated for CAD, 312 underwent stoma creation: 292 end colostomies and 20 diverting stomas. During follow-up, stoma reversal surgery was performed in 161 patients (51.6%) after a median of 9 months. The main causes for not performing stoma reversal were comorbidities and the death of the patient. Advanced age was an adverse factor in the multivariate analysis, and the actuarial rate of reversal was higher in men and in patients with no previous Hartmann's operation. Stoma reversal surgery was completed in all but one patient, and a loop ileostomy was associated in four. Morbidity and mortality rates were 35.7% and 1.9%, respectively. A total of 8.4% of patients underwent re-operation, and 6% experienced an anastomotic leak. Twelve patients remained with a stoma after the attempted reconstruction surgery. CONCLUSIONS: Surgery for CAD is frequently associated with an end stoma, which will ultimately not be reversed in almost 50% of patients. Moreover, reversal surgery is frequently delayed and is associated with significant morbidity and mortality.

Tratamiento quirúrgico de la diverticulitis aguda. Estudio retrospectivo multicéntrico / Surgical treatment of acute diverticulitis. A retrospective multicentre study

INTRODUCCIÓN: Se pretende analizar los resultados a corto y medio plazo de diferentes técnicas quirúrgicas en el tratamiento de la diverticulitis aguda complicada (DAC). MÉTODOS: Estudio retrospectivo y multicéntrico de pacientes operados de urgencia o de urgencia diferida por DAC. RESULTADOS: Estudiamos a 385 pacientes: 218 hombres y 167 mujeres, de edad media 64,4 ± 15,6 años, intervenidos en 10 hospitales. La mediana (25-758 percentiles) de evolución desde el inicio de los síntomas hasta la cirugía fue de 48 h(24-72), y su indicación más frecuente, un cuadro peritonítico (66%). El abordaje fue generalmente abierto (95,1%) y los hallazgos más comunes, peritonitis purulenta (34,8%) o absceso pericólico (28,6%). La técnica más habitual fue el procedimiento de Hartmann (PHT) en 278 (72,2%), seguida de resección y anastomosis primaria (RAP) en 69 (17,9%). Se complicaron 205 pacientes (53,2%) y fallecieron 50 (13%). Edad avanzada, inmunodepresión, factores de riesgo quirúrgico y peritonitis fecal se asociaron a mayor mortalidad. El lavado peritoneal laparoscópico (LPL) tuvo elevada tasa de reintervenciones, implicando frecuentemente un estoma, y la RAP se complicó con dehiscencia de sutura en el 13,7% de pacientes, sin diferencias en la morbimortalidad al compararla con el PHT. La mediana de estancia postoperatoria fue de 12 días; su mayor duración se relacionó con la mayor edad, riesgo quirúrgico ASA, hospital y complicaciones postoperatorias. CONCLUSIONES: La cirugía por DAC tiene importante morbimortalidad y se asocia frecuentemente a un estoma terminal. Además, el LPL presenta alta tasa de reintervenciones. LA RAP, aun asociando un estoma de protección, parece de elección en muchos casos

INTRODUCTION: To analyze short and medium-term results of different surgical techniques in the treatment of complicated acute diverticulitis (CAD). METHODS: Multicentre retrospective study including patients operated on as surgical emergency or deferred-urgency with the diagnosis of CAD. RESULTS: A series of 385 patients: 218 men and 167 women, mean age 64.4 ± 15.6 years, operated on in 10 hospitals were included. The median (25th-75th percentile) time from symptoms to surgery was 48 (24-72) h, being peritonitis the main surgical indication in a 66% of cases. Surgical approach was usually open (95.1%), and the commonest findings, a purulent peritonitis (34.8%) or pericolonic abscess (28.6%). Hartmann procedure (HP) was the most used technique in 278 (72.2%) patients, followed by resection and primary anastomosis (RPA) in 69 (17.9%). The overall postoperative morbidity and mortality was 53.2% and 13% respectively. Age, immunosupression, presence of general risk factors and faecal peritonitis were associated with increased mortality. Laparoscopic peritoneal lavage (LPL) was associated with an increased reoperation rate frequently involving a stoma, and anastomotic leaks presented in 13.7 patients after RPA, without differences in morbimortality when compared with HP. Median postoperative length of stay was 12 days, and was correlated with age, surgical risk, ASA score, hospital and postoperative complications. CONCLUSIONS: Surgery for CAD has important morbidity and mortality and is frequently associated with an end-stoma. Moreover LPL presented high reoperation rates. It seems better to resect and anastomose in most cases, even with an associated protective stoma

Surgical treatment of acute diverticulitis. A retrospective multicentre study. / Tratamiento quirúrgico de la diverticulitis aguda. Estudio retrospectivo multicéntrico.

