Control de calidad en cirugía mayor y menor ambulatoria / No disponible

Introducción: Entre los medios para conseguir una mejor asistencia progresiva en la unidad de cirugía ambulatoria (UCMA )están la medición y evaluación de los resultados, comparándolos con otras unidades y la posterior aplicación de correcciones. Las publicaciones citan unos indicadores constantes y otros variables no figurando siempre la complejidad de los procedimientos. La cirugía menor ambulatoria (cma) es una alternativa a la UCMA cada vez mayor para determinados procedimientos y sus indicadores de calidad no están establecidos. Material y métodos: Exponemos nuestra casuística de 13 años en la UCMA y de 7,5 en cma. Utilizamos como indicadores de calidad en la UCMA: índice de sustitución, ingresos (inmediatos y diferidos), anulaciones, visitas a urgencias y llamadas telefónicas; los comparamos con otras series. En cma hemos valorado los casos fallidos. Entregamos una encuesta de satisfacción y dos escala spsiquiátricas para evaluar el estado de ansiedad a 117 pacientes. Resultados: Asistimos en la UCMA 1.467 pacientes. Ingresos 3%, reingresos 0,34%, anulaciones 0,75%, llamadas 10,4%,índice de sustitución general 25%. En las 1.346 pacientes asistidas en cma los fracasos oscilaron, según los procedimientos, entre 2,5 y 22%. Promedio de satisfacción en CMA 9,4/10 y en cma8,9/10. Conclusiones: La evolución de nuestra calidad es favorable aunque podemos mejorar algunos aspectos. Convendría unificarlos índices utilizados para hacer más fácil el estudio comparativo entre unidades. El índice de sustitución debería referirse a los procedimientos susceptibles de realizarse en la UCMA. Sería conveniente notificar las intervenciones que han pasado de efectuarse en la UCMA a cma (AU)

Introduction: One of the means used to achieve a better progressive assistance in the Ambulatory Surgical Unit (ASU) is, first of all, to measure and to evaluate the results, comparing them with those of other units, and, then, to apply improvements. Publications mention some changing and some unchanging indicators, and the complexity of the procedures is not always mentioned. Outpatient Surgery (OS) is an increasing alternative to Ambulatory Surgery for certain procedures, and its quality indicators have not yet been established. Material and methods: We present our case history of the last 13 years in the ASU and of 7.5 years in the OS. The ASU quality indicators being used were: the replacement index, admissions(immediate and deferred), cancellations, visits to the emergency room and phone calls, and we compared them with other case histories. In OS, we have valued the unsuccessful cases. We handed out a satisfaction questionnaire and two psychiatric scalesto evaluate the anxiety state of 117 patients. Results: We attended 1,467 patients in the ASU. The admissions represented a 3%; readmissions, 0.34%; cancellations,0.75%; phone calls, 10.4%, and general substitution index, 25%. Amongst the 1,346 patients attended in OS, the unsuccessful cases varied from 2.5% to 22%, depending on the procedures. The average of satisfaction in the ASU was 9.4/10, and in OS was 8.9/10.Conclusions: The development of our quality control index is favorable, although some aspects may be improved. Some of the indexes being used should be unified in order to make the comparative study amongst Units easier. The replacement index should refer to procedures susceptible to being carried out in the ASU. It would be advisable to notify which surgical procedures were performed in the ASU and are now performed in OS (AU)

Estudio comparativo de la técnica del ganglio centinela entre los casos de carcinoma de mama multifocal y unifocal / Comparative study of sentinel node biopsy in patients with multifocal breast carcinoma versus in those with unifocal breast carcinoma

