La simulación como modelo de enseñanza en cirugía / Simulation as a surgical teaching model

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Formación en cirugía general en España: troncalidad y áreas de capacitación específica / General surgery training in Spain: Core curriculum and specific areas of training

Se ha publicado el R.D. 639/2014 que regula la troncalidad y las áreas de capacitación específica (A.C.E.) que constituyen una norma de gran interés en la especialidad de Cirugía General y del Aparato Digestivo (C.G. y del A.D.)Se pretende exponer y concretar las principales disposiciones y reflexionar sobre sus implicaciones en la especialidad de C.G. y del A.D., para promover iniciativas y regulaciones. Después de una gestación compleja, este R.D. supondrá un hito en nuestra especialidad, que pondrá a prueba su fortaleza, si no es que culmina finalmente con su degradación frente a la emergencia de nuevas especialidades quirúrgicas, como ya sucedió en el pasado. Se inicia una etapa en la que la Asociación Española de Cirujanos deberá implicarse, para definir las bases conceptuales de la C.G. y del A.D. en el siglo XXI, y la creación de las nuevas A.C.E., para seguir manteniendo la «esencia de nuestra especialidad»

The royal decree RD 639/2014 has been published, regulating among others, the core curriculum, and specific areas of training (SAT). It is of great interest for the specialty of General and Digestive Surgery (GS and DS).The aim is to expose and clarify the main provisions and reflect on their implications for the practical application of the core curriculum and SAT in the specialty of General and Digestive Surgery, to promote initiatives and regulations. This RD will be a milestone in our specialty that will test the strength of the specialty, if it does not finally culminate in its degradation against the emergence of new surgical specialties. A new stage begins in which the Spanish Association of Surgeons should be involved to define the conceptual basis of GS and DS in the XXI century, and the creation of new SAT to continue to maintain the «essence of our specialty»

General surgery training in Spain: core curriculum and specific areas of training.

The royal decree RD 639/2014 has been published, regulating among others, the core curriculum, and specific areas of training (SAT). It is of great interest for the specialty of General and Digestive Surgery (GS and DS). The aim is to expose and clarify the main provisions and reflect on their implications for the practical application of the core curriculum and SAT in the specialty of General and Digestive Surgery, to promote initiatives and regulations. This RD will be a milestone in our specialty that will test the strength of the specialty, if it does not finally culminate in its degradation against the emergence of new surgical specialties. A new stage begins in which the Spanish Association of Surgeons should be involved to define the conceptual basis of GS and DS in the XXI century, and the creation of new SAT to continue to maintain the "essence of our specialty".

Localización infrecuente del quiste hidatídico suprarrenal primario / Uncommon location of the primary adrenal hydatid cyst

El quiste hidatídico suprarrenal primario es una patología muy infrecuente por su localización y se encuentra en este órgano en menos del 0,5 por ciento de los casos, incluso en países con presencia endémica del Echinococcus. La mayoría de los quistes hidatídicos suprarrenales son asintomáticos, siendo el diagnóstico un hallazgo incidental. Las pruebas serológicas para el diagnóstico pueden ser negativas en muchos casos y el tratamiento es en su mayoría quirúrgico, con múltiples vías de abordaje. Es una patología poco común; el diagnóstico, manejo, tratamiento y vías de abordaje no se encuentran aún muy establecidos. Con este artículo tratamos de realizar un acercamiento más certero en cuanto a estos aspectos(AU)

The primary adrenal hydatid cyst is a very rare disease for its location and it is found in less than 0.5 percent of the cases, even in countries with endemic presence of Echinococcus. Most adrenal hydatid cysts are asymptomatic, and the diagnosis is an incidental finding, the serological tests for the diagnosis are negative in many cases and the treatment is mostly surgical, with multiple surgical approaches. It is a rare pathology whose diagnosis, management, treatment and surgical approaches are not yet well established. This article was intended to address these aspects in a more accurate way(AU)

La banda gástrica ajustable como tratamiento de la obesidad mórbida: ¿son reproducibles los resultados mundiales en España? Análisis de 132 pacientes intervenidos en los últimos 10 años / Adjustable gastric band as surgical treatment for morbid obesity. Are worldwide results reproducibles in Spain?