INTRODUCTION: To analyze short and medium-term results of different surgical techniques in the treatment of complicated acute diverticulitis (CAD). METHODS: Multicentre retrospective study including patients operated on as surgical emergency or deferred-urgency with the diagnosis of CAD. RESULTS: A series of 385 patients: 218 men and 167 women, mean age 64.4±15.6 years, operated on in 10 hospitals were included. The median (25th-75th percentile) time from symptoms to surgery was 48 (24-72) h, being peritonitis the main surgical indication in a 66% of cases. Surgical approach was usually open (95.1%), and the commonest findings, a purulent peritonitis (34.8%) or pericolonic abscess (28.6%). Hartmann procedure (HP) was the most used technique in 278 (72.2%) patients, followed by resection and primary anastomosis (RPA) in 69 (17.9%). The overall postoperative morbidity and mortality was 53.2% and 13% respectively. Age, immunosupression, presence of general risk factors and faecal peritonitis were associated with increased mortality. Laparoscopic peritoneal lavage (LPL) was associated with an increased reoperation rate frequently involving a stoma, and anastomotic leaks presented in 13.7 patients after RPA, without differences in morbimortality when compared with HP. Median postoperative length of stay was 12 days, and was correlated with age, surgical risk, ASA score, hospital and postoperative complications. CONCLUSIONS: Surgery for CAD has important morbidity and mortality and is frequently associated with an end-stoma. Moreover LPL presented high reoperation rates. It seems better to resect and anastomose in most cases, even with an associated protective stoma.

Variabilidad interhospitalaria de la dehiscencia anastomótica en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos: La influencia del volumen quirúrgico / Hospital variation in anastomotic leakage after rectal cancer surgery in the Spanish Association of Surgeons project: The contribution of hospital volume

INTRODUCCIÓN: El objetivo de este estudio observacional multicéntrico fue determinar la tasa de dehiscencia anastomótica en los hospitales que participan en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos y evaluar si había diferencias atribuibles al volumen quirúrgico entre los hospitales que participan en él. MÉTODOS: La variación interhospitalaria se cuantificó mediante un estudio multinivel realizado con una base de datos prospectiva de los pacientes operados por un adenocarcinoma de recto con una resección anterior en 84 hospitales, entre marzo de 2006 y diciembre de 2013. En los análisis se incluyeron: las variables demográficas, la clasificación de la American Society of Anaesthesiologists, la utilización de un estoma de derivación, la localización y el estadio del tumor, la administración de tratamiento neoadyuvante y el volumen quirúrgico anual del hospital. RESULTADOS: Se analizó a 7.231 pacientes operados consecutivamente. La tasa de dehiscencia anastomótica fue del 10,0%. Los porcentajes de dehiscencia de los hospitales, estratificados por el volumen quirúrgico annual, variaron entre el 9,9 y el 11,3%. En el análisis de regresión multinivel el sexo masculino, los tumores localizados por debajo de 12 cm medidos desde el margen anal y los estadios T avanzados favorecieron la aparición de la dehiscencia, mientras que la presencia de un estoma de derivación la previno. El volumen quirúrgico anual del hospital no se asoció con la dehiscencia (OR: 0,852; [0,487-1,518]; p = 0,577). Además, se observó una variación significativa de la tasa de dehiscencia entre los hospitales (MOR: 1,475; [1,321-1,681]; p < 0,001). CONCLUSIÓN: La dehiscencia anastomótica varía de forma estadísticamente significativa entre los hospitales incluidos en el proyecto, y esta diferencia no se puede atribuir al volumen quirúrgico anual

