[Consensus of the ambulatory surgery commite section of the Spanish Association of Surgeons on the role of ambulatory surgery in the SARS-CoV-2 pandemic]. / Consenso de la sección de cirugía mayor ambulatoria de la Asociación Española de Cirujanos sobre el papel de la cirugía mayor ambulatoria en la pandemia SARS-CoV-2.

The current situation of the SARS-CoV-2 pandemic has paralyzed non-urgent and/or oncological surgery in many hospitals in our country with what it means for the health of citizens who are awaiting a surgical procedure. Outpatient Surgery can afford more than 85% of the surgical procedures that are performed in a surgical department and is presented as a feasible and safe alternative at the present time since it does not require admission and decreases clearly the risk of infection. In addition, it is the tool that should be generalized to solve the accumulation of patients on the waiting list that the pandemic is generating, so it seems appropriate that the Ambulatory Surgery section of the Spanish Association of Surgeons present a series of recommendations for the implementation of outpatient surgery in these exceptional circumstances that we have to live.

Contribution of the virtual colonoscopy in a case of intestinal intussusception.

The present paper describes a case of ileocecal intussusception detected by ultrasound and confirmed by CT, including the imaging characteristics allowing its diagnosis. The patient was referred for colonoscopy, which could not be completed, to assess the cause of intussusception. Then it was decided to resort to Virtual colonoscopy, which allowed to identify and characterize a cecal neoplasm serving as a lead point for the intussusception.

Bowel ischaemia and cocaine consumption; case study and review of the literature.

BACKGROUND: Amongst others, cocaine consumption has a detrimental effect in the vascular supply to the mesenteric area causing abdominal ischemic changes. Early recognition of these changes and adequate treatment are essential to avoid serious complications and possible death of the patient from sepsis. CASE REPORT: In this case study, the subject is a 40-years-old gentleman presenting with acute abdominal pain due to multiple ischemic changes in both small bowel and sigmoid loops. The patient required emergency surgical intervention consisting of bowel resection and anastomosis. The pathologic analysis of the segment showed transmural necrosis and necrotizing phlebitis caused by the ingestion of drugs or toxic agents. The patient later confirmed the habitual consumption of cocaine. DISCUSSION: The increase in cocaine consumption and other recreational toxins substructed from erythroyilon coca alkaloids amongst young people have generated a large number of admissions to Hospital Accident and Emergency Departments with patients complaining of acute abdominal pain. In many of these cases, surgical intervention is required and in some cases patients will sadly die without a proper diagnosis. Some of the most common effects of cocaine and its compounds includes; hollow viscus perforation, gastro-intestinal bleed, and other vascular problems such as enteritis and ischemic colitis. It appears clear that there is a great need for an advance history taking of these patients and their habit to cocaine and other drugs together with a urine test for drug screening. These together with a suspicion of a non- occlusive ischemic bowel caused by the effects of cocaine in young adults with no cardiac risk factors will guide clinicians and establish, and plan the correct treatment for these categories of patients.

Training in ambulatory surgery. A pending subject in our country.

The implementation and generalized use of Ambulatory Surgery worldwide is currently a clear reality. Its progressive growth is expected in the short term, but this globalization can also negatively affect the education and training of future doctors, as well as those who are being trained now, if it is not standardized and regulated, since a significant part of the management of the most common pathology that could be performed in Ambulatory Surgery is completed outside the training circuits of hospitals where resident doctors are trained.

Consensus of the ambulatory surgery commite section of the Spanish Association of Surgeons on the role of ambulatory surgery in the SARS-CoV-2 pandemic.

The current situation of the SARS-CoV-2 pandemic has paralyzed non-urgent and/or oncological surgery in many hospitals in our country with what it means for the health of citizens who are awaiting a surgical procedure. Outpatient Surgery can afford more than 85% of the surgical procedures that are performed in a surgical department and is presented as a feasible and safe alternative at the present time since it does not require admission and decreases clearly the risk of infection. In addition, it is the tool that should be generalized to solve the accumulation of patients on the waiting list that the pandemic is generating, so it seems appropriate that the Ambulatory Surgery section of the Spanish Association of Surgeons present a series of recommendations for the implementation of outpatient surgery in these exceptional circumstances that we have to live.

The influence of immunosuppression switching in liver function in adult hepatic transplantation.