Introducción La banda gástrica ajustable es una técnica afianzada en el mundo en el tratamiento de la obesidad mórbida. En España, las cifras de pacientes intervenidos de banda gástrica distan mucho de las cifras mundiales, habiéndose alegado un alto número de reintervenciones. Material y métodos En el año 2001 iniciamos, un programa de tratamiento quirúrgico de la obesidad mediante la implantación de banda gástrica ajustable. Paralelamente, desarrollamos un sistema exhaustivo de seguimiento para evitar complicaciones y mejorar los resultados. Resultados Desde el año 2001 hasta el 2011 hemos intervenido un total de 132 pacientes, 102 mujeres y 30 hombres, con una edad media de 39 años y un índice de masa corporal medio de 43. El seguimiento fue superior a 5 años en 61 pacientes; en el resto, el seguimiento medio fue de 44, 4 meses. La mortalidad y complicaciones graves fue 0. Ocho pacientes requirieron cirugía de revisión (6,06%), 3 por complicaciones relacionadas con el reservorio, 4 por deslizamiento y una por erosión. Tres deslizamientos se convirtieron a otra técnica y otro se resolvió con colocación de una nueva banda de tipo Lap Band. El porcentaje de sobrepeso perdido medio se mantuvo en los pacientes con un seguimiento superior a los 5 años en 54, 8%.ConclusionesLos resultados de nuestra serie son superponibles a los publicados en la literatura mundial en nuestro medio y demuestran que, reproduciendo el seguimiento realizado, la banda gástrica es un método eficaz y seguro para el control del peso en los pacientes con obesidad mórbida también en España(AU)

Introduction Adjustable gastric banding is a surgical technique used all over the world for the treatment of morbid obesity. In Spain, the number of patients treated with adjustable gastric banding is far lower than the average worldwide average. A number of reasons have been put forward to explain this difference. Material and methods A program of bariatric surgery by means of implantation of an adjustable gastric banding was started in 2001, together with a dedicated follow-up protocol in order to prevent complications and improve results. Results A total of 132 patients were operated on between 2001 and 2011. The mean age of the 102 female and 30 male patients was 39 years, and the mean body mass index was 43. Follow-up was longer than 5 years in 61 patients, while the mean follow-up in the rest was 44.4 months. There was no mortality or severe morbidity. Eight patients (6.06%) underwent reoperation, 3 of them for complications related to the reservoir, 4 for slipping of the band, and one for erosion. One slipped band was removed, and a new one (of the Lap Band type) was inserted. Three slipping bands were converted to other techniques. The percentage excessive body weight loss was maintained in 54.8% of the patients followed-up for longer than 5 years. Conclusions The results of our series are comparable to those reported in the literature and show that, provided that a close follow-up, like that performed by most groups, is implemented, adjustable gastric banding can also be a safe and effective bariatric surgery technique in our country (AU)

[Adjustable gastric band as surgical treatment for morbid obesity. Are worldwide results reproducibles in Spain?]. / La banda gástrica ajustable como tratamiento de la obesidad mórbida: ¿son reproducibles los resultados mundiales en España? Análisis de 132 pacientes intervenidos en los últimos 10 años.

INTRODUCTION: Adjustable gastric banding is a surgical technique used all over the world for the treatment of morbid obesity. In Spain, the number of patients treated with adjustable gastric banding is far lower than the average worldwide average. A number of reasons have been put forward to explain this difference. MATERIAL AND METHODS: A program of bariatric surgery by means of implantation of an adjustable gastric banding was started in 2001, together with a dedicated follow-up protocol in order to prevent complications and improve results. RESULTS: A total of 132 patients were operated on between 2001 and 2011. The mean age of the 102 female and 30 male patients was 39 years, and the mean body mass index was 43. Follow-up was longer than 5 years in 61 patients, while the mean follow-up in the rest was 44.4 months. There was no mortality or severe morbidity. Eight patients (6.06%) underwent reoperation, 3 of them for complications related to the reservoir, 4 for slipping of the band, and one for erosion. One slipped band was removed, and a new one (of the Lap Band type) was inserted. Three slipping bands were converted to other techniques. The percentage excessive body weight loss was maintained in 54.8% of the patients followed-up for longer than 5 years. CONCLUSIONS: The results of our series are comparable to those reported in the literature and show that, provided that a close follow-up, like that performed by most groups, is implemented, adjustable gastric banding can also be a safe and effective bariatric surgery technique in our country.

Utilización de adhesivos biológicos a base de fibrina en la prevención de fugas anastomóticas en anastomosis del tubo digestivo de alto riesgo: resultados preliminares del ensayo clínico fase iv multicéntrico, prospectivo, aleatorizado y controlado simple ciego: Protissucol001 / Use of fibrin based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract: preliminary results of the multicentre, prospective, randomised, controlled, and simple blind phase IV clinical trial: Protissucol001