OBJECTIVE: This multicentre observational study aimed to determine the anastomotic leak rate in the hospitals included in the Rectal Cancer Project of the Spanish Society of Surgeons and examine whether hospital volume may contribute to any variation between hospitals. METHODS: Hospital variation was quantified using a multilevel approach on prospective data derived from the multicentre database of all adenocarcinomas of the rectum operated by an anterior resection at 84 surgical departments from 2006 to 2013. The following variables were included in the analysis; demographics, American Society of Anaesthesiologists classification, use of defunctioning stoma, tumour location and stage, administration of neoadjuvant treatment, and annual volume of elective surgical procedures. RESULTS: A total of 7231 consecutive patients were included. The rate of anastomotic leak was 10.0%. Stratified by annual surgical volume hospitals varied from 9.9 to 11.3%. In multilevel regression analysis, the risk of anastomotic leak increased in male patients, in patients with tumours located below 12 cm from the anal verge, and advanced tumour stages. However, a defunctioning stoma seemed to prevent this complication. Hospital surgical volume was not associated with anastomotic leak (OR: 0.852, [0.487-1.518]; P=.577). Furthermore, there was a statistically significant variation in anastomotic leak between all departments (MOR: 1.475; [1.321-1.681]; P<0.001). CONCLUSION: Anastomotic leak varies significantly among hospitals included in the project and this difference cannot be attributed to the annual surgical volumen

[Hospital variation in anastomotic leakage after rectal cancer surgery in the Spanish Association of Surgeons project: The contribution of hospital volume]. / Variabilidad interhospitalaria de la dehiscencia anastomótica en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos: La influencia del volumen quirúrgico.

OBJECTIVE: This multicentre observational study aimed to determine the anastomotic leak rate in the hospitals included in the Rectal Cancer Project of the Spanish Society of Surgeons and examine whether hospital volume may contribute to any variation between hospitals. METHODS: Hospital variation was quantified using a multilevel approach on prospective data derived from the multicentre database of all adenocarcinomas of the rectum operated by an anterior resection at 84 surgical departments from 2006 to 2013. The following variables were included in the analysis; demographics, American Society of Anaesthesiologists classification, use of defunctioning stoma, tumour location and stage, administration of neoadjuvant treatment, and annual volume of elective surgical procedures. RESULTS: A total of 7231 consecutive patients were included. The rate of anastomotic leak was 10.0%. Stratified by annual surgical volume hospitals varied from 9.9 to 11.3%. In multilevel regression analysis, the risk of anastomotic leak increased in male patients, in patients with tumours located below 12 cm from the anal verge, and advanced tumour stages. However, a defunctioning stoma seemed to prevent this complication. Hospital surgical volume was not associated with anastomotic leak (OR: 0.852, [0.487-1.518]; P=.577). Furthermore, there was a statistically significant variation in anastomotic leak between all departments (MOR: 1.475; [1.321-1.681]; P<0.001). CONCLUSION: Anastomotic leak varies significantly among hospitals included in the project and this difference cannot be attributed to the annual surgical volume.

Variabilidad interhospitalaria de la mortalidad postoperatoria en el proyecto del cáncer de recto de la Asociación Española de Cirujanos. La influencia del volumen quirúrgico / Hospital variability in postoperative mortality after rectal cancer surgery in the Spanish association of surgeons project: The impact of hospital volume

INTRODUCCIÓN: El objetivo de este estudio observacional multicéntrico ha sido examinar la variación de la mortalidad postoperatoria de la cirugía electiva entre los hospitales que participan en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos, y evaluar si el volumen quirúrgico anual del hospital y las características de los pacientes contribuyen a la variación entre los hospitales. MÉTODOS: La variación interhospitalaria se cuantificó mediante un estudio multinivel realizado con una base de datos prospectiva de los pacientes operados por un adenocarcinoma de recto con una resección anterior y una amputación abdominoperineal en 84 hospitales, entre marzo de 2006 y diciembre de 2013. En los análisis se incluyeron: las variables demográficas, la clasificación ASA, la localización y el estadio del tumor, la administración de tratamiento neoadyuvante y el volumen quirúrgico anual del hospital. RESULTADOS: Se analizó a 9.809 pacientes operados consecutivamente. La tasa de mortalidad operatoria fue 1,8%. Los porcentajes de mortalidad de los hospitales estratificados por el volumen quirúrgico anual variaron entre 1,4 y 2,0%. En el análisis de regresión multinivel, el sexo masculino (OR 1,623 [1,143; 2,348]; p < 0,008), la edad avanzada (OR 5,811 [3,479; 10,087)]; p < 0,001) y la puntuación del ASA (OR 10,046 [3,390; 43,185]; p < 0,001) se asociaron con la mortalidad a los 30 días de la operación. Sin embargo, el volumen quirúrgico anual del hospital no se asoció con la mortalidad (OR 1,309 [0,483; 4,238]; p = 0,619). Además, se observó una variación significativa de la mortalidad entre los hospitales (MOR 1,588 [1,293; 2,015]; p < 0,001). CONCLUSIÓN:La mortalidad operatoria varía de forma estadísticamente significativa entre los hospitales incluidos en el proyecto, y esta diferencia no se puede atribuir al volumen quirúrgico anual