Objetivo valorar los resultados de la biopsia del ganglio centinela (BGC) en pacientes con cáncer de mama multifocal (CMMF) en comparación con el unifocal (CMUF). Pacientes y métodos se han realizado e incluido en una base de datos de manera prospectiva 1.535 BGC a pacientes de 9 centros hospitalarios. De ellos 174 presentaban CMMF. Para la BGC se utilizaron coloides de Tc-99m y la vía de administración fue mayoritariamente la profunda, repartiendo el trazador en los diferentes focos. Resultados el índice de detección global fue del 93,8%, sin encontrar diferencias entre ambos grupos (el 94,8% en CMMF frente al 93,4%). La media de GC detectados fue de 1,46, siendo mayor en el grupo CMMF (1,58 frente a 1,45; p=0,036). La localización fue extraaxilar en el 19,6%, más frecuente en el grupo CMMF (el 23,4 frente al 18,9%, no significativo) y más en el territorio de la cadena mamaria interna y en el nivel III axilar. La incidencia de metástasis en los GC biopsiados fue del 27,3%, mayor en el grupo CMMF (el 29,1 frente al 26,7%, no significativo), con una media de GC afectados mayor (0,42 frente a 0,32, no significativo). En la linfadenectomía axilar se identificó afectación de ganglios adicionales en una proporción igual en ambos grupos (29,7%). Conclusionesla BGC parece tener un rendimiento similar en tumores unifocales y multifocales. En tumores multifocales, parece haber un patrón de drenaje linfático específico, con mayor número de GC detectados y probablemente con mayor número de localizaciones de GC extraaxilares (AU)

Objective To evaluate the results for sentinel node biopsy (SNB) in patients with multifocal breast cancer (MBC) in comparison to in those with unifocal breast cancer (UBC). Patients and methods A total of 1535 prospective SNB (174 on patients with MBC) were performed at 9 hospitals. In most patients, Tc-99m album in colloids were injected intraparenchymally into each tumoral focus for SNB. Results The overall identification rate was 93.8%; no differences between groups were observed (94.8% in MBC vs 93.4% in UBC). The mean number of sentinel nodes detected was 1.46, being higher in the MBC group than in the UBC group (1.58 vs 1.45; p=0.036). Extra-axillary sentinel nodes were found in 19.6%; extra-axillary sentinel nodes were more common in the MBC group (23.4% vs 18.9%, ns) and in the internal mammary chain and in level III axillary lymph nodes. The incidence of sentinel node metastasis was 27.3% (29.1% MBC vs 26.7% UBC, ns), and the mean number of positive sentinel nodes was 0.42 in the MBC group vs 0.32 in the UBC group (p=ns). Axillary dissection identified the same rate of positive additional nodes (29.7%) in both groups. Conclusions The diagnostic yield of SNB seems similar in MBC and UBC. In MBC, there appears to be a specific pattern of lymphatic drainage, with a higher number of sentinel nodes detected and probably a higher number of extra-axillary sentinel nodes (AU)

[Comparative study of sentinel node biopsy in patients with multifocal breast carcinoma versus in those with unifocal breast carcinoma.]. / Estudio comparativo de la técnica del ganglio centinela entre los casos de carcinoma de mama multifocal y unifocal.

OBJECTIVE: To evaluate the results for sentinel node biopsy (SNB) in patients with multifocal breast cancer (MBC) in comparison to in those with unifocal breast cancer (UBC). PATIENTS AND METHODS: A total of 1535 prospective SNB (174 on patients with MBC) were performed at 9 hospitals. In most patients, Tc-99m albumin colloids were injected intraparenchymally into each tumoral focus for SNB. RESULTS: The overall identification rate was 93.8%; no differences between groups were observed (94.8% in MBC vs 93.4% in UBC). The mean number of sentinel nodes detected was 1.46, being higher in the MBC group than in the UBC group (1.58 vs 1.45; p=0.036). Extra-axillary sentinel nodes were found in 19.6%; extra-axillary sentinel nodes were more common in the MBC group (23.4% vs 18.9%, ns) and in the internal mammary chain and in level III axillary lymph nodes. The incidence of sentinel node metastasis was 27.3% (29.1% MBC vs 26.7% UBC, ns), and the mean number of positive sentinel nodes was 0.42 in the MBC group vs 0.32 in the UBC group (p=ns). Axillary dissection identified the same rate of positive additional nodes (29.7%) in both groups. CONCLUSIONS: The diagnostic yield of SNB seems similar in MBC and UBC. In MBC, there appears to be a specific pattern of lymphatic drainage, with a higher number of sentinel nodes detected and probably a higher number of extra-axillary sentinel nodes.