We evaluate the 5-year results of a single-centre prospective randomized trial that compared cyclosporine microemulsion (CyA-me) in triple therapy (plus steroids and azathioprine) and Tacrolimus (Tac) in double therapy (plus steroids) for primary immunosuppression. One hundred adult patients undergoing liver transplantation were randomized to receive Tac (n=51) or CyA-me (n=49). Ten patients in group A, and thirty-one patients in group B had their main immunosuppressive agent switched. The switch was much more frequent from CyA-me to Tac (n=31; 62.3%), mainly because of lack of efficacy (n=12; 38.7%). Six of 10 patients were shifted from Tac to CyA-me for side effects. The clinical course of the majority of patients converted from CyA-me to Tac improved clearly after conversion. Donor age and acute rejection (number, severity and rejection free days) had a significative association with lack of efficacy in group B. In these series, the conversion to Tac from CyA-me could be accomplished safely, with an excellent long-term outcome.

Adalimumab vs Azathioprine in the Prevention of Postoperative Crohn's Disease Recurrence. A GETECCU Randomised Trial.

BACKGROUND AND AIMS: Postoperative recurrence of Crohn's disease [POR-CD] is almost certain if no prophylaxis is administered. Evidence for optimal treatment is lacking. Our aim was to compare the efficacy of adalimumab [ADA] and azathioprine [AZA] in this setting. METHODS: We performed a phase 3, 52-week, multicentre, randomised, superiority study [APPRECIA], in which patients with ileocolonic resection were randomised either to ADA 160-80-40 mg subcutaneously [SC] or AZA 2.5 mg/kg/day, both associated with metronidazole. The primary endpoint was endoscopic recurrence at 1 year [Rutgeerts i2b, i3, i4], as evaluated by a blinded central reader. RESULTS: We recruited 91 patients [median age 35.0 years, disease duration 6.0 years, 23.8% smokers, 7.1% previous resections]. The study drugs were administered to 84 patients. Treatment was discontinued owing to adverse events in 11 patients [13.1%]. Discontinuation was significantly less frequent in the ADA [4.4%] than in the AZA group [23.2%] (dif.: 18.6% [95% CI 4.1-33.2], p = 0.011). According to the intention-to-treat analysis, therapy failed in 23/39 patients in the AZA group [59%] and 19/45 patients in the ADA group [42.2%] [p = 0.12]. In the per-protocol analysis [61 patients with centrally evaluable images], recurrence was recorded in 8/24 [33.3%] patients in the AZA and 11/37 [29.7%] in the ADA group [p = 0.76]. No statistically significant differences between the groups were found for recurrence in magnetic resonance images, biological markers of activity, surgical procedures, or hospital admissions. CONCLUSIONS: ADA has not demonstrated a better efficacy than AZA [both associated with metronidazole] for prophylaxis of POR-CD in an unselected population, although tolerance to ADA is significantly better. ClinicalTrials.gov NCT01564823.

Prevalence and management of hernias in peritoneal dialysis patients.

OBJECTIVES: The aim of this study was to assess the prevalence of hernias before and after the start of continuous ambulatory peritoneal dialysis (CAPD) in patients with end-stage renal disease, and to evaluate the result of a proposed surgical treatment. DESIGN: Prospective observational study. SETTING: University hospital. PATIENTS: 122 patients who started CAPD from 1994 to 2000; 26 hernias were diagnosed in 21 (17.2%) patients. MAIN OUTCOME MEASURES: Finding of hernias; morbidity associated with catheter insertion and hernia repair; recurrence of hernias. RESULTS: 19 hernias were detected in 15 patients (12.3%) before they began CAPD; only 7 hernias were observed while on CAPD. Umbilical (61.5%) and inguinal (26.9%) hernias were the most common. Multiple hernias were detected in 4 patients. Simultaneous repair of hernia and catheter insertion was performed in patients with pre-existing hernias. Under local anesthesia, most patients were operated on with surgical techniques of tension-free hernioplasty using a polypropylene mesh. Only mild post-operative complications were recorded: 3 seromas and 1 hematoma. No fluid leakage was found in our series. There were no long-term complications (infection or recurrence) related to the mesh. CONCLUSIONS: 73% of hernias in peritoneal dialysis patients occur before starting dialysis. Hernia problems in these high-risk patients can be safely solved using a careful technique with application of tension-free hernioplasty. Most may be repaired under local anesthesia with simultaneous catheter insertion.