OBJECTIVE: This multicentre observational study examines variation between hospitals in postoperative mortality after elective surgery in the Rectal Cancer Project of the Spanish Society of Surgeons and explores whether hospital volume and patient characteristics contribute to any variation between hospitals. METHODS: Hospital variation was quantified using a multilevel approach on prospective data derived from the multicentre database of all rectal adenocarcinomas operated by an anterior resection or an abdominoperineal excision at 84 surgical departments from 2006 to 2013. The following variables were included in the analysis; demographics, American Society of Anaesthesiologists classification, tumour location and stage, administration of neoadjuvant treatment, and annual volume of surgical procedures. RESULTS: A total of 9809 consecutive patients were included. The rate of 30-day postoperative mortality was 1.8% Stratified by annual surgical volume hospitals varied from 1.4 to 2.0 in 30-day mortality. In the multilevel regression analysis, male gender (OR 1.623 [1.143; 2.348]; P < .008), increased age (OR: 5.811 [3.479; 10.087]; P < .001), and ASA score (OR 10.046 [3.390; 43.185]; P < .001) were associated with 30-day mortality. However, annual surgical volume was not associated with mortality (OR 1.309 [0.483; 4.238]; P = .619). Besides, there was a statistically significant variation in mortality between all departments (MOR 1.588 [1.293; 2.015]; P < .001). CONCLUSION: Postoperative mortality varies significantly among hospitals included in the project and this difference cannot be attributed to the annual surgical volume

Hospital variability in postoperative mortality after rectal cancer surgery in the Spanish Association of Surgeons project: The impact of hospital volume.

OBJECTIVE: This multicentre observational study examines variation between hospitals in postoperative mortality after elective surgery in the Rectal Cancer Project of the Spanish Society of Surgeons and explores whether hospital volume and patient characteristics contribute to any variation between hospitals. METHODS: Hospital variation was quantified using a multilevel approach on prospective data derived from the multicentre database of all rectal adenocarcinomas operated by an anterior resection or an abdominoperineal excision at 84 surgical departments from 2006 to 2013. The following variables were included in the analysis; demographics, American Society of Anaesthesiologists classification, tumour location and stage, administration of neoadjuvant treatment, and annual volume of surgical procedures. RESULTS: A total of 9809 consecutive patients were included. The rate of 30-day postoperative mortality was 1.8% Stratified by annual surgical volume hospitals varied from 1.4 to 2.0 in 30-day mortality. In the multilevel regression analysis, male gender (OR 1.623 [1.143; 2.348]; P<.008), increased age (OR: 5.811 [3.479; 10.087]; P<.001), and ASA score (OR 10.046 [3.390; 43.185]; P<.001) were associated with 30-day mortality. However, annual surgical volume was not associated with mortality (OR 1.309 [0.483; 4.238]; P=.619). Besides, there was a statistically significant variation in mortality between all departments (MOR 1.588 [1.293; 2.015]; P<.001). CONCLUSION: Postoperative mortality varies significantly among hospitals included in the project and this difference cannot be attributed to the annual surgical volume.

Impact of a diverting stoma in an enhanced recovery programme for rectal cancer.