UCMA ginecológica: experiencia de 10 años / Gynaecological ambulatory surgery: 10 years experience

INTRODUCCIÓN: Nuestro hospital dispone de una Unidad de Cirugía Mayor Ambulatoria (UCMA) autónoma, integrada al mismo, con la que comparte el área quirúrgica. Ginecología se incorporó a la UCMA en julio de 1994 y tras 10 años de actividad, habiendo sobrepasado las 1.000 intervenciones, hemos creido oportuno revisar y presentar nuestra casuística, con las nuevas indicaciones y las que hemos abandonado. Comentamos las posibilidades futuras de nuestra especialidad en Cirugía Mayor Ambulatoria (cma). MATERIAL y Métodos. Efectuamos un estudio retrospectivo de nuestra experiencia durante 10 años (julio 1994 – junio 2004). Exponemos las indicaciones y su evolución. Efectuamos el control de calidad mediante los ingresos inmediatos y diferidos, anulaciones y llamadas telefónicas. Analizamos las repercusiones de la UCMA sobre nuestra actividad quirúrgica general y sobre la productividad. RSULTADOS: Durante este período efectuamos 4.369 intervenciones, 1.141 (26%) en la UCMA. El Servicio de Ginecología participó con el 7% en la actividad total de la UCMA, que recibió durante este período 16.513 pacientes. Las intervenciones más frecuentes fueron histerosocpia de flujo (47,5%), laparoscopia (19,5%) y cirugía mamaria (14%). Hemos dejado de efectuar el legrado uterino. Iniciamos la minilaparosocpia para la (..) (AU)

INTRODUCTION: Our hospital has an autonomous Ambulatory Surgical (ASU) which is into the main building and shares the Surgical Area with the rest of the hospital. The Department of Gynaecology was incorporated into this ASU in July 1994. After ten years of activity and having done over 1,000 operations, we have thought fit to review and present our case history, with the new procedures that have been included and those that were abandoned. We will comment onthe future possibilities of our speciality in Ambulatory Surgery (AS). MATERIAL AND METHODS: we carried out a retrospective study of our experience over 10 years (July 1994 – Jun 2004). We described the surgical indications and their evolution. The control of quality was evaluated by means of the most significant indicators: immediate hospital admission, delayed re-admissions, cancellations and phone calls to the ASU. We analyzed the influence of its activity on our general surgical activity and productivity. RESULTS: Over these 10 years we have carried out 4,369 gynaecological procedures, 1,141 (26%) of them were performed in the ASU. The Gynaecological Department took part with 7% of the total activity of the ASU, where 16,513 patients from all the surgical specialities were received. The most frequent procedures were: hysteroscopy (47.5%), laparosocpy (19.5%) and breast surgery (14%). We stopped doing uterine curettage. We recently started mini-laparosocpy for tubal occlusion, under local anesthesia and sedation, in 26 patients; we have increased the surgical indications for laparoscopy for treatment of adnexal pathology. In breast surgery, 3 cases of sentinel node biopsy were included, we decreased the number of biopsies of non-palpable lesions, previously marked with a needle. We started to perform vaginal hysterectomy at the end of this series. We had 37 (3.2%) immediate admissions, 5 (0.4%) delayed re-admissions, 10 (0.9%) cancellations and 138 (12%) telephone calls. During this time, we have improved our Ambulatory Surgery and Office Surgery activites, with the consequent increase inproductivity. DISCUSSION: Our speciality has great possibilities in AS. We have updated some resources procedures (Le Font operation and Manchester Operation), included some new techniques (continous flow histeroscopy, mini-laparoscopy, sentinel node biopsy), and we have abandoned some others (uterine curettage, breast biopsy with needle localization). Our Quality controls are appropriated, and we have increases our surgical productivity,. In the future. We want to add hysterosocpic tubal occlusion and the treatment of urinary stress incontinence with tension-free vaginal tape (TVT) to our surgical indications (AU)

Successful pregnancy after combined pancreas-kidney transplantation.

In this paper we report a successful pregnancy after combined pancreas-kidney transplantation. During pregnancy the patient was treated with prednisone and cyclosporin. Pancreatic and renal function remained normal during pregnancy, but moderate hypertension was detected in the 28th week. A healthy baby of 1900 g (below the tenth percentile) was born at 36 weeks. In this case, urine pregnancy tests were negative throughout the pregnancy, probably due to the exocrine secretion of the pancreas, which had been diverted to the urinary bladder. This possibility has not been previously reported.

Ultