Safety and Cost-Effectiveness in Thyroidectomy Using the HARMONIC Scalpel Compared to Traditional Hemostasis: A Controlled Clinical Assay.

INTRODUCTION: The aim of this clinical control trial is to analyze the cost-effectiveness and to understand the efficacy of the HARMONIC FOCUS®+ (Ethicon Inc., Somerville, New Jersey) scalpel as the only system to cut and coagulate in thyroidectomy. MATERIALS AND METHODS: One hundered patients of the thyroid clinic of the Mexico City General Hospital were included. All patients underwent surgery and were divided into two randomized groups. In Group 1, the HARMONIC scalpel was the only device used for cut and coagulate (50 patients), and in Group 2 clamp, tie, and electrocautery (50 patients) were used. Surgical bleeding, operative time, complications, diagnosis, thyroid size, and hospital stay were evaluated in both groups. The statistical analysis was done using central trend measurements, Student's t-, chi-squared, and Fisher's exact test, with a significance level of p < 0.05. The cost-effectiveness analysis was completed by determining the total cost of the surgical procedure per hour in US dollars, and the evolution to compare efficacy will be the number of re-interventions due to postoperative bleeding. RESULTS: The use of the HARMONIC scalpel in thyroid surgery had the same results as the traditional method when comparing complications, reoperation, hospital stay, and hypoparathyroidism. In total thyroidectomy patients, the bleeding in Group 1 was 55.16ml ( ± 32.97) and 85.4ml ( ± 69.41) in Group 2 , p=0.034. Operative time in Group 1 was 74.6 minutes (± 23.39) and 104.09 minutes (± 34.66) in Group 2, p= 0.0001. In both groups, there were no statistical differences in lobectomy. Cost-effectiveness analysis implies an adequate hemostasis if we are using a hemostatic device, and above all, the avoidance of a re-intervention due to hematoma, and the cost-effectiveness with regard to the re-intervention as a result of a hematoma implies that $161 US more is spent for each re-intervention. CONCLUSION: The utilization of the HARMONIC scalpel device is similar to the traditional technique of ligature and knots as far as cost-effectiveness is concerned, due to the fact that the greater expense of the device is compensated by the lower expense in time and surgical re-intervention.

[Cervical lymphangioma in the adult. A report of 2 cases]. / Linfangioma de cuello en el adulto. Reporte de 2 casos.

BACKGROUND: Cervical lymphangiomas are uncommon benign congenital malformations usually present in children, and are rare in adults. Currently, complete resection is still the standard care. Two cases are presented of a cervical lymphangioma in an adult. The diagnosis and surgical approach is also discussed. CLINICAL CASE: Case 1. The first case is a 23 year old male with chief complaint of a tumour in the posterior triangle of the neck, which showed a substantial increase in size in the last 9 months. No associated signs or symptoms, or any trauma history was reported. CT scan of the neck showed images suggestive of a posterior cervical lymphangioma. Exploratory cervical surgery was performed, with complete resection of a cystic tumour located in the posterior triangle of the neck. Surgery was performed without complications and postoperative care was unremarkable. CASE 2: The second case is a 28 woman with a cystic tumour in submandibular space. She had history of a previous incomplete operation in another institution 2 years ago, with recurrence of the tumour. A second surgery was performed with complete resection without complications, and with a good outcome. CONCLUSIONS: Cervical lymphangioma is a very rare benign disease, surgical treatment is preferred, but sclerotherapy can be used as alternative treatment.

Cirugía de corta estancia en sábados, domingos y días festivos, experiencia en el Servicio de Cirugía General del Hospital General de México, O.D / Short stay surgery on weekends and holidays, experience at the General Surgery Service of the General Hospital of Mexico, O.D

Objetivo: Demostrar las bondades del impacto, tiempo y costo-eficacia de la cirugía de corta estancia en sábados, domingos y días festivos. Sede: Hospital General de México. Diseño: Estudio prospectivo, transversal, observacional, comparativo. Análisis estadístico: Prueba t de Student, chi cuadrada y análisis costo-eficacia. Material y método: Durante 4 años se realizaron 1,200 cirugías dentro de este programa piloto, utilizando la capacidad hospitalaria instalada y al mismo personal contratado para la atención médica de dichos días, sin contar con una unidad de cirugía de corta estancia como tal. Los procedimientos realizados fueron: plastía inguinal, resección de enfermedad pilonidal, plastía umbilical, resección de tumor benigno de partes blandas, plastía de pared, mastectomía subcutánea, hemorroidectomía, fistulectomía y excisión de tumores benignos mamarios y se comparó con los mismos procedimientos, pero realizados en forma de cirugía programada, evaluando y comparando las siguientes variables: edad, género, procedimiento realizado, tiempo de estancia hospitalaria y costo-beneficio del procedimiento. También se evaluó necesidad de hospitalización, reingreso en menos de 24 h, morbilidad y mortalidad. Resultados: Los diagnósticos incluyeron: hernias inguinales con 486 casos, tumores de partes blandas en 359 casos, hernia umbilical en 185 casos, eventración en 88 casos, enfermedad anorrectal en 27 casos, enfermedad pilonidal en 17 casos, ginecomastia en 17 casos, fimosis en 10 y otros en 11. Se realizaron plastía inguinal, resección de enfermedad pilonidal, plastía umbilical, excisión de tumor benigno de partes blandas, plastía de pared, mastectomía subcutánea, hemorroidectomía y/o fistulectomía, circuncisión y otros. El tiempo empleado para el manejo quirúrgico se redujo de 36 horas en promedio a doce horas (p < 0.05). El costo-eficacia fue del 40% menor en comparación con los pacientes que se operaron con el método tradicional. El promedio de tiempo quirúrgico y anestésico no fue diferente entre cirugía ambulatoria y el método tradicional. Conclusión: Se puede realizar con gran eficiencia cirugía de corta estancia en sábados domingos y días festivos con un ahorro de 40%.

Objective: To demonstrate the benefits of the impact, time, and cost-effectiveness of short stay surgery performed on weekends and holidays. Setting: General Hospital of Mexico (Third level health care hospital). Design: Prospective, cross-sectional, observational, and comparative study. Statistical analysis: Student's t test, chi square, and cost-effectiveness analysis. Material and method: During 4 years, 1,200 surgeries were performed within this pilot program, using the installed hospital infrastructure and the same personnel employed for medical care in those days, without having a special short stay surgery unit as such. Performed procedures were: inguinal plasty, resection of pilonidal disease, umbilical plasty, resection of benign soft tissue tumor, wall plasty, subcutaneous mastectomy, hemorrhoidectomy, fistulectomy, and excision of benign breast tumors, these were compared with the same procedures but performed as programmed surgeries. We assessed and compared the following variables: age, gender, performed procedure, time of hospital stay, and cost-benefit of the procedure. We also evaluated the need of hospitalization, re-admittance in less than 24 h, morbidity and mortality. Results: Diagnoses included: inguinal hernias with 486 cases, 359 cases of soft tissue tumors, 185 cases of umbilical hernia, 88 cases of eventration, 22 cases of anorectal disease, 17 cases of pilonidal disease, 17 cases of gynecomastia, 10 cases of phimosis, and 11 other diagnoses. We performed inguinal plasties, resection of pilonidal disease, umbilical plasty, excision of soft tissue tumor, wall plasty, subcutaneous mastectomy, hemorrhoidectomy and/or fistulectomy, circumcision and other procedures. The time used for surgical management was reduced from an average of 36 to 12 hours (p < 0.05). Cost-effectiveness was 40% lower as compared with the traditional method. Surgical and anesthetic times were not different between ambulatory and traditional surgeries. Conclusion: Short stay surgery can be performed efficiently on the weekends and holydays with a 40% savings.

Prevención de quejas y demandas al aplicar las metas de seguridad en el paciente quirúrgico / Prevention of complaints and claims by applying the Safety Guidelines to the surgical patient