PURPOSE: The association of a loop ileostomy decreases the severity of complications after rectal surgery but can increase the postoperative stay. The aim of this study is to investigate if a diverting ileostomy influences the postoperative outcomes in a series of patients included in a multimodal rehabilitation program (MMRP). METHODS: We analyzed a series of 104 patients that underwent elective surgery with primary anastomosis for rectal adenocarcinoma using a MMRP: 66 men and 38 women, with a median age of 64 (IQR: 55-75) years. Group A included patients with an associated loop ileostomy, and Group B, those without a protective stoma. RESULTS: Group A = 58, group B = 46 patients without differences in age, ASA, BMI and other risk factors, nor in the surgical approach (laparoscopic in 34%), although there were more neoadjuvant treatments in group A: 77.5 vs. 36.9%; P=.001. In group A, the most common operation was total mesorectal excision (96%) and in the B, a subtotal mesorectal excision (90%). There were no differences in postoperative complications (Group A 34.4 vs. group B28.2%; P=.322), anastomotic leaks (8.3 vs. 10.8%; P=.475), or postoperative ileus (20.7 vs. 10.9%; P=.140), neither in postoperative stay (7.9 vs. 6.9 days; P= .058, readmissions (7 vs. 13.6%; P= .22), or postoperative stay, including readmissions (8.4 vs. 9.1 days; P= .49). CONCLUSIONS: The association of a loop ileostomy does not extend the length of stay nor increases the rate of complications in patients that underwent a rectal resection with anastomosis included in a MMRP.

Multicenter study of outcome in relation to the type of resection in rectal cancer.

BACKGROUND: A surgical teaching and auditing program has been implemented to improve the results of treatment for patients with rectal cancer. OBJECTIVE: The aim of this study was to assess the treatment and outcome in patients resected for rectal cancer, focusing on differences relating to the type of resection. DESIGN: This was an observational study. SETTINGS: The study took place throughout the network of hospitals that compose the National Health Service in Spain. PATIENTS: This study included a consecutive cohort of 3355 patients from the Spanish Rectal Cancer Project. The data of patients who were operated on electively, with curative intent, by anterior resection (n = 2333 [69.5%]), abdominoperineal excision (n = 774 [23.1%]), and Hartmann procedure (n = 248 [7.4%]) between March 2006 and May 2010 were analyzed. MAIN OUTCOME MEASURES: Clinical, pathologic, and outcome results were analyzed in relation to the type of surgery performed. RESULTS: After a median follow-up time of 37 months (interquartile range, 30-48 months), bowel perforations were found to be more common in the Hartmann procedure (12.6%) and abdominoperineal groups (10.1%) than in the anterior resection group (2.3%; p < 0.001). Involvement of the circumferential resection margin was also more common in the Hartmann (16.6%) and abdominoperineal groups (14.3%) than in the anterior resection group (6.6%; p < 0.001). Multivariate analysis showed a negative influence on local recurrence, metastasis, survival for advanced stage, intraoperative perforation, invaded circumferential margin, and Hartmann procedure. However, abdominoperineal excision did not significantly influence local recurrence (HR, 0.945; 95% CI, 0.571-1.563; p = 0.825). LIMITATIONS: The main weakness of this study was the voluntary nature of registration in the Spanish Rectal Cancer Project. CONCLUSIONS: Although bowel perforation and involvement of the circumferential resection margin were more common after abdominoperineal excision than after anterior resection, this study did not identify abdominoperineal excision as a determinant of local recurrence in the context of 3 years of median follow-up.

Estudio prospectivo, multicéntrico sobre la actividad de los residentes de cirugía general y del aparato digestivo en España a través del libro informático del residente / A prospective, multicentre study on the activity of general and digestive surgery residents based on the use of the computerised logbook

Introducción: No hay datos cuantificados de la actividad real conseguida durante los 5 años de formación en España de la especialidad de Cirugía General y del Aparato Digestivo (CGAD). Igualmente, hay escasos datos en los programas de otros países y especialidades quirúrgicas. El objetivo es estimar la actividad media quirúrgica global, por áreas de capacitación específica y grado de complejidad, del programa español de la especialidad. Participantes y método Estudio multicéntrico prospectivo observacional sobre la actividad de los residentes de CGAD en España a través del libro informático del residente de la Asociación Española de Cirujanos (LIR-AEC). Cada residente registra su propia actividad supervisado por su tutor. El periodo de muestra fue de 6 meses. A partir de los resultados se estimaron las medianas de actividad anual y del periodo de la residencia. Resultados Actividad quirúrgica: se ha estimado que durante la residencia asisten a 1.325 intervenciones, realizan como cirujano principal 654 (49%). Actividad asistencial: la media de guardias es de 5,2±1,8 al mes. La actividad en consultas externas es de 548 primeras visitas y casi el doble de segundas visitas. Actividad científica: el número total de cursos y congresos es de 34. La media estimada de comunicaciones a congresos es de 14 y de publicaciones de 3.ConclusionesEl LIR-AEC es una herramienta adecuada para verificar la actividad del programa español de CGAD. Estos resultados permitirán una evaluación comparativa con la formación de los programas de otros países y especialidades quirúrgicas (AU)

