Epidemiología de la apendicitis aguda en Colombia: Un análisis de las bases de datos administrativas del Ministerio de Salud / Epidemiology of acute appendicitis in Colombia: An Analysis of the Ministry of Health administrative databases

Introducción. La apendicitis aguda es una afección común, con un pico de incidencia entre los 10 y 20 años. La cirugía es el tratamiento preferido y la apendicectomía por laparotomía sigue siendo el estándar, aunque el abordaje laparoscópico ha mostrado menos complicaciones. El objetivo de este artículo fue caracterizar tanto la enfermedad como el tratamiento quirúrgico en Colombia, usando datos de bases oficiales. Métodos. Se accedió a la base de datos del Sistema Integrado de Información para la Protección Social (SISPRO) del Ministerio de Salud de Colombia en febrero de 2023. Se recogieron datos de los pacientes con diagnóstico de apendicitis y con procedimiento de apendicectomía entre 2017 y 2021, y se analizaron por edad, sexo y ubicación geográfica. Resultados. Entre 2017 y 2021 se diagnosticaron 345.618 casos de apendicitis (51,8 % mujeres), con pico de incidencia a los 15-20 años. Se realizaron 248.133 apendicectomías, el 16,7 % por laparoscopia. Los hospitales con más procedimientos reportados estaban en Bogotá, Yopal, Popayán y Florencia. La mortalidad fue de 0,56 % en hombres y 0,51 % en mujeres. Conclusión. La apendicitis es común, con pico a los 10-19 años. Las mujeres tienen mayor probabilidad de apendicectomía, debido a otras afecciones ginecológicas. El acceso a la apendicectomía disminuye la mortalidad; en estos pacientes, el 16 % fue laparoscópica, lo que sugiere que se necesita más entrenamiento y acceso a esta técnica. Este estudio aporta a la comprensión de la epidemiología de la apendicitis y apendicectomías en Colombia.

Introduction. Acute appendicitis is a common condition, with a peak incidence between 10 and 20 years of age. Surgery is the preferred treatment and laparotomy appendectomy remains the standard, although the laparoscopic approach has shown fewer complications. The objective of this article was to characterize both the disease and the surgical treatment in Colombia, using data from official databases. Methods. The Integrated Information System for Social Protection (SISPRO) database of the Ministry of Health was accessed in February 2023. Data with diagnosis of apendicitis and with appendectomy between 2017 and 2021 were collected. Analysis was done by age, gender, and geographic location. Results. Between 2017 and 2021, 345,618 cases of appendicitis were diagnosed (51.8% females), with peak incidence at 15-20 years of age. A total of 248,133 appendectomies were performed, 16.7% by laparoscopy. The hospitals with most reported procedures were located in Bogotá, Yopal, Popayán, and Florencia. Mortality was 0.56% in men and 0.51% in women. Conclusion. Appendicitis is common, peaking at ages 10-19. Women are more likely undergo appendectomy due to other gynecological conditions. Access to appendectomy improves mortality. In these patients, 16% were laparoscopic, suggesting that more training and access to this technique is needed. This study contributes to the understanding of the epidemiology of appendicitis and appendectomies in Colombia.

True Giant Diverticulum of the Left Colon. A Case Report

This abstract presents a clinical case of a male patient who exhibited clinical symptoms and tomographic findings of an abdominal mass in the descending colon. The diagnostic process and treatment are described, accompanied by a literature review. The review establishes the definition of the condition and its surgical indications. It is important to note that true giant diverticulum of the colon is a rare entity, with fewer than 200 reported cases in the literature.

Se presenta el caso clínico de un paciente masculino, con clínica y hallazgos tomográficos de masa abdominal en el colon descendente. Se describe el proceso diagnóstico y el tratamiento. Se realiza una revisión de la literatura, en la que se establece su definición e indicaciones quirúrgicas, teniendo en cuenta que el divertículo gigante verdadero del colon es una entidad rara, con menos de 200 casos reportados en la literatura.

Hydromediastinum and hydrothorax as delayed complications of peripherally inserted central catheter used for total parenteral nutrition: A case report.

INTRODUCTION: Central venous catheters (CVCs) and peripherally inserted central catheters (PICCs) may cause delayed complications, such as venous erosion, hydrothorax, or hydromediastinum. Vascular erosion is most frequently associated with left-sided CVC insertions. We report a case of hydropneumomediastinum and hydropneumothorax as a delayed complication of right-sided PICC used for total parenteral nutrition. PRESENTATION OF CASE: A 77-year-old man with muscle-invasive urothelial bladder cancer underwent pelvic lymphadenectomy and radical cystectomy with uretero-ileostomy reconstruction (Bricker). The patient developed postoperative ileus, and thus, a right PICC was inserted for total parenteral nutrition. On postoperative day 8, he developed bilateral hydromediastinum, and bilateral thoracentesis was performed. After the procedure, he presented with respiratory and hemodynamic deterioration and was transferred to the intensive care unit for 12 days. The patient was eventually discharged and followed-up at the outpatient department. DISCUSSION: Ruptured SVC has been predominantly described in left-sided CVCs at the right angle of the junction of the left brachiocephalic vein and SVC. However, our patient is the second documented case of bilateral hydropneumothorax and hydropneumomediastinum as a delayed complication of a PICC used to administer total parenteral nutrition. Catheters may migrate from their initial position due to breathing, bloodstream flow dynamics, postural rotation, and neck movements. Chemical irritation of the vessel wall may be caused by hyperosmolar hyperalimentation fluid. CONCLUSION: A right-sided vascular approach is preferred to avoid friction complications, and the tip should be placed at the lower third of the vena cava to prevent vascular erosion.

Machine learning for surgical time prediction.

BACKGROUND AND OBJECTIVE: Operating Rooms (ORs) are among the most expensive services in hospitals. A challenge to optimize the OR efficiency is to improve the surgery scheduling task, which requires the estimation of surgical time duration. Surgeons or programming units (based on people's experience) typically do the duration estimation using an experience-based strategy, which may include some bias, such as overestimating the surgery time, increasing ORs' operational cost. METHODS: This paper analyzes a machine learning-based solution for surgical time predictions. We apply and compare four machine-learning algorithms (Linear Regression, Support Vector Machines, Regression Trees, and Bagged Trees) to predict the surgical time duration at a tertiary referral university hospital in Bogotá, Colombia. Historical data from 2004 until 2019 was used to train the algorithms. Comparison among algorithms was given in terms of the Root Mean Square Error (RMSE) of the predicted surgery duration and the algorithms' computing time. The algorithm with the best performance was compared to the currently used experience-based method. RESULTS: All the ML algorithms predict the surgery duration with an error between 26 and 37 min. The best overall performance was obtained using Bagged Trees (26 min RMSE, 3.16 min training time, 0.49 min testing time) when using a subset of the DB with the nine specialties containing 80% of the surgeries. Bagged Trees also outperformed the experience-based method with a lower RMSE; however, it also shifted from a predominant overestimation to underestimating surgeries' duration. CONCLUSIONS: Different ML algorithms for predicting the surgical time duration, showing and comparing their performance. Bagged Trees showed the best performance in terms of RMSE and computing time. Depending on the initial data, Bagged Trees outperformed the experience-based method, but future work is necessary to suit it, like any other ML algorithm, to the hospitals' needs.

Invaginación del apéndice: un hallazgo poco frecuente en colonoscopia. Informe de caso / Appendiceal intussusception: a rare finding during colonoscopy. Case report

Resumen Se presenta el caso de una mujer joven con hallazgo endoscópico incidental en una colonoscopia de seguimiento, que consistía en una lesión en el ciego con histología benigna. Se describe el proceso diagnóstico y el tratamiento quirúrgico. Se revisa la literatura existente y se discuten la incidencia, el cuadro clínico y las indicaciones de tratamiento quirúrgico de una patología rara de baja aparición.

Abstract This is the case of a young patient with an incidental endoscopic finding of a lesion in the cecum during follow-up colonoscopy with benign histology. The diagnostic process and surgical treatment are described. The existing literature was reviewed and the incidence, symptoms and indications of surgical treatment of this rare condition are discussed.

Futilidad en cirugía: el caso de la gastrostomía / Futility in surgery: the case of the gastrostomy

Introducción. La nutrición se ha considerado tradicionalmente una necesidad básica y el garantizarla se ha asumido como una responsabilidad médica. Se cuestiona la utilización de procedimientos que permitan la nutrición artificial en situaciones clínicas limítrofes, en las cuales su beneficio puede ser limitado o nulo. En el presente estudio se busca determinar el éxito de un procedimiento quirúrgico, la gastrostomía, desde la perspectiva del beneficio para el paciente y, así, aproximarse a una definición de gastrostomía fútil. Métodos. Se llevó a cabo un estudio observacional, retrospectivo y analítico, basado en la revisión de las historias clínicas de los pacientes sometidos a gastrostomía abierta o endoscópica en el Hospital Universitario San Ignacio. El grupo de investigadores principales analizaron los datos para determinar si las gastrostomías practicadas fueron fútiles o no lo fueron. Resultados. Se incluyeron 145 pacientes tratados durante el periodo del 2015 al 2018 y en el 53 % de los cuales se cumplieron los criterios para considerar el procedimiento como fútil. Los procedimientos ­108 endoscópicos y 37 abiertos­fueron practicados principalmente en pacientes con neoplasias de cabeza y cuello, y enfermedades neurológicas. Si bien no hubo mortalidad asociada con el procedimiento, 26 de los pacientes fallecieron en los primeros 15 días después de la intervención. Discusión. El determinar en qué condiciones se debe considerar la gastrostomía una intervención realmente beneficiosa es un desafío. Es necesario incorporar un análisis ético, antes de ofrecer este procedimiento, con el fin de minimizar las gastrostomías innecesarias que actualmente constituyen un problema global

Introduction. Nutrition has traditionally been considered a basic need and ensuring it has been assumed as a medical responsibility. The use of procedures that allow artificial nutrition in borderline clinical situations is questioned, in which their benefit may be limited or null. The present study seeks to determine the success of a surgical procedure, gastrostomy, from the perspective of benefit to the patient and, thus, to approximate a definition of futile gastrostomy. Methods. An observational, retrospective and analytical study was carried out, based on the review of the medical records of patients undergoing open or endoscopic gastrostomy at the Hospital Universitario San Ignacio. The group of main researchers analyzed data to determine if the gastrostomies performed were futile or not.Results. Results. A total of 145 patients treated during the period from 2015 to 2018 were included, and 53% of whom met the criteria to consider the procedure as futile. The procedures - 108 endoscopic and 37 open - were practiced mainly in patients with head and neck malignancies, and neurological diseases. Although there was no mortality associated with the procedure, 26 of the patients died in the first 15 days after the intervention.Discussion. Determining under what conditions a gastrostomy should be considered a truly beneficial intervention is challenging. It is necessary to incorporate an ethical analysis, before offering this procedure, in order to minimize unnecessary gastrostomies that currently constitute a global problem

Cost-effectiveness of laparoscopic versus open appendectomy in developing nations: a Colombian analysis.

BACKGROUND: Colombia is a developing nation in need for efficient resource administration in fields such as health care, where innovation is constant. Since the introduction of laparoscopic appendectomy (LA), direct costs have been increasing without definitive results in terms of clinical outcomes. The objective of this study is to determine the cost-effectiveness of open appendectomy (OA) versus LA and thereby help surgeons in clinical decision-making in a limited resource setting. METHODS: A retrospective cost-effectiveness analysis comparing OA versus multiport LA during 2013 in a third-level university hospital (Hospital Universitario San Ignacio) in Bogota, Colombia was performed. Effectiveness was determined as the number of days in additional length of stay (LOS) due to the complications saved. A total of 377 clinical histories were collected by the authors and analyzed for the following variables: surgery type, conversion to open laparotomy, complications (surgical site infection, reintervention, and readmission), hospital LOS, and total cost of hospitalization for initial surgery and subsequent complications-related hospitalizations. The total accumulative costs and LOS for OA and LA plus complications were estimated. The cost-effectiveness threshold was set at US $46 (139,000 Colombian Peso [COP]), the cost of an additional day in LOS. An incremental cost-effectiveness ratio was calculated for OA as the comparator and LA as the intervention. RESULTS: The number of LA was 130 and of OA was 247. The two groups were balanced in terms of population characteristics. Complication rate was 13.7 % for OA and 10.4% for LA (P < 0.05), and LOS was 2 days for LA and OA (P = 0.9). No conversions from LA to OA were recorded. The total costs for complications for OA were US $8523 (25,569,220 COP) and US 3385 (10,157,758 COP) for LA. Cumulative costs including cost of surgery and complications and LOS for OA were US $65,753 (197,259,310 COP) and 297, respectively. Similarly, for LA were US $66,425 (199,276,948 COP) and 271, respectively. The incremental cost-effectiveness ratio was US $25.86 (77,601 COP) making LA a cost-effective alternative with a difference of US $20.76 (62,299 COP) under the cost-effectiveness threshold. CONCLUSIONS: LA is a cost-effective alternative over OA with an increasing cost of $25.85 per day of additional hospitalization due to complications saved. This is accounting the low cost of surgical interventions and complications in developing nations such as Colombia.

Experimental and Outcome-Based Approaches to Protein Requirements in the Intensive Care Unit.

Insight into protein requirements of intensive care unit (ICU) patients is urgently needed, but at present, it is unrealistic to define protein requirements for different diagnostic groups of critical illness or at different stages of illness. No large randomized controlled trials have randomized protein delivery, adequately addressed energy intake, and evaluated relevant clinical outcomes. As a pragmatic approach, experimental studies have focused on protein requirements of heterogeneous ICU patients. Data are scarce and the absolute value of protein requirements therefore is an approximation. Experimental studies indicate a protein requirement of >1.2 g/kg protein, which is supported by several outcome-based observational studies. Protein intake levels of up to 2.0-2.5 g/kg appear to be safe. A higher level of personalized treatment, within 1.2 and 2.5 g/kg, must involve identification of patients with low muscle protein mass that might benefit most from adequate protein nutrition in the ICU.

Protein Kinetics and Metabolic Effects Related to Disease States in the Intensive Care Unit.

Evaluating protein kinetics in the critically ill population remains a very difficult task. Heterogeneity in the intensive care unit (ICU) population and wide spectrum of disease processes creates complexity in assessing protein kinetics. Traditionally, protein has been delivered in the context of total energy. Focus on energy delivery has recently come into question, as the importance of supplemental protein in patient outcomes has been shown in several recent trials. The ICU patient is prone to catabolism, immobilization, and impaired immunity, which is a perfect storm for massive loss of lean body tissue with a unidirectional flow of amino acids from muscle to immune tissue for immunoglobulin production, as well as liver for gluconeogenesis and acute phase protein synthesis. The understanding of protein metabolism in the ICU has been recently expanded with the discovery of how the mammalian target of rapamycin complex 1 is regulated. The concept of "anabolic resistance" and identifying the quantity of protein required to overcome this resistance is gaining support among critical care nutrition circles. It appears that a minimum of at least 1.2 g/kg/d with levels up to 2.0 g/kg/d of protein or amino acids appears safe for delivery in the ICU setting and may yield a better clinical outcome.

Summary Points and Consensus Recommendations From the International Protein Summit.

The International Protein Summit in 2016 brought experts in clinical nutrition and protein metabolism together from around the globe to determine the impact of high-dose protein administration on clinical outcomes and address barriers to its delivery in the critically ill patient. It has been suggested that high doses of protein in the range of 1.2-2.5 g/kg/d may be required in the setting of the intensive care unit (ICU) to optimize nutrition therapy and reduce mortality. While incapable of blunting the catabolic response, protein doses in this range may be needed to best stimulate new protein synthesis and preserve muscle mass. Quality of protein (determined by source, content and ratio of amino acids, and digestibility) affects nutrient sensing pathways such as the mammalian target of rapamycin. Achieving protein goals the first week following admission to the ICU should take precedence over meeting energy goals. High-protein hypocaloric (providing 80%-90% of caloric requirements) feeding may evolve as the best strategy during the initial phase of critical illness to avoid overfeeding, improve insulin sensitivity, and maintain body protein homeostasis, especially in the patient at high nutrition risk. This article provides a set of recommendations based on assessment of the current literature to guide healthcare professionals in clinical practice at this time, as well as a list of potential topics to guide investigators for purposes of research in the future.

How Many Nonprotein Calories Does a Critically Ill Patient Require? A Case for Hypocaloric Nutrition in the Critically Ill Patient.

Calculation of energy and protein doses for critically ill patients is still a matter of controversy. For more than 40 years of nutrition support, the total amount of nutrients to be delivered to these patients has been calculated based on expert recommendations, and this calculation is based on the administration of nonprotein calories in one attempt to ameliorate catabolic response and avoid the weight loss. New evidence suggests protein delivery is the most important intervention to improve clinical and metabolic outcomes. This article describes the metabolic rationale and the new evidence supporting a change in the approach of metabolic support of the critically ill, proposing a physiological-based intervention supported by the recognition of ancillary characteristics of the metabolic response to trauma and injury. A moderate dose of calories around 15 kcal/kg/d with a delivery of protein of 1.5 g/kg/d appears to be the new recommendation for many hypercatabolic patients in the first week following injury.

How Much and What Type of Protein Should a Critically Ill Patient Receive?

Protein loss, manifested as loss of muscle mass, is observed universally in all critically ill patients. Depletion of muscle mass is associated with impaired function and poor outcomes. In extreme cases, protein malnutrition is manifested by respiratory failure, lack of wound healing, and immune dysfunction. Protecting muscle loss focused initially on meeting energy requirements. The assumption was that protein was being used (through oxidation) as an energy source. In healthy individuals, small amounts of glucose (approximately 400 calories) protect muscle loss and decrease amino acid oxidation (protein-sparing effect of glucose). Despite expectations of the benefits, the high provision of energy (above basal energy requirements) through the delivery of nonprotein calories has failed to demonstrate a clear benefit at curtailing protein loss. The protein-sparing effect of glucose is not clearly observed during illness. Increasing protein delivery beyond the normal nutrition requirements (0.8 g/k/d) has been investigated as an alternative solution. Over a dozen observational studies in critically ill patients suggest that higher protein delivery is beneficial at protecting muscle mass and associated with improved outcomes (decrease in mortality). Not surprisingly, new Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition guidelines and expert recommendations suggest higher protein delivery (>1.2 g/kg/d) for critically ill patients. This article provides an introduction to the concepts that delineate the basic principles of modern medical nutrition therapy as it relates to the goal of achieving an optimal management of protein metabolism during critical care illness, highlighting successes achieved so far but also placing significant challenges limiting our success in perspective.

Sistema de evaluación de habilidades psicomotrices en cirujanos de laparoscopia / An Assessment of Psychomotor Skills in Laparoscopy / Sistema de avaliação de habilidades psicomotoras em cirurgiões de laparoscopia

Objetivo: este estudio tiene como propósito diseñar y validar un sistema de evaluación objetivo y práctico de habilidades psicomotrices en laparoscopia que permita discriminar la competencia de los cirujanos. Materiales y métodos: fue llevado a cabo en el Centro de Simulación Clínica de la Universidad Javeriana. Voluntariamente participaron seis cirujanos expertos, seis residentes de cirugía y seis estudiantes de Medicina. Cada participante hizo una evaluación compuesta por ocho actividades en simuladores de caja con instrumental regular de laparoscopia. Los resultados obtenidos en los tres grupos fueron analizados por medio de un Anova y un test de Tukey. Además, se hizo un análisis de validez por fuentes de evidencia y la fiabilidad del sistema de evaluación se valoró con alfa de Cronbach. Resultados: tres actividades evaluativas discriminaron los tres grupos de estudio o grados de competencia (novato, intermedio y experto) y otras dos actividades revisaron dos de los grupos. La validez del sistema de evaluación fue comprobada al considerar el contenido, la respuesta del proceso, la estructura interna y las consecuencias de la evaluación. La fiabilidad del sistema de evaluación fue sobresaliente (alfa de Cronbach=0,90). Conclusión: el sistema de evaluación propuesto es una herramienta viable en procesos de formación de cirujanos que permite complementar el método tradicional de evaluación.

Objective: this study aims at designing and validating an objective and practical assessment of psychomotor skills in laparoscopy. This assessment would allow a classification of the surgeons and residents by their psychomotor competence. Materials and methods: this study evaluated the psychomotor competence of three groups of voluntaries: experts (6 senior surgeons), residents (6 surgery residents), and novices (6 students of medical school). The assessment was performed at the Clinical Simulation Center in the Pontificia Universidad Javeriana. The assessment was designed as a composition of eight different activities to be performed by each of the participants in a box trainer and using minimally invasive surgical instruments. The results were analyzed using an Anova and a Tukey's test. Additionally, a validity test by evidence source and the assessment reliability was evaluated using a Cronbach's alpha analysis. Results: three of the eight assessment's activities correctly discriminated three study groups, and other two activities only discriminate two of the three groups. The validity of the assessment was positively evaluated using a content analysis, the response to the assessment, the internal structure and the possible future consequences of the assessment. The reliability of the assessment was considered excellent (Cronbach's alpha=0,90). Conclusion: the propose assessment is a good alternative in formative processes of surgeons and allows to complement the traditional assessment method in surgery education.

Objetivo: este estudo tem como objetivo desenhar e validar um sistema de avaliação objetiva e prática de habilidade psicomotoras em laparoscopia que permita discriminar o nível de competência dos cirurgiões. Metodologia: O estudo foi levado a cabo no Centro de Simulação Clínica da Universidad Javeriana onde voluntariamente participaram 6 cirurgiões expertos, 6 residentes de cirurgia e 6 estudantes de medicina. Cada participante realizou uma avaliação composta por oito atividades em simuladores de caixa com instrumental regular de laparoscopia. Os resultados obtidos pelos três grupos de participantes foram analisados através de um ANOVA e um teste de Tukey. Adicionalmente, realizou-se uma análise de validez por fontes de evidência e a fiabilidade do sistema de avaliação valorou-se empregando uma análise de Alpha de Cronbach. Resultados: três atividades avaliativas discriminaram os três grupos de estudo ou níveis de competência (novato, intermédio e experto), e outras duas atividades discriminaram dois dos grupos. A validez do sistema de avaliação foi comprovada ao considerar o conteúdo, a resposta do processo, a estrutura interna e as consequências da avaliação. A fiabilidade do sistema de avaliação foi sobressalente (Alpha de Cronbach=0,90). Conclusão: O sistema de avaliação proposto é uma ferramenta viável em processos de formação de cirurgiões que permite complementar o método tradicional de avaliação de médicos cirurgiões.

High-protein hypocaloric vs normocaloric enteral nutrition in critically ill patients: A randomized clinical trial.

PURPOSE: Appropriate caloric intake in critically ill patients receiving enteral nutrition is controversial. This study evaluates the impact of different caloric regimens on severity of organ failure measured with Sequential Organ Failure Assessment (SOFA). MATERIALS AND METHODS: We conducted a randomized prospective controlled trial. Study population included adult intensive care unit (ICU) patients expected to require enteral nutrition for more than 96 hours. Goals in the intervention group were hypocaloric (15 kcal/kg per day) enteral nutrition compared to normocaloric (25 kcal/kg per day) enteral nutrition, both with hyperproteic intake (1.7 g of protein/kg per day). Primary end point was change in SOFA score (ΔSOFA) from baseline at 48 hours. Secondary end points were ΔSOFA at 96 hours, insulin requirements, hyperglycemia or hypoglycemic episodes, length of ICU stay, days on ventilator, and 28-day mortality. RESULTS: After screening 443 patients, 120 patients were analyzed. There were no differences between groups in baseline characteristics. We did not find a statistically significant difference in ΔSOFA at 48 hours. Patients in the hypocaloric group showed lower average daily insulin requirements and percentage of patients requiring any insulin. CONCLUSIONS: Hyperproteic, hypocaloric nutrition did not show different outcomes compared to normocaloric nutrition, except lower insulin requirements. Hypocaloric nutrition could provide a more physiologic approach with lower need for care and metabolic impact.

Evaluación del mejoramiento de habilidades básicas para cirugía laparoscópica por medio del entrenamiento con un videojuego / Evaluation of Basic Skills Improvement for Laparoscopy by Training with a Video Game / Avaliação do melhoramento de habilidades básicas para cirurgia laparoscópica por meio do treinamento com um videojogo

Introducción: debido a las crecientes limitaciones éticas y de recursos en el entrenamiento de aprendices en cirugía mínimamente invasiva (CMI, E. G. laparoscopia) en pacientes, se pretende evaluar el efecto de la práctica continua con un videojuego en particular en el desarrollo de las habilidades fundamentales a la hora de ejecutar una de estas cirugías. Materiales y métodos: se seleccionaron tres actividades esenciales (corte, sutura y coordinación mano-ojo) por realizar en simuladores laparoscópicos, con el fin de establecer si la práctica con el videojuego es efectiva en el desarrollo de las habilidades necesarias en CMI. Se evaluaron en total ocho variables de desempeño en las tres actividades seleccionadas. Con base en esto, se evaluaron catorce aprendices médicos sin experiencia en laparoscopia, divididos en dos grupos (control e intervención), antes y después de un programa de entrenamiento estandarizado con el videojuego Marblemanía® y una duración de un mes. Resultados: se evidenció que la práctica continua con el videojuego Marblemanía® mejoró todas las variables de desempeño. Estos resultados positivos fueron significativamente diferentes a favor del grupo que tuvo acceso al programa de entrenamiento con el videojuego en 3 de las 8 variables de desempeño medidas en las tres actividades seleccionadas: errores en la actividad de sutura (p = 0,003), y el tiempo de ejecución y errores en la actividad coordinación mano-ojo (p = 0,025 y 0,001, respectivamente).

Introduction: Due to the growing economical and ethical limitations in surgeons training for minimally invasive surgery (MIS, e.g. laparoscopy), this study aims at evaluating the effect of a continuous practice of a particular videogame on the development of the fundamental and specific skills needed to perform this type of procedure successfully. Materials and methods: To evaluate the effectiveness of video game practicing, three essential and common activities were chosen (cutting, suturing, and eye-hand coordination) to be performed in laparoscopic simulators. Eight different indexes or variables of performance were measured in the three activities. Fourteen voluntaries without previous experience in surgery were divided in two groups (intervention and control) and their performance was evaluated before and after a one-month standardized training program with the video game Marble Mania®. Results: A general improvement of all the performance variables was observed after one month training in the intervention group. This improvement was significant with respect to the control group in three of the eight variables: suturing errors (p = 0.003), and the execution and number of errors in the eye-hand coordination (p = 0.025 and 0.001, respectively).

Introdução: devido às crescentes limitações éticas e de recursos no treinamento de aprendizes em cirurgia minimamente invasiva (CMI, e.g. laparoscopia) em pacientes, pretende-se avaliar o efeito da prática contínua com um videojogo em particular no desenvolvimento das habilidades fundamentais na hora de executar uma destas cirurgias. Materiais e métodos: se selecionaram três atividades essenciais (corte, sutura e coordenação mão-olho), a realizar em simuladores laparoscópicos, com o fim de estabelecer se a prática com o videojogo é efetiva no desenvolvimento das habilidades necessárias em CMI. Em total, avaliaram-se oito variáveis de desempenho nas três atividades selecionadas. Com base nisso, avaliaram-se catorze aprendizes médicos sem experiência em laparoscopia, divididos em dois grupos (controles e intervenção), antes e depois de um programa de treinamento estandardizado com o videojogo Marblemanía® em uma duração de um mês. Resultados: se evidenciou que a pratica contínua com o videojogo Marblemanía® melhorou todas as variáveis de desempenho. Estes resultados positivos foram significativamente diferentes a favor do grupo que teve acesso ao programa de treinamento com o videojogo em três das oito variáveis de desempenho medidas nas três atividades selecionadas: erros na atividade de sutura (p = 0.003), o tempo de execução e erros na atividade coordenação mão-olho (p = 0.025 y 0.001, respectivamente).

Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial.

INTRODUCTION: Our aim was to evaluate the impact of hyperproteic hypocaloric enteral feeding on clinical outcomes in critically ill patients, particularly on severity of organic failure measured with the Sequential Organ Failure Assessment (SOFA). MATERIALS AND METHODS: In a double blind clinical trial, 80 critically ill adult patients were randomized to hyperproteic hypocaloric or to isocaloric enteral nutrition; all patients completed follow-up of at least 4 days. Prescribed caloric intake was: Hyperproteic hypocaloric enteral nutrition (15 kcal/kg with 1.7 g/kg of protein) or isocaloric enteral nutrition (25 kcal/kg with 20% of the calories as protein). The main outcome was the differences in delta SOFA at 48 h. Secondary outcomes were intensive care unit (ICU) length of stay, days on ventilator, hyperglycemic events, and insulin requirements. RESULTS: There were no differences in SOFA score at baseline (7.5 (standard deviation (SD) 2.9) vs 6.7 (SD 2.5) P = 0.17). The total amount of calories delivered was similarly low in both groups (12 kcal/kg in intervention group vs 14 kcal/kg in controls), but proteic delivery was significantly different (1.4 vs 0.76 g/kg, respectively P ≤ 0.0001). The intervention group showed an improvement in SOFA score at 48 h (delta SOFA 1.7 (SD 1.9) vs 0.7 (SD 2.8) P = 0.04) and less hyperglycemic episodes per day (1.0 (SD 1.3) vs 1.7 (SD 2.5) P = 0.017). DISCUSSION: Enteral hyperproteic hypocaloric nutrition therapy could be associated with a decrease in multiple organ failure measured with SOFA score. We also found decreased hyperglycemia and a trend towards less mechanical ventilation days and ICU length of stay.

Nutrición y metabolismo en cirugía. Conferencia Rafael Casas Morales 2009 / Nutrition and metabolism in surgery Rafael Casas Morales Lecture

La desnutrición tiene una prevalencia alta en los pacientes quirúrgicos y un impacto negativo en el pronóstico, y se asocia con mayores tasas de morbilidad y mortalidad; también con estancias hospitalarias más prolongadas y costos más altos para el sistema de salud.Este artículo describe el impacto de las deficiencias nutricionales en la enfermedad quirúrgica y en la respuesta metabólica al trauma, enfatizando en la relación que existe entre el estado nutricional y metabólico, y el desenlace del paciente quirúrgico. También, presenta el conocimiento científico actual sobre los resultados de la intervención nutricional especializada y su impacto sobre las complicaciones y la mortalidad. En la parte final, describe la fuerte asociación que existe entre estilos de vida y desarrollo, y recaída de cáncer, y cómo la consejería nutricional debería formar parte del arsenal terapéutico del cirujano. Concluye el escrito con una recomendación perentoria para incluir la educación nutricional en las escuelas de medicina y en los posgrados de cirugía general.

El ejercicio de la Cirugía en Colombia: una encuesta nacional y algunas reflexiones sobre sus resultados / The practice of surgery in Colombia: a national survey and some reflections on results

Introducción. El ejercicio de la cirugía general ha sido afectado por las nuevas regulaciones de la Ley 100 de Seguridad Social y la introducción de nuevas tecnologías y tendencias quirúrgicas. En busca de tener datos reales, la Asociación Colombiana de Cirugía diseñó y aplicó una encuesta nacional. Se presentan los datos más importantes.Materiales y métodos. La encuesta fue diseñada por un comité de la Asociación Colombiana de Cirugía. Una empresa encuestadora buscó contactar al mayor número de cirujanos generales durante 180 días. Se practicó un análisis estadístico de frecuencias en forma anónima.Resultados. Se encuestó el 48% (492) de los miembros de la Asociación Colombiana de Cirugía. Se incluyó una muestra de 108 cirujanos no miembros. El 44% manifestó tener una segunda especialidad, aunque ésta no siempre correspondió a programas aprobados. La gran mayoría basan su práctica en la cirugía general, que desempeñan en más de una institución en más de 70% de los casos. Las horas trabajadas a la semana superan las jornadas laborales legales. La vinculación laboral cubre apenas el 44% de la muestra. Los ingresos son relativamente bajos si se comparan con las horas trabajadas.Conclusión. Los cirujanos generales de Colombia están concentrados en las grandes ciudades, desempeñan su profesión principalmente en el área de la cirugía general y tienen jornadas laborales largas, combinando varias instituciones. Las nuevas modalidades de contratación por prestación de servicios son crecientes y amenazan la estabilidad laboral y la posibilidad de tener una pensión de jubilación.