Objetivo: Demostrar si el cumplimiento de las ''metas internacionales de seguridad en el paciente'' pueden disminuir la frecuencia de quejas y/o demandas. Sede: Hospital General de México. Diseño: Observacional, descriptivo, retrospectivo, transversal. Análisis estadístico: Porcentaje como medida de resumen para variables cualitativas. Material y métodos: Se evaluaron las quejas y demandas relacionadas al Servicio de Cirugía General y manejada por el Departamento Jurídico de enero de 2008 a octubre de 2009, al requerir peritaje por tercero en discordia, previo a instrumentar la aplicación del programa de metas internacionales de seguridad en el paciente. Se evalúo la causa específica de la queja y si ésta hubiera sido o no prevenida al aplicar las metas internacionales de seguridad del paciente. Resultados: Durante el periodo de estudio se requirió de ocho peritajes relacionados a cirugía general, si se hubieran aplicado las metas internacionales de seguridad del paciente, el 50% de la quejas hubieran sido prevenidas. La cuarta meta internacional que garantiza cirugía en el lugar correcto, con el procedimiento correcto y al paciente correcto destaca sobre las demás en casos relacionados a cirugía general para prevenir quejas. Conclusión: La aplicación correcta de las metas internacionales de seguridad del paciente logra detectar fallas en la atención médica y, en consecuencia, previene en un 50% la frecuencia de quejas o demandas relacionadas con la atención médica.

Objective: To demonstrate whether complying with the ''International Safety Guidelines for the Patient'' can decrease the frequency of complaints and/or claims. Setting: General Hospital of Mexico. Design: Observational, descriptive, retrospective, cross-sectional study. Statistical analysis: Percentages as summary measure for qualitative variables. Material and methods: We evaluated the complaints and claims related to the general surgery service and handled by the legal department from January 2008 to October 2009 that required expert advice from a third arbitrator, and which occurred before applying the International Safety Guidelines for the Patient. We assessed the specific cause of the complaints and whether these could have or not been prevented by applying the Safety Guidelines. Results: During the studied period, eight third arbitrator revisions were required related to general surgery. If the Safety Guidelines had been applied, 50% of the complaints could have been avoided. The fourth guideline that warrants that surgery be performed in the right place, use of the correct procedure, and the correct patient stands out above the other guidelines in cases related to general surgery to avoid complaints. Conclusion: Adequate application of the International Safety Guidelines for the Patient is instrumental in detecting failures related to medical care.

[Frequency of organic failure in acute necrotic pancreatitis]. / Frecuencia de falla orgánica en la pancreatitis aguda necrótica.

INTRODUCTION: Theacute pancreatitis is classified as severe by the presence of glandular necrosis or organic failure. However both conditions are not simultaneous. We determine the frequency of organic failure in patients with pancreatic necrosis for acute pancreatitis. MATERIAL AND METHODS: A study retrospective, traverse, descriptive and observational is carried. Were included the cases of pancreatic necrosis by acute pancreatitis presented of January 1 from 1996 to December 31 2000. The presence of organic failure was determined, as well as ages, sex, etiology, nutritional state, Ranson's criteria, surgeries carried and mortality. RESULTS: 45% of the patients with necrosis pancreatic development organic failure. The masculine sex and the realization of some surgery predominated in them. 92% of the patients with organic failure presents it to the admission, the system circulatory was the more frequently affected, continued by the respiratory, and the renal. The patients with organic failure had a mortality of 88% against 0% of those that didn't present it. The SIRPA and irreversible shock were the causes of death. DISCUSSION: Not is clear the relationship between necrosis and organic failure. The death of pancreatic tissue for apoptosis, that limits the damage and the necrosis, that it favors, is factors to consider. The hypoperfusion tissular can be the determinant among these two lesion forms.

Frecuencia de falla orgánica en la pancreatitis aguda necrótica / Frecuency of organic failure in acute necrosis pancreatitis

Introducción: La pancreatitis aguda se clasifica como severa por la presencia de necrosis glandular o falla orgánica. Sin embargo, ambas condiciones no son simultáneas. En este estudio determinamos la frecuencia de falla orgánica en pacientes con necrosis pancreática por pancreatitis aguda. Material y Métodos: Se realizó un estudio retrospectivo, transversal, descriptivo y observacional. Se incluyeron los casos de necrosis pancreática por pancreatitis aguda presentados del 1 de enero de 1996 al 31 de diciembre de 2000. Se determinó la presencia de falla orgánica, así como edades, sexo, etiología, estado nutricional, criterios de Ranson, cirugías realizadas y mortalidad. Resultados: De los pacientes con necrosis pancreática, 45% desarrolló falla orgánica. En ellos predominó el sexo masculino y la realización de alguna cirugía. De los pacientes con falla orgánica, 92% la presentó al ingreso; el sistema afectado más frecuente fue el circulatorio, seguido por el pulmonar y el renal. Los pacientes con falla orgánica tuvieron mortalidad de 88%. Las causas de muerte fueron SIRPA y choque irreversible. Discusión: La relación entre necrosis y falla orgánica no es clara. Existen factores a considerar tales como la muerte de tejido pancreático por apoptosis, que limita el daño y la necrosis que lo favorece. La hipoperfusión tisular puede ser determinante entre estas dos formas de lesión.

Introduction: The acute pancreatitis is classified as severe by the presence of glandular necrosis or organic failure. However both conditions are not simultaneous. We determine the frequency of organic failure in patients with pancreatic necrosis for acute pancreatitis. Material and Methods: A study retrospective, transverse, descriptive and observational is carried. Were included the cases of pancreatic necrosis by acute pancreatitis presented of January 1 from 1996 to December 31 2000. The presence of organic failure was determined, as well as ages, sex, etiology, nutritional state, Ranson's criteria, surgeries carried and mortality. Results: 45% of the patients with necrosis pancreatic development organic failure. The masculine sex and the realization of some surgery predominated in them. 92% of the patients with organic failure presents it to the admission, the system circulatory was the more frequently affected, continued by the respiratory and the renal. The patients with organic failure had a mortality of 88% against 0% of those that didn 't present it. The SIRPA and irreversible shock were the causes of death. Discussion: Not is clear the relationship between necrosis and organic failure. The death of pancreatic tissue for apoptosis, that limits the damage and the necrosis, that it favors, is factors to consider. The hypoperfusion tissular can be the determinant among these two lesion forms.

[Acute pancreatitis: five year experience at the Hospital General de Mexico]. / Pancreatitis aguda: experiencia de cinco años en el Hospital General De México.

INTRODUCTION: In Mexico acute pancreatitis is an important cause of morbility and mortality. We here describe the characteristics of patients managed with that diagnosis at the Hospital General de Mexico. MATERIAL AND METHODS: Retrospective, descriptive and observational study. Patients with acute panrcreatitis were seen between January 1996 to December 2000. RESULTS: The acute pancreatitis prevalence found in the hospital setting was 5%. We identified 104 patients, 62% men, with mean age 37 yrs. In 74% ofcases seen, we made a correct early diagnosis upon admission. The biliary (49%) and the alcoholic (37%) were the most frequent causes. Abdominal pain was the most common symptom at onset (94%). High leukocyte count (78%), followed by serum lipase (74%) was the most sensitive laboratory test. Only 34% of patients studied had an adequate nutritional status. 54% of' patients presented severe pancreatitis. The mean number of hospital days was 17 and 44% required ICU management. Thirty five percent required surgery where necrosectomy was performed and a mortality of 67% was found. The total mortality rate was 21%. CONCLUSIONS: The correct clinical diagnosis of acute pancreatitis is frequent. It is a more common finding than severe pancreatitis, but it does not increase the morbility and mortality in our patient population.

Pancreatitis aguda: experiencia de cinco años en el Hospital General de México / Acute pancreatitis: five year experience at the Hospital General de Mexico

Introducción: la pancreatitis aguda constituye una importante causa de morbilidad y mortalidad en México. Se describen las características de la población manejada con ese diagnóstico en el Hospital General de México. Material y métodos: estudio retrospectivo, descriptivo y observacional. Se obtuvieron los datos de los pacientes con pancreatitis aguda manejados del 1 de enero de 1996 al 31 de diciembre de 2000. Resultados: la prevalencia de pancreatitis aguda entre la población hospitalaria es de 3%. Se identificaron 104 pacientes, 62% hombres, con edad promedio de 37 años. En 74% se sospechó correctamente el diagnós tico al ingreso. Las causas más frecuentes fueron la biliar (49%) y la alcohólica (37%). El síntoma de inicio más común fue el dolor abdominal (94%). El estudio de laboratorio más sensible fue la presencia de leucocitosis (78%), seguido por la lipasa sérica (74%). Sólo 34% de los pacientes tuvieron un adecuado estado nutricional. El 54% de los pacientes presentaron pancreatitis severa. Los días promedio de hospitalización fueron 17 y 44% necesitaron manejo en la UCI. El 35% de los pacientes fueron sometidos a cirugía, en los que se realizó necrosectomía la mortalidad fue de 67%. La mortalidad total fue de 21%. Conclusión: el diagnóstico clínico correcto de la pancreatitis aguda es frecuente. La pancreatitis severa es más común, pero no incrementó la morbilidad y la mortalidad en la muestra.

Introduction: In Mexico acute pancreatitis is an important cause of morbility and mortality. We here describe the characteristics of patients managed with that diagnosis at the Hospital General de Mexico. Material and methods: Retrospective, descriptive and observational study. Patients with acute pancreatitis were seen between January 1996 to December 2000. Results: The acute pancreatitis prevalence found in the hospital setting was 5%. We identified 104 patients, 62% men, with mean age 37 yrs. In 74% of cases seen, we made a correct early diagnosis upon admission. The biliary (49%) and the alcoholic (37%) were the most frequent causes. Abdominal pain was the most common symptom at onset (94%). High leukocyte count (78%), followed by serum lipase (74%) was the most sensitive laboratory test. Only 34% of patients studied had an adequate nutritional status. 54% of patients presented severe pancreatitis. The mean number of hospital days was 17 and 44% required ICU management. Thirty five percent required surgery where necrosectomy was performed and a mortality of 67% was found. The total mortality rate was 21%. Conclusions: The correct clinical diagnosis of acute pancreatitis is frequent. It is a more common finding than severe pancreatitis, but it does not increase the morbility and mortality in our patient population.

Causes for early reintervention after thyroidectomy.

BACKGROUND: The purpose of our study was to ascertain the causes for early reintervention after thyroidectomy performed by a surgical team using a systematized surgical technique. MATERIAL/METHODS: We analyzed 1131 patients, 939 (83.1%) women and 192 (16.9%) men, average age 38.7 years (range 12 to 79). Of these patients, there were 675 hemithyroidectomies with isthmusectomy (59.74%), 189 subtotal thyroidectomies (16.71%), and 267 total thyroidectomies, alone or with regional lymphatic dissection at levels VI and VII (23.55%). Statistical analysis was performed by main tendency measures and chi square (chi-squared) for comparison of two independent samples; the dependent variable was the rate of early reintervention, while the independent variables included causes, time of presentation, hormonal functional state and extent of surgery. RESULTS: Early reintervention was necessary in 11 cases (0.97%). 9 were due to hematoma (0.79%) resolved with drainage and hemostasis, and two (0.18%) due to acute respiratory failure (ARF) caused by laryngeal edema, resolved by tracheostomy. Analysis based on diagnosis, extent of surgery and functional state failed to reveal statistically significant differences. The maximum time presentation of complications was 6 hours. CONCLUSIONS: The most intense postoperative monitoring is necessary during the first six hours. The low frequency of early reintervention and the appearance of complications in less than 8 hours enable thyroid surgery to be performed on a short-stay basis with adequate safety margins.

Diagnóstico y tratamiento de los tumores de cuello: análisis de 100 pacientes / Diagnosis and treatment of neck tumors: analysis of 100 patients

Objetivo. Informar la experiencia de los autores en el tratamiento quirúrgico de 100 pacientes con tumor de cuello. Diseño. Análisis descriptivo, retrospectivo, de 100 pacientes con tumores de cuello operados en un lapso de tres años de un total de 1500 operaciones. Sede. Hospital General de México de la Secretaría de Salud servicios de cirugía gneral 104 y 306, pabellones 3 y 18. Resultados. Se trató de 90 mujeres y 10 hombres, con edades entre 15 y 80 años, con mayor frecuencia ubicados entre la cuarta y sexta década de la vida. la principal manifestación clínica fue tumor a nivel cervical que se localizó en 45 pacientes en la cara lateral derecha de cuello, en 25 en la izquierda y en 30 abarcó ambos lados. En el 88 por ciento la patología correspondió a enfermedad de tiroides y de éstos un 60 por ciento correspondieron a bocio en sus diversas variedades. La tiroidectomía sub total se utilizó en 58 por ciento, seguida de la hemitiroidectomía derecha en un 10 por ciento de los pacientes. La mortalidad fue del 1 por ciento.