Introduction: There are no quantified data on the real activity carried out by residents during the 5 years of training in the specialty of general and digestive surgery (GGS) in Spain. There are also limited data on programs in other surgical specialities, and in other countries. The aim of the study is to estimate the mean overall surgical activity by (..) (AU)

[A prospective, multicentre study on the activity of general and digestive surgery residents based on the use of the computerised logbook]. / Estudio prospectivo, multicéntrico sobre la actividad de los residentes de cirugía general y del aparato digestivo en España a través del libro informático del residente.

INTRODUCTION: There are no quantified data on the real activity carried out by residents during the 5 years of training in the specialty of general and digestive surgery (GGS) in Spain. There are also limited data on programs in other surgical specialities, and in other countries. The aim of the study is to estimate the mean overall surgical activity by specific skill areas and by the level of complexity of the Spanish program in the specialty of GGS. PATIENTS AND METHOD: A prospective, observational, multicentre study was performed on the activity of GGS residents in Spain using the Resident Computerised Logbook of the Spanish Surgeons Association (LIR-AEC). Each of the residents registered their own activity supervised by their tutor. The sample period was 6 months. The medians of the annual activity and the period of residency were calculated from the results. RESULTS: Surgical activity: during the residency, it was estimated that that they attended 1,325 operations, 654 (49%) as lead surgeon. Health care activity: the mean number of times on-call was 5.2±1.8 per month. Activity in outpatient clinics was 548 first visits, and almost double for second visits. Scientific activity: the total number of courses and conferences attended was 34. The estimated mean number of presentations at conferences was 14, with 3 publications. CONCLUSIONS: LIR-AEC is a suitable tool to verify activity in the Spanish GGS Program. These results may be useful for comparing with training programs in other countries and in other surgical specialties.

Preparación intestinal selectiva en un programa de rehabilitación multimodal. Influencia en el confort preoperatorio y resultados tras cirugía colorrectal / Selective intestinal preparation in a multimodal rehabilitation program. Influence on preoperative comfort and the results after colorectal surgery

Introducción: Pese a no haberse evidenciado ventajas de su empleo, la preparación mecánica anterograda (PMA) sigue siendo usual en cirugía colorrectal. Nuestro objetivo es analizar el impacto de su empleo selectivo respecto a confort y resultados en pacientes de un programa de rehabilitación multimodal perioperatoria (RHMM) o con cuidados convencionales (CC). Material y métodos: Estudio prospectivo de 108 pacientes propuestos para cirugía electiva, asignados consecutivamente 2:1 a un protocolo de RHMM que incluyo emplear solamente PMA en cirugía rectal con anastomosis baja o a CC en los que se empleo PMA, salvo en cirugía del colon derecho. Además se estudiaron dos grupos (A y B) en función de si se uso o no PMA. Se analizaron su tolerabilidad, sus resultados y las variables de recuperación postoperatoria. Resultados: Se incluyo a 39 pacientes en el grupo A y a 69 en el B; 69 siguieron el protocolo de RHMM. Los pacientes del grupo A presentaron más dolor abdominal, malestar anal, nauseas y sed, pero no hubo diferencias en lo que respecta a la tasa de muertes, complicaciones globales o su tipo, mientras que sý tuvieron menos complicaciones, fallos de sutura y muertes los pacientes del grupo RHMM (p < 0,05). Tampoco hubo ventajas del empleo de PMA respecto al inicio del tránsito intestinal, tolerancia a la dieta o estancias, pero estos parametros fueron favorables al grupo de RHMM. Conclusiones: La restricción de la PMA a casos seleccionados es segura, y asociada a un programa de RHMM contribuye a una recuperación mas rápida y cómoda sin incrementarlas complicaciones (AU)

Introduction: Despite there being no evidence of the advantages of its use, mechanical bowel preparation (MBP) continues to be routine in colorectal surgery. Our objective is to analyse the impact of its selective use, as regards patient comfort and results, comparing a perioperative multimodal rehabilitation program (MMRH) with conventional care (CC). Material and methods: A prospective study of 108 patients proposed for elective surgery, assigned consecutively 2:1 to an MMRH protocol which only included MBP in rectal surgery with low anastomosis, or to CC in whom MBP was used except in right colon surgery. We also studied two Groups (A and B) with and without the use of MBP. Their tolerance, results and postoperative recovery variables were analysed. Results: Thirty-nine patients were included in Group A, and 69 in Group B. A MMRH protocol was used in another 69 patients. The Group A patients had more abdominal pain, anal discomfort, nausea and thirst, but there were no differences as regards, death, overall or local complications, whilst there was less complications, suture failures and death in the MMRH when compared with CC Group (P < .05). There were no advantages observed in the use of MBP as regards the start of bowel movements, tolerance to diet or hospital stay, but these parameters were favourable to the MMRH when compared with CC Group. Conclusions: The restriction of MBP is safe, and associated with an MMRH program, contributes to a faster and more comfortable recovery, without increasing complications (AU)

[Selective intestinal preparation in a multimodal rehabilitation program. Influence on preoperative comfort and the results after colorectal surgery]. / Preparación intestinal selectiva en un programa de rehabilitación multimodal. Influencia en el confort preoperatorio y resultados tras cirugía colorrectal.

INTRODUCTION: Despite there being no evidence of the advantages of its use, mechanical bowel preparation (MBP) continues to be routine in colorectal surgery. Our objective is to analyse the impact of its selective use, as regards patient comfort and results, comparing a perioperative multimodal rehabilitation program (MMRH) with conventional care (CC). MATERIAL AND METHODS: A prospective study of 108 patients proposed for elective surgery, assigned consecutively 2:1 to an MMRH protocol which only included MBP in rectal surgery with low anastomosis, or to CC in whom MBP was used except in right colon surgery. We also studied two Groups (A and B) with and without the use of MBP. Their tolerance, results and postoperative recovery variables were analysed. RESULTS: Thirty-nine patients were included in Group A, and 69 in Group B. A MMRH protocol was used in another 69 patients. The Group A patients had more abdominal pain, anal discomfort, nausea and thirst, but there were no differences as regards, death, overall or local complications, whilst there was less complications, suture failures and death in the MMRH when compared with CC Group (P<.05). There were no advantages observed in the use of MBP as regards the start of bowel movements, tolerance to diet or hospital stay, but these parameters were favourable to the MMRH when compared with CC Group. CONCLUSIONS: The restriction of MBP is safe, and associated with an MMRH program, contributes to a faster and more comfortable recovery, without increasing complications.

[Cocaine-induced ischemic colitis in a high-risk patient treated conservatively]. / Colitis isquémica inducida por cocaína en un paciente de riesgo, tratada de forma conservadora.

Drug consumption is among the non-occlusive causes of ischemic colitis. We report a case of cocaine-induced ischemic colitis in a 34-year-old man who had undergone sigmoid resection and loop colostomy due to abdominal-pelvic injury 3 months previously. The patient presented with abdominal pain associated with diarrhea and slight transient fever of doubtful etiology and reported intranasal cocaine consumption. He was hemodynamically stable and showed no peritoneal irritation. Traces of blood were found in the colostomy bag. Colonoscopy showed ulcers and necrosis proximal to the stoma. Computed tomography angiography scan showed no abnormalities except filiform inferior mesenteric artery. The symptoms were self-limiting and the patient was discharged 3 days after admission. Subsequently the colostomy was closed without complications. A high degree of suspicion is required in young patients with abdominal pain not identified by conventional methods and a recent history of drug consumption.

Colitis isquémica inducida por cocaína en un paciente de riesgo, tratada de forma conservadora / Cocaine-induced ischemic colitis in a high-risk patient treated conservatively

Entre las causas no oclusivas de isquemia cólica están las inducidas farmacológicamente. Presentamos un caso de colitis isquémica provocada por consumo de cocaína en un paciente de 34 años de edad con antecedentes de traumatismo abdomino-pélvico tres meses antes, en el que se efectuó resección de sigma y colostomía en asa. Consultó por dolor abdominal asociado a diarrea y febrícula, y refería consumo de cocaína intranasal. Estaba hemodinámicamente estable y sin peritonismo, evidenciándose restos hemáticos en la bolsa de colostomía. Una colonoscopia objetivó úlceras y necrosis proximales al estoma y la angiotomografía no mostró hallazgos patológicos a excepción de una arteria mesentérica inferior filiforme. El cuadro fue autolimitado, y el paciente dado de al tercer día. Más adelante se reconstruyó el tránsito intestinal sin complicaciones. Debe existir un elevado grado de sospecha ante un dolor abdominal no filiado en pacientes jóvenes con antecedentes de consumo reciente de la droga (AU)

Drug consumption is among the non-occlusive causes of ischemic colitis. We report a case of cocaine-induced ischemic colitis in a 34-year-old man who had undergone sigmoid resection and loop colostomy due to abdominal-pelvic injury 3 months previously. The patient presented with abdominal pain associated with diarrhea and slight transient fever of doubtful etiology and reported intranasal cocaine consumption. He was hemodynamically stable and showed no peritoneal irritation. Traces of blood were found in the colostomy bag. Colonoscopy showed ulcers and necrosis proximal to the stoma. Computed tomography angiography scan showed no abnormalities except filiform inferior mesenteric artery. The symptoms were self-limiting and the patient was discharged 3 days after admission. Subsequently the colostomy was closed without complications. A high degree of suspicion is required in young patients with abdominal pain not identified by conventional methods and a recent history of drug consumption (AU)

Falsa hernia inguinal por endometriosis en el ligamento redondo / False inguinal hernia due to endometriosis in the round ligament

La localización extraperitoneal de la endometriosis es muy infrecuente; el ligamento redondo es una zona de posible asentamiento, lo que condiciona la aparición de una tumoración inguinal en ciertas ocasiones. Presentamos el caso de una paciente de 43 años que consulta por tumoración inguinal derecha de 2 años de evolución con aumento progresivo de su tamaño y molestias locales. A la exploración, se aprecia una tumoración dolorosa que protruye por el orificio inguinal externo. Se la interviene por vía preperitoneal y se evidencia una tumoración adherida al ligamento redondo sin orificios herniarios, por lo que se practica una exéresis amplia y completa de la lesión. El informe histopatológico indicó la presencia de tejido altamente sugestivo de endometriosis del ligamento redondo. Las formas extraperitoneales de endometriosis son infrecuentes y, entre ellas, las de la pared abdominal suelen localizarse en cicatrices laparotómicas y perineales tras intervenciones quirúrgicas. Pueden presentar dispareunia, irregularidades menstruales, dismenorrea e infertilidad o, en ciertos casos, la clínica puede pasar inadvertida. La exéresis completa es la estrategia más apropiada en la enfermedad inguinal localizada; es importante el estudio de exclusión de la endometriosis pélvica intraperitoneal, ya que la asociación de ambas entidades alcanza un 25%(AU)

An extraperitoneal endometriosis is a rare condition, with the round ligament being a possible location, sometimes leading to inguinal tumours. A 43 year-old women, who was seen due to having a tumour in right groin of 2 years progression gradually increasing in size and with local discomfort. On examination a painful tumour was found which protruded from the external inguinal orifice. She was intervened using a preperitoneal approach, showing evidence of tumour adhered to the round ligament with no hernial orifices. An extensive and complete exeresis was performed. The histopathology report indicated the presence of tissue highly suggestive of an endometriosis of the round ligament. Extra-peritoneal forms of endometriosis are uncommon, and among them, they are usually located in the abdominal wall in laparotomy and perineal scars after surgical interventions. They can present as dyspareunia, irregular periods, dysmenorrhea and infertility, or in some cases, the clinical picture may pass unnoticed. Complete removal is the most appropriate strategy in localised inguinal disease, with the study to exclude intraperitoneal pelvic endometriosis being important, since both conditions reach percentages of 25%(AU)

Tratamiento del prolapso rectal. ¿Todavía un misterio? / Treatment of rectal prolapse. Still a mystery?

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