Introducción: Con el objetivo de demostrar la eficacia de los adhesivos biológicos a base de fibrina en la prevención de fugas anastomóticas, en enero de 2007 iniciamos un estudio multicéntrico, prospectivo, aleatorizado, controlado, simple ciego, sobre la prevención de fugas anastomóticas en anastomosis del tubo digestivo de alto riesgo mediante la utilización de adhesivos biológicos a base de fibrina. Material y métodos En enero de 2007 iniciamos un ensayo clínico multicéntrico en el que participan los hospitales Gregorio Marañón, Universitario de San Carlos y Hospital del Sureste, de Madrid sobre la prevención de defectos de cicatrización anastomótica mediante la aplicación de adhesivos biológicos a base de fibrina en la linea de sutura. Los pacientes reclutados se aleatorizan asignando al paciente en función de esta aleatorización a uno de los 2 grupos: grupo de estudio en el que se aplica adhesivo en la línea de sutura y grupo control en el que no se aplica. La variable principal del estudio es la presencia o ausencia de fugas. El ensayo ha sido aprobado por los correspondientes Comités de Ética e Investigación Clínica, por la Agencia Española del Medicamento y registrado en www.clinicaltrials.gov (NCT01306851). Ninguno de los autores manifiesta tener conflicto de interés con la empresa Baxter, que comercializa el producto en España. Resultados Desde enero de 2007 hasta noviembre de 2010, se ha reclutado a 104 pacientes que han sido asignados tras aleatorización, 52 al grupo de estudio y 52 al grupo control. Se han registrado 22 fugas anastomóticas de las cuales 7 en el grupo de estudio (13, 4%) y 15 en el grupo control (28, 8%) con un valor de la P de 0,046. El índice de riesgo de fugas fue de 0,384, es decir, se produce una reducción del 61% en las fugas de los pacientes a los que se aplica adhesivo biológico a (..) (AU)

Introduction: A multicentre, prospective, randomised, controlled, and simple blind clinicaltrial was started in January 2007, with the aim of demonstrating the eficacy of fibrin-based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract. Material and methods: A study on the prevention of anastomotic healing defects by applying biological adhesives along the suture line began in January 2007, and included the hospitals, Gregorio Marañón, Universitario de San Carlos, and Hospital del Sureste, in Madrid. The enrolled patients were randomised to one of 2 groups: the study group in which the adhesive was applied to the suture line, and a control group in which it was not applied. The primary outcome of the study was the presence or absence of leaks. The trial was approved by the corresponding Clinical Research Ethics Committees and the Spanish Medicines Agency(AEMPS) and registered www.clinicaltrials.gov (NCT01306851). The authors declared not to have any (..) (AU)

[Use of fibrin based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract: preliminary results of the multicentre, prospective, randomised, controlled, and simple blind phase IV clinical trial: Protissucol001]. / Utilización de adhesivos biológicos a base de fibrina en la prevención de fugas anastomóticas en anastomosis del tubo digestivo de alto riesgo: resultados preliminares del ensayo clínico fase iv multicéntrico, prospectivo, aleatorizado y controlado simple ciego: Protissucol001.

INTRODUCTION: A multicentre, prospective, randomised, controlled, and simple blind clinical trial was started in January 2007, with the aim of demonstrating the efficacy of fibrin-based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract. MATERIAL AND METHODS: A study on the prevention of anastomotic healing defects by applying biological adhesives along the suture line began in January 2007, and included the hospitals, Gregorio Marañón, Universitario de San Carlos, and Hospital del Sureste, in Madrid. The enrolled patients were randomised to one of 2 groups: the study group in which the adhesive was applied to the suture line, and a control group in which it was not applied. The primary outcome of the study was the presence or absence of leaks. The trial was approved by the corresponding Clinical Research Ethics Committees and the Spanish Medicines Agency (AEMPS) and registered www.clinicaltrials.gov (NCT01306851). The authors declared not to have any conflict of interests with the company, Baxter, which markets the product in Spain. RESULTS: A total of 104 patients were recruited between January 2007 and November 2010, of whom 52 were randomised to the study group, and 52 to the control group. A total of 22 anastomotic leaks were recorded, of which 7 (13.4%) were in the study group, and 15 (28.8%) in the control group (P=.046). The leak risk index was 0.384, which means that there was a 61% reduction in leaks in the patients who had the fibrin-based biological adhesive applied. There were 3 (5.7%) further surgeries in the study group, compared to 12 (23%) in the control group (P=.12). On analysing the mortality, it was observed that 3 patients in the study group and 4 patients in the control group died (5.7% vs. 7.7%, P=.5). No other significant differences were found as regards the type of suture, surgical time, or pre-surgical history, except that the use of drainages appeared to be a protective factor of anastomotic leak (P=.041), although the use or not of a drainage was not a controlled factor, but at the discretion of each surgeon. CONCLUSIONS: Our study demonstrates, significantly, that in the 104 patients in the study that fibrin based biological adhesives are capable of preventing anastomotic leaks in the high risk digestive tract, reducing the risk of leaks by 61% and a further surgeries. This is the first clinical trial that shows these significant results. If our results are maintained at the end of the study, it will show that anastomotic leaks can be prevented with the application of these adhesives, thus their application may be recommended in all the anastomosis of the high risk digestive tract.

Formación quirúrgica en España: resultados de una encuesta nacional / Surgical training in Spain: Results of a national survey

Introducción: El objetivo del estudio intenta realizar una aproximación al estado de la formación quirúrgica en España y analizar su adecuación a los objetivos del programa. Material y métodos: Se presentan y se analizan los resultados de dos encuestas realizadas por la Asociación Española de Cirujanos a los residentes y a los tutores de Cirugía General basadas en las conclusiones del XXVII Congreso Nacional de Cirugía. Las cuestiones formuladas hacían referencia a aspectos generales del servicio y particulares en relación con el acceso, la actividad docente, la actividad quirúrgica, la actividad investigadora y las perspectivas personales. Las respuestas fueron definidas, adaptadas y categorizadas como variables cuantitativas y cualitativas. Se utilizó un programa estadístico G Stat 2.0 para el procesamiento y la presentación descriptiva de los resultados. Resultados: El número de residentes y tutores a quienes se enviaron las encuestas fue de 626 y 142. Fueron respondidas el 19% de las encuestas de residentes y el 29% de las encuestas de tutores. Según el año de residencia, predominaron las de residentes de primer año (32%) frente a los de años ulteriores, siendo el índice de respuesta de los R5 del 7,2%. El 91% conocía bien el programa de la especialidad y el 76% estaba satisfecho con la formación recibida. Conclusiones: Los resultados obtenidos en cuanto a actividad quirúrgica concuerdan con los previstos en el programa tanto en el número de procedimientos como en su progresión a lo largo de la residencia, aunque no es posible asegurar su uniformidad. Las funciones y la acreditación de los tutores que constituyen uno de los pilares fundamentales del proceso formativo están pendientes de regulación específica (AU)

Introduction: The aim of the study is to try and find out the state of surgical training in Spain and to determine whether it meets the objectives of the Program. Material and methods: The results of two surveys carried out on Residents and General Surgery Tutors by the Spanish Surgeons Association, based on the conclusions of the XXVII Congreso Nacional de Cirugía. The questions formulated referred to general aspects of the Service and specific ones related to access, teaching activity, surgery, research and personal perspectives. The responses were defined, adjusted and categorised as quantitative and qualitative variables. The statistics program G Stat 2.0 was used for processing and the descriptive presentation of the results. Results: The surveys were sent to 626 Residents and 142 Tutors, with a response rate of 19% and 29%, respectively. First year residents predominated (32%) compared to later years, with an R-5 response index of 7.2%. A total of 91% knew the speciality Program well, and 76% were satisfied with the training received. Conclusions: The results obtained as regards surgical activity agree with those established in the Program, both in the number of procedures and in their progression throughout the Residency, although it is not possible to ensure its uniformity. The functions and accreditation of the Tutors which are one of the main foundations of the training process are pending specific regulations (AU)

[Surgical training in Spain: results of a national survey]. / Formación quirúrgica en España: resultados de una encuesta nacional.

INTRODUCTION: The aim of the study is to try and find out the state of surgical training in Spain and to determine whether it meets the objectives of the Program. MATERIAL AND METHODS: The results of two surveys carried out on Residents and General Surgery Tutors by the Spanish Surgeons Association, based on the conclusions of the XXVII Congreso Nacional de Cirugía. The questions formulated referred to general aspects of the Service and specific ones related to access, teaching activity, surgery, research and personal perspectives. The responses were defined, adjusted and categorised as quantitative and qualitative variables. The statistics program G Stat 2.0 was used for processing and the descriptive presentation of the results. RESULTS: The surveys were sent to 626 Residents and 142 Tutors, with a response rate of 19% and 29%, respectively. First year residents predominated (32%) compared to later years, with an R-5 response index of 7.2%. A total of 91% knew the speciality Program well, and 76% were satisfied with the training received. CONCLUSIONS: The results obtained as regards surgical activity agree with those established in the Program, both in the number of procedures and in their progression throughout the Residency, although it is not possible to ensure its uniformity. The functions and accreditation of the Tutors which are one of the main foundations of the training process are pending specific regulations.

Lesiones gastrointestinales y mesentéricas en el paciente politraumatizado: incidencia, demora diagnóstica y pronóstico / Gastrointestinal and mesenteric injuries in the trauma patient: incidence, diagnosis delay and prognosis

Introducción Las lesiones gastrointestinales y mesentéricas (LGIM) son poco frecuentes en el traumatizado, y su diagnóstico es, en ocasiones, tardío. Nuestros objetivos han sido determinar la fiabilidad diagnóstica inicial de la tomografía computarizada (TC) en nuestro centro, así como la posible repercusión clínica de la demora diagnóstica en estas lesiones. Material y método Estudio retrospectivo de los pacientes con LGIM recogidos en nuestro Registro de Trauma Grave entre 1993 y 2006.ResultadosDe los 1.495 traumatizados registrados, 632 tenían traumatismo abdominal y 105 (16,6%) presentaron LGIM, en un 46% secundarias a un traumatismo cerrado. El ISS y el NISS medios fueron 20 y 25, respectivamente. La mortalidad fue de 9 (8,5%) pacientes, 4 contra pronóstico. En 56 (53%) casos se realizó una TC, y se observaron signos de LGIM en sólo 37. En otros 43 (41%) pacientes se indicó una laparotomía urgente por inestabilidad o signos clínicos de lesión intraabdominal. En 21 (20%) casos la cirugía se demoró más de 8h, y la causa más frecuente fue un falso negativo en la TC. Conclusiones La incidencia total de LGIM ha sido alta en nuestro medio (el 31% en traumatismo abdominal penetrante y el 10,7% en cerrado). Diversos factores como la ausencia inicial de clínica, la baja sensibilidad diagnóstica de la TC (un 34% de falsos negativos) y el manejo conservador de las lesiones de órgano sólido han llevado a diagnóstico y tratamiento tardíos en 1 de cada 5 pacientes de nuestra serie, sin que ello haya implicado un aumento significativo de la morbilidad infecciosa (AU)

Background Gastrointestinal and mesenteric injuries (GIMI) are uncommon in trauma patients, and their diagnosis are often delayed. Our aims were to determine the reliability of CT scan in our centre, and to assess the clinical significance of a delayed diagnosis. Materials and method Retrospective analysis of cases confirmed at laparotomy. Patients were identified at the Severe Trauma Registry of Gregorio Marañón University General Hospital, between 1993 and 2006.ResultsWe found 105 (16.6%) GIMI out of 632 patients with abdominal trauma, in a Registry with 1495 severe trauma cases included. A total of 46% had blunt injuries. The mean injury severity score (ISS) and new ISS (NISS) were 20 and 25, respectively. There were 9 (8.5%) deaths, 4 of which were unexpected. A CT scan was performed in 56 (53%) cases, and only in 37 there were signs suggestive of a GIMI. In another 43 (41%) patients an urgent laparotomy was indicated because of positive clinical findings or instability. Surgery was delayed for more than 8 hours in 21 (20%) patients, the most common reason being a false negative result in the CT scan. Conclusions The overall incidence of GIMI was high in our centre (31% due to penetration and 10.7% blunt trauma). Several factors, such as the initial lack of symptoms, a low diagnostic sensitivity of the CT scan (34% false negatives), and the non-surgical management of solid organ injuries, have contributed to a delayed diagnosis and treatment in one out of each five patients in our series, but this has not led to a significant increase in septic complications in this group (AU)

[Gastrointestinal and mesenteric injuries in the trauma patient: incidence, diagnosis delay and prognosis]. / Lesiones gastrointestinales y mesentéricas en el paciente politraumatizado: incidencia, demora diagnóstica y pronóstico.

BACKGROUND: Gastrointestinal and mesenteric injuries (GIMI) are uncommon in trauma patients, and their diagnosis are often delayed. Our aims were to determine the reliability of CT scan in our centre, and to assess the clinical significance of a delayed diagnosis. MATERIALS AND METHOD: Retrospective analysis of cases confirmed at laparotomy. Patients were identified at the Severe Trauma Registry of Gregorio Marañón University General Hospital, between 1993 and 2006. RESULTS: We found 105 (16.6%) GIMI out of 632 patients with abdominal trauma, in a Registry with 1495 severe trauma cases included. A total of 46% had blunt injuries. The mean injury severity score (ISS) and new ISS (NISS) were 20 and 25, respectively. There were 9 (8.5%) deaths, 4 of which were unexpected. A CT scan was performed in 56 (53%) cases, and only in 37 there were signs suggestive of a GIMI. In another 43 (41%) patients an urgent laparotomy was indicated because of positive clinical findings or instability. Surgery was delayed for more than 8 hours in 21 (20%) patients, the most common reason being a false negative result in the CT scan. CONCLUSIONS: The overall incidence of GIMI was high in our centre (31% due to penetration and 10.7% blunt trauma). Several factors, such as the initial lack of symptoms, a low diagnostic sensitivity of the CT scan (34% false negatives), and the non-surgical management of solid organ injuries, have contributed to a delayed diagnosis and treatment in one out of each five patients in our series, but this has not led to a significant increase in septic complications in this group.

[Safety and efficiency of ambulatory treatment of acute diverticulitis]. / Eficiencia y seguridad del tratamiento ambulatorio de la diverticulitis aguda.

INTRODUCTION: The treatment of acute diverticulitis is currently being modified, showing a tendency to limit surgical treatment and favor conservative management. OBJECTIVE: To analyze the safety and efficiency of ambulatory treatment of acute diverticulitis in a selected group of patients. METHODS: We performed a prospective study of domiciliary oral antibiotic therapy for acute diverticulitis in a cohort of patients in the Emergency Surgery Section of our hospital. Seventy-four patients (44 men and 30 women) were included between 2000 and 2006. Patients with Hinchey stage 1 diverticulitis and those with Hinchey stage 2 diverticulitis and abscesses of less than 3cm, who were clinically and biochemically stable, were selected. The patients were treated with oral ciprofloxacin and metronidazole for 7-10 days. Follow-up was performed in the outpatients unit with clinical evaluation at 10 days and an imaging test at 1 month. RESULTS: The mean age of the patients was 55 years. The most frequent clinical presentation was spontaneous abdominal pain associated with leukocytosis. The mean duration of treatment was 8.8 days. Four patients (5.4%) required subsequent hospital admission for intravenous antibiotic administration and 70 (94.6%) completed treatment without complications. During follow-up, two cases of colonic adenocarcinoma and six cases of polyposis were diagnosed. Only 13 patients underwent elective surgery. CONCLUSIONS: In most of the patients studied, ambulatory conservative management was safe and effective in the treatment of uncomplicated acute diverticulitis. Moreover, this approach reduces length of hospital stay and lowers costs.

Eficiencia y seguridad del tratamiento ambulatorio de la diverticulitis aguda / Safety and efficiency of ambulatory treatment of acute diverticulitis

Introducción: el tratamiento de la diverticulitis aguda está siendo recientemente revisado y muestra una tendencia a limitar el tratamiento quirúrgico y potenciar el de tipo conservador.Objetivo: analizar la eficiencia y la seguridad del tratamiento ambulatorio de la diverticulitis aguda en un grupo seleccionado de pacientes.Métodos: estudio prospectivo sobre el tratamiento antibiótico oral domiciliario de la diverticulitis aguda en una cohorte de pacientes, realizado en la sección de cirugía de urgencias de nuestro centro.Pacientes y tratamiento: 74 pacientes (44 varones y 30 mujeres) fueron incluidos en el período 2000–2006; se seleccionaron los tipo I de Hinchey y los tipo II con absceso menor de 3cm, clínica y analíticamente estables, y se trataron con ciprofloxacino y metronidazol, por vía oral, durante 7–10 días. El seguimiento se realizó en consultas externas mediante control clínico a los 10 días y prueba de imagen al cabo de un mes.Resultados: la edad media era de 55 años. La presentación clínica más frecuente fue dolor abdominal espontáneo asociado a leucocitosis. La duración media del tratamiento fue de 8,8 días. Cuatro pacientes (5,4%) precisaron ingreso posterior para tratamiento antibiótico intravenoso y 70 (94,6%) completaron el tratamiento sin complicaciones. Durante el seguimiento diagnosticamos 2 casos de adenocarcinoma de colon y 6 de poliposis. Solamente 13 pacientes recibieron cirugía electiva.Conclusiones: el manejo conservador ambulatorio ha demostrado ser seguro y eficaz en el tratamiento de la diverticulitis aguda no complicada en la mayoría de los pacientes de nuestro estudio, consiguiendo además una reducción de la estancia hospitalaria y una minimización de los costes(AU)

Introduction: The treatment of acute diverticulitis is currently being modified, showing a tendency to limit surgical treatment and favor conservative management.Objective: To analyze the safety and efficiency of ambulatory treatment of acute diverticulitis in a selected group of patients.Methods: We performed a prospective study of domiciliary oral antibiotic therapy for acute diverticulitis in a cohort of patients in the Emergency Surgery Section of our hospital. Seventy-four patients (44 men and 30 women) were included between 2000 and 2006. Patients with Hinchey stage 1 diverticulitis and those with Hinchey stage 2 diverticulitis and abscesses of less than 3cm, who were clinically and biochemically stable, were selected. The patients were treated with oral ciprofloxacin and metronidazole for 7–10 days. Follow-up was performed in the outpatients unit with clinical evaluation at 10 days and an imaging test at 1 month.Results: The mean age of the patients was 55 years. The most frequent clinical presentation was spontaneous abdominal pain associated with leukocytosis. The mean duration of treatment was 8.8 days. Four patients (5.4%) required subsequent hospital admission for intravenous antibiotic administration and 70 (94.6%) completed treatment without complications. During follow-up, two cases of colonic adenocarcinoma and six cases of polyposis were diagnosed. Only 13 patients underwent elective surgery.Conclusions: In most of the patients studied, ambulatory conservative management was safe and effective in the treatment of uncomplicated acute diverticulitis. Moreover, this approach reduces length of hospital stay and lowers costs(AU)

Overall Asessment of the Response to Terrorist Bombings in Trains, Madrid, 11 March 2004.