[Application of new technologies to the teaching of surgery in the school of medicine]. / Aplicación de las nuevas tecnologías en la enseñanza de la cirugía en la licenciatura de medicina.

INTRODUCTION: The new methods of teaching, based on new technologies, already available in other educational and professional fields are gradually being introduced in our Medical Schools. The aim of our study is to present our initial experience in the introduction of a subject on the principles of surgery in our university. MATERIAL AND METHODS: The subject was offered voluntary to undergraduate students, with a maximum of 65 students per course during two consecutive academic years, while maintaining the traditional teaching with a formal lecture program with a different lecturer. The subject was designed with 60% virtuality on a WebCT platform and later in Moodle. The virtual subject was structured into teaching units, academically directed activities and communication tools. The subject was assessed in a report prepared by Cadiz University Department of Evaluation and Quality. RESULTS: There were 32 students in the 2005-2006 course and 62 in the following course. The mean activity of the students was: 602 accesses, 13 subjects for discussion forums and 20 e-mails between students and teachers. The students who participated in the Virtual subject have remarked that virtualisation make it more attractive and is an aid in the acquisition of knowledge. The data obtained from the report showed better results than the mean obtained in other subjects of the Department, School of Medicine and Cadiz University. CONCLUSIONS: The virtual subject of principles of surgery has been well evaluated in our university campus. We believe that the provision of teaching tools and new communication models make an effective contribution to the teaching of surgery as a subject in the school of medicine curriculum.

Cáncer de mama en varones: casos recogidos en 20 años (1990-2011) / Breast cancer in males and cases observed in 20 years (1990-2011)

Introducción: en la sociedad occidental el cáncer de mama es el de mayor prevalencia en el sexo femenino, pero es muy raro en el sexo masculino (0,1-0,2 por ciento). Tras analizar la epidemiología y los factores de riesgo, se realizó un estudio retrospectivo de los casos hallados en una unidad de unidad de cirugía menor ambulatoria (CmA) del Hospital General de Especialidades Juan Grande en el periodo de 1990 a 2011 (n = 10). Métodos: se describen los hallazgos en la unidad CmA, adonde acuden pacientes con diagnósticos de afecciones benignas, fundamentalmente de piel, anejos cutáneos y tejidos subcutáneos. Se eligió, describió y siguió a los varones que resultaron tener un carcinoma de mama. Los criterios de inclusión fueron el sexo masculino y la confirmación histológica de cáncer de mama. Se estudiaron las variables epidemiológicas, tumorales y terapéuticas, y la supervivencia. Resultados: hubo 10 sujetos con edades de 58 ± 15 años, sin antecedentes de especial interés. Las tumoraciones se localizaban en la cara anterior del tórax, en la región mamaria, de forma unilateral. El 100 por ciento de los pacientes acudieron con diagnóstico de una afección benigna, e igualmente en el 100 por ciento de los casos el diagnóstico anatomopatológico definitivo fue carcinoma ductal. Conclusiones: los pacientes se diagnosticaron después de una cirugía y no hubo diagnóstico clínico previo. La supervivencia estuvo condicionada por la tardanza en el diagnóstico y, por tanto, en el inicio del tratamiento. La supervivencia a los 5 años de revisiones fue de 7 pacientes, aunque algunos fallecieron por otras causas(AU)

Introduction: breast cancer in the Western society has the highest prevalence rate in females, but it is very rare in males (0.1-0.2 percent). After analyzing the epidemiology and the risk factors, a retrospective study was conducted on the cases found in an outpatient minor surgery unit of Juan Grande general hospital of medical specialties in the period of 1990 through 2011 (n= 10). Methods: the findings observed in this unit were described, where patients with benign disease diagnoses fundamentally went because of skin problems, cutaneous adnexes and subcutaneous tissues. The males suffering breast carcinoma were selected, described and followed-up. Inclusion criteria were being male and histological confirmation of breast cancer. The epidemiological, tumoral and therapeutical variables were under study as well as survival rates. Results: there were 10 individuals aged 58 ± 15 years, with no history of special interest. Tumors were located in the anterior side of thorax, unilateral, in the breast region. One hundred percent of patients went to the unit with benign diagnosis and, the final anatomopathological diagnosis of all the cases was ductal carcinoma. Conclusions: the patients were diagnosed after one surgery and there was not previous clinical diagnosis. The survival depended on the time of diagnosis and on the time of beginning the treatment. The survival rate after 5 years of review was 7 patients, although some died from other causes(AU)

[Retroperitoneal sarcomas. Report of five new cases and review of the current situation]. / Sarcomas retroperitoneales. Aportación de cinco nuevos casos y revisión de la situación actual.

INTRODUCTION: Soft-tissue sarcomas represent a heterogeneous group of rare tumors arising from the mesenchymal cells of the connective tissue. Approximately 15% of these tumors arise in the retroperitoneum. These neoplasms are locally aggressive and the only curative treatment is surgical resection "en-bloc". The main cause of mortality is locoregional recurrence. Five-year survival is 3-58%, depending on the histologic subtype and grade. PATIENTS AND METHOD: Over a 5-year period (2001 to 2006), we performed surgery in five patients with retroperitoneal sarcomas. The mean age was 59 years (range, 46-76) with a male-to-female ratio of 3:2. The most frequent signs were abdominal pain and the appearance of a mass. In 2 patients, an incidental diagnosis was made during the surgical intervention. RESULTS: Surgical resection was performed in 5 patients but was incomplete in two patients. We removed 2 liposarcomas, 1 leiomyosarcoma, 1 chondrosarcoma and 1 fusocellular sarcoma arising in the kidney. Locoregional recurrence occurred in four patients, requiring between 1 and 2 new relaparotomies (using the retroperitoneal approach in 2 patients). There was one death. CONCLUSIONS: Retroperitoneal sarcomas are a heterogeneous group of tumors, in which the only common factor is the anatomical location. New randomized, prospective, multicenter trials are required to apply different therapeutic options according to the subtype of retroperitoneal sarcoma.

Differences in polypropylene shrinkage depending on mesh position in an experimental study.

BACKGROUND: Polypropylene (PP) mesh is one of the most frequent materials used in hernia repair. We have experimentally evaluated the shrinkage of PP mesh depending on the place of implantation. METHODS: In 15 New Zealand rabbits a muscular defect measuring 3 x 3 cm was created in both pararectal sides of the abdominal wall. The defect was repaired using a PP mesh measuring 5 x 3.5 cm that was placed in the right side in the sublay location and in the left side in the onlay location. Five animals were killed on the 30th, 60th, and 90th postoperative days. Macroscopic measurement and microscopic study of the prosthesis-host tissue interfaces were performed. RESULTS: One rabbit was killed because of severe infection in the onlay mesh. Another 2 infections were tolerated in the onlay mesh side. All the prostheses were integrated in the host tissue at death. In the macroscopic evaluation the mesh areas were reduced by 25.92% on the 30th day, by 28.67% on the 60th day, and by 29.02% on the 90th day. The mesh shrinkage was greater in the onlay group than in the sublay group at the 3 time intervals. More inflammatory leukocyte and mononuclear responses also were seen in the onlay group. CONCLUSIONS: These observations support the theory of PP mesh shrinkage as a consequence of the incorporation of the biomaterial to the scarring tissue. This shrinkage is significantly more intense if the meshes are placed in the onlay position.

[Surveillance of shrinkage of polypropylene mesh used in the repair of ventral hernias]. / Seguimiento de la contracción de las mallas de polipropileno empleadas en la reparación de eventraciones.

INTRODUCTION: Polypropylene (PP) mesh is one of the most frequently used materials in the surgical repair of ventral hernias. Despite the widely recognized ability of PP to integrate into the host tissue, these meshes may shrink during the healing process in the patient. OBJECTIVE: To quantify polypropylene mesh shrinkage. PATIENTS AND METHOD: A radiological follow-up study was performed in 23 consecutive patients who underwent surgery for midline ventral hernias with diameters of at least 5 cm. PP meshes were marked with titanium clips at the ends of their longest transverse and longitudinal axes. X-rays were performed on the first postoperative day and at 1, 3, 6 and 12 months. The distances between clips were measured and the area of the mesh was calculated. RESULTS: Seventeen women and six men underwent surgery. In nine patients the mesh was placed on the prefascial space (onlay) and in 14 in the subfascial space (sublay). There were four seromas in patients with mesh placed with the onlay technique. The reduction in the calculated area was 12% at 1 month, 24% at 3 months, 29% at 6 months and 34% at 12 months. CONCLUSIONS: PP mesh provided excellent clinical results. Radiological surveillance revealed substantial shrinkage, mainly in the first 3 months after implantation.