Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico.

BACKGROUND: Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources. METHODS: A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question. RESULTS: From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made. CONCLUSIONS: This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.

Correlation between the Bethesda system for thyroid nodules and post-thyroidectomy histopathological diagnosis / Correlación entre el sistema Bethesda de nódulos tiroideos y el diagnóstico histopatológico postiroidectomía

BACKGROUND: Thyroid nodules are a common clinical condition. Thyroid nodules may be identified with ultrasonography in roughly 50% of the population. The risk of malignancy varies between 4 and 15% of the nodules. Fine needle aspiration (FNA) with a cytopathology report using the Bethesda system is the most utilized methods to diagnose thyroid carcinoma. MATERIAL AND MEHOTDS: A retrospective, descriptive study was performed to investigate the correlation between the cytopathology of the FNA biopsies, and the final histopathology after thyroidectomy. RESULTS: A total of 128 nodules in 128 patients were studied; 24 males and 104 females. In the Bethesda category I, a 67% malignancy rate was reported, Bethesda II 14%, Bethesda III 28% for follicular lesions and 15% for atypia, Bethesda IV 36%, Bethesda V 79% and Bethesda VI 100%. CONCLUSION: The Bethesda system has been widely adopted internationally and has become an unassailable tool for the pathologist and clinicians for the evaluation and management of thyroid nodules. Since its implementation in the ABC Medical Center, the Bethesda system has granted the institution with favorable and reproducible results.

INTRODUCCIÓN: En la población general, los nódulos tiroideos representan una causa común de consulta al especialista; en poblaciones aleatorizadas, con el uso del ultrasonido se pueden observar hasta en un 50% de los pacientes. El nódulo tiroideo tiene un riesgo de malignidad del 4-15%. El método citopatológico más utilizado para el diagnóstico del cáncer tiroideo es la toma de biopsia por aspiración con aguja fina (BAAF) de los nódulos tiroideos y la utilización del sistema Bethesda para su reporte citopatológico. MATERIAL Y MÉTODOS: Se realizó un estudio descriptivo comparando los porcentajes de malignidad entre las piezas quirúrgicas y el reporte citopatológico de las BAAF utilizando el sistema Bethesda 2010. RESULTADOS: Se estudiaron 128 nódulos en 128 pacientes. En los nódulos Bethesda I se reportó un 67% de malignidad en la histopatología final; en los Bethesda II, un 14%,; en los Bethesda III, un 28% para atipia y un 15% para lesiones foliculares; en los Bethesda IV, un 36%; en los Bethesda V, un 79%; y en los Bethesda VI, un 100%. CONCLUSIÓN: El sistema Bethesda es una herramienta disponible y de gran utilidad para el patólogo y el clínico. Desde su implementación en el Centro Médico ABC ha demostrado ser comparable con los resultados reportados en la literatura internacional.

[Evolution of type 2 diabetes and carbohydrate intolerance following bariatric surgery in a Mexican mestizo population]. / Evolución de los pacientes con diabetes mellitus tipo 2 e intolerancia a los carbohidratos posterior a cirugía bariátrica en la población mexicana.

BACKGROUND: Bariatric surgery continues to be the best treatment for weight loss and control of obesity related comorbidities. Gastric bypass and sleeve gastrectomy have demonstrated to be the most effective surgeries, but this has not been established in a Mexican (non-American) population. OBJECTIVE: To analyse the improvement in type 2 diabetes mellitus and carbohydrate intolerance in obese patients after bariatric surgery. MATERIAL AND METHODS: A retrospective analysis was performed on the data collected prospectively between 2013 and 2015 on every obese patient with diabetes and carbohydrate intolerance submitted for bariatric surgery. Analysis was performed at baseline, and at 1, 3, 6, 9 and 12 months, and included metabolic, clinical, lipid, and anthropometrical parameters. A peri-operative and morbidity and mortality analysis was also performed. Remission rates for patients with diabetes were also established. RESULTS: The analysis included 73 patients, 46 with diabetes and 27 with carbohydrate intolerance. Sixty-two patients were female with a mean age of 42 years. Baseline glucose and glycosylated haemoglobin were 123±34mg/dl and 6.8±1.6%, and at 12 months they were 90.1±8mg/dl and 5.4±0.3%, respectively. Diabetes remission was observed in 68.7% of patients, including 9.3% with partial remission and 21.8% with an improvement. There was also a significant improvement in all metabolic and non-metabolic parameters. CONCLUSIONS: Bariatric surgery safely improves the metabolic status of patients with diabetes mellitus or carbohydrate intolerance during the first year, inducing high rates of complete remission. It has also shown a significant improvement on blood pressure, lipid, and anthropometric parameters during the first year of follow-up.

Neuroblastoma in the adult. Case report.

BACKGROUND: Neuroblastoma is a common malignancy in infancy but extremely rare in adults. These tumors, commonly found in the abdomen, originate in the sympathetic nervous system. Staging and management are standardized in children and adults, although their prognosis is very different, being more aggressive and with a poorer outcome in the adult. CLINICAL CASE: We present the case of a 31-year-old male with non-specific abdominal pain and constipation. After several studies, a stage III giant retroperitoneal neuroblastoma was diagnosed. We discuss here the evaluation, management and follow-up of the patient. A literature review is presented as well. CONCLUSIONS: Adult neuroblastoma is an unusual disease with an insidious presentation and is usually diagnosed in advanced stages. Unlike its behavior in young patients, in the adult it is more aggressive and with a poor prognosis.

Neuroblastoma en el adulto: informe de un caso / Neuroblastoma in the adult: case report

Introducción: El neuroblastoma es una neoplasia común en la infancia, pero extremadamente rara en el adulto. Se origina del sistema nervioso simpático y su localización más común es abdominal. Su estadificación y tratamiento se han estandarizado en niños y adultos, aunque el pronóstico es muy distinto debido a un comportamiento más agresivo y menor sobrevida en los segundos. Caso clínico: Hombre de 31 años de edad evaluado por dolor abdominal inespecífico y constipación, a quien se le diagnosticó gran neuroblastoma retroperitoneal estadio III. Al no tolerar quimioterapia se realizó cirugía. Se presenta la evaluación, manejo y seguimiento, así como una revisión de la literatura. Conclusiones: El neuroblastoma en el adulto es una enfermedad poco común que cursa con una evolución inicial insidiosa y la presentación suele ser en estadios avanzados. A diferencia del comportamiento en la infancia, en el adulto es más agresivo y con menor sobrevida a pesar de realizar el mismo tratamiento.

BACKGROUND: Neuroblastoma is a common malignancy in infancy but extremely rare in adults. These tumors, commonly found in the abdomen, originate in the sympathetic nervous system. Staging and management are standardized in children and adults, although their prognosis is very different, being more aggressive and with a poorer outcome in the adult. CLINICAL CASE: We present the case of a 31-year-old male with non-specific abdominal pain and constipation. After several studies, a stage III giant retroperitoneal neuroblastoma was diagnosed. We discuss here the evaluation, management and follow-up of the patient. A literature review is presented as well. CONCLUSIONS: Adult neuroblastoma is an unusual disease with an insidious presentation and is usually diagnosed in advanced stages. Unlike its behavior in young patients, in the adult it is more aggressive and with a poor prognosis.