OBJECTIVES: To provide an overall assessment of the response to the terrorist bombings in Madrid, 11 March 2004, which were considered the deadliest terrorist attack on European soil in modern times. MATERIALS AND METHODS: Overall data on the number of victims treated at the scenes and at primary care facilities and hospitals, as well as the logistics involved, were reported by the EMS and the Health Authority of the Comunidad de Madrid local government. Data were mainly obtained by retrospective chart review, and did not include casualties who had only emotional shock, superficial bruises or transient hearing loss from barotraumas without eardrum perforation. We defined as critical any casualty with an Injury Severity Score (ISS) >15. RESULTS: Over 70,000 personnel were mobilized in the care of the victims. EMS response and total evacuation times at the four blast scenes averaged 7 and 99 min, respectively. There were around 2,000 casualties, and a typical bimodal distribution of deaths, with 177 immediate fatalities and 14 subsequent in-hospital deaths. Almost 60% of casualties were taken to the two closest hospitals. Problems related to security, identification of casualties and record-keeping were encountered at the closest hospital. Closed doors increased the immediate fatality rate in the trains. Most survivors had noncritical injuries, but 14% of the 512 casualties assessed had an ISS >15. The critical mortality rate was 19.5%. The most frequently injured body regions were the head/neck and face. In all, 124 major surgical interventions were performed on 82 victims in the first 24 h, and orthopedic trauma procedures accounted for 50% of the case load. Most patients with lung injuries from the blasts required intubation and mechanical ventilation, and their survival rate was 88.3%. Also, 35% of laparotomies were either negative or nontherapeutic. CONCLUSION: There was a rapid EMS response and evacuation, but also overtriage, uneven distribution of casualties and difficulties in communication. The sizes and resources of the closest hospitals, as well as the early hour, were probably decisive in the adequacy of the overall response.

[Severe pelvic fractures, associated injuries and hemodynamic instability: incidence, management and outcome in our center]. / Fracturas de pelvis graves, lesiones asociadas e inestabilidad hemodinámica: incidencia, manejo y pronóstico en nuestro medio.

INTRODUCTION: The aim of this study was to review the incidence, treatment and outcome of severe pelvic fractures, as well as associated injuries, in our center. PATIENTS AND METHOD: We performed a retrospective study of patients included in our trauma registry between June 1993 and January 2005. Pelvic fractures were classified according to the system proposed by Tile. Clinical and demographic data such as age, gender, mechanism of injury, transfer time, hemodynamic status, and trauma scores were compared and analyzed statistically. Shock was defined as a systolic blood pressure of < or = 90 mmHg during the primary assessment. Mortality and associated risk factors were analyzed, with emphasis on patients in shock on admission. RESULTS: Of 1274 patients with severe trauma admitted during the study period, 192 (15%) had pelvic fracture. Only 6.7% were isolated fractures and 6% were open fractures. Twenty percent of the patients were in shock on admission. The mean Injury Severity Score of the series was 28.5 +/- 14 and that of patients in shock was 38 +/- 16. The most frequently associated injuries were thoracic (70%), abdominal (55%), long bone fractures (52%), and head injuries (40%). Twenty-three percent of the patients had retroperitoneal hematoma. Arteriograms were performed in 16 patients, with four embolizations. Eight patients underwent external orthopedic fixation, and none posterior orthopedic fixation. Five patients underwent pelvic packing and two patients underwent ligation of hypogastric arteries. Overall mortality was 30% and mortality in patients in shock was 61%. Predictors of mortality were shock on admission, a Glasgow Coma Scale score of < or = 8, ISS > 25 and age > 55 years. CONCLUSIONS: Patients in shock with pelvic fractures have a poor prognosis in our center, frequently related to the severity of associated injuries, the relative rarity of these fractures, and the lack of a clearly defined management protocol. The main cause of death was massive hemorrhage.

Fracturas de pelvis graves, lesiones asociadas e inestabilidad hemodinámica: incidencia, manejo y pronóstico en nuestro medio / Severe pelvic fractures, associated injuries and hemodynamic instability: incidence, management and outcome in our center

Introducción. El objetivo de esta revisión ha sido conocer la incidencia, lesiones asociadas, tratamiento y resultados obtenidos en el manejo de los pacientes con fracturas graves de pelvis en nuestro centro. Pacientes y método. Estudio retrospectivo de los pacientes incluidos en nuestro registro de traumatizados graves entre junio de 1993 y enero de 2005. La clasificación de las fracturas pelvianas se ha realizado con los criterios de Tile. Se comparan y analizan estadísticamente aspectos demográficos y clínicos, incluidos la edad, el sexo, el mecanismo lesivo, tiempo de traslado, la situación hemodinámica al ingreso y las escalas de gravedad. Se ha definido el estado de shock como una presión arterial sistólica ≤ 90 mmHg durante la revisión primaria. Se analizan la mortalidad y los factores de riesgo asociados, con especial énfasis en el grupo de pacientes en shock. Resultados. De los 1.274 politraumatizados graves atendidos en el período de estudio, 192 (15%) presentaban fractura pelviana. Muy pocas fracturas se han presentado como lesiones aisladas (6,7%), y el porcentaje de fracturas abiertas ha sido del 6%. El 20% de los pacientes presentaba shock al ingreso. El Injury Severity Score (ISS) medio de la serie fue de 28,5 ± 14, y el de los pacientes en shock fue de 38 ± 16. Las lesiones asociadas más frecuentes fueron las torácicas (70%), seguidas por las abdominales (55%), fracturas de huesos largos (52%) y craneoencefálicas (40%). El 23% de los pacientes presentaba hematoma retroperitoneal. Se realizaron 16 arteriografías y 4 embolizaciones pelvianas. Se colocaron 8 fijadores externos anteriores y ninguno posterior. Se realizaron 5 taponamientos pelvianos y 2 ligaduras de arterias hipogástricas. La mortalidad general fue del 30%, y del 61% en los pacientes en shock al ingreso. El shock a la llegada, una escala de coma de Glasgow ≤ 8, un ISS > 25 y la edad > 55 años se correlacionaron con la mortalidad. Conclusiones. El pronóstico de los pacientes en shock y con fracturas de pelvis graves en nuestro medio es sombrío y, con frecuencia, está condicionado por la gravedad de las lesiones asociadas, la relativa escasa incidencia de estas fracturas y la heterogeneidad de criterios de manejo de los equipos de guardia. La hemorragia masiva incontrolada ha sido la causa principal de muerte (AU)

Introduction. The aim of this study was to review the incidence, treatment and outcome of severe pelvic fractures, as well as associated injuries, in our center. Patients and method. We performed a retrospective study of patients included in our trauma registry between June 1993 and January 2005. Pelvic fractures were classified according to the system proposed by Tile. Clinical and demographic data such as age, gender, mechanism of injury, transfer time, hemodynamic status, and trauma scores were compared and analyzed statistically. Shock was defined as a systolic blood pressure of ≤ 90 mmHg during the primary assessment. Mortality and associated risk factors were analyzed, with emphasis on patients in shock on admission. Results. Of 1274 patients with severe trauma admitted during the study period, 192 (15%) had pelvic fracture. Only 6.7% were isolated fractures and 6% were open fractures. Twenty percent of the patients were in shock on admission. The mean Injury Severity Score of the series was 28.5 ± 14 and that of patients in shock was 38 ± 16. The most frequently associated injuries were thoracic (70%), abdominal (55%), long bone fractures (52%), and head injuries (40%). Twenty-three percent of the patients had retroperitoneal hematoma. Arteriograms were performed in 16 patients, with four embolizations. Eight patients underwent external orthopedic fixation, and none posterior orthopedic fixation. Five patients underwent pelvic packing and two patients underwent ligation of hypogastric arteries. Overall mortality was 30% and mortality in patients in shock was 61%. Predictors of mortality were shock on admission, a Glasgow Coma Scale score of ≤ 8, ISS > 25 and age > 55 years. Conclusions. Patients in shock with pelvic fractures have a poor prognosis in our center, frequently related to the severity of associated injuries, the relative rarity of these fractures, and the lack of a clearly defined management protocol. The main cause of death was massive hemorrhage (AU)

[Use of the round ligament in the repair of large bile duct defects in type II Mirizzi's syndrome]. / Utilización del ligamento redondo en la reparación de defectos amplios de la vía biliar en el síndrome de Mirizzi de tipo II.

Mirizzi's syndrome is a rare complication of cholelithiasis, and type II (cholecystocholedochal fistula) can be a technical challenge due to inflammation and the biliary duct defect. We report two cases that were treated with a simple and little known technique that uses the round ligament as a plasty to seal the large bile duct defect.

Utilización del ligamento redondo en la reparación de defectos amplios de la vía biliar en el síndrome de Mirizzi de tipo II / Use of the round ligament in the repair of large bile duct defects in type II Mirizzi’s syndrome

El síndrome de Mirizzi es una rara complicación de la litiasis biliar, y el de tipo II (fístula colecistocoledociana) puede plantear un problema técnico complejo en razón de la gran inflamación encontrada y el defecto en la vía biliar. Describimos 2 casos tratados con una técnica sencilla y poco conocida que utiliza una plastia con el ligamento redondo para sellar el gran defecto encontrado en la vía biliar (AU)

Mirizzi's syndrome is a rare complication of cholelithiasis, and type II (cholecystocholedochal fistula) can be a technical challenge due to inflammation and the biliary duct defect. We report two cases that were treated with a simple and little known technique that uses the round ligament as a plasty to seal the large bile duct defect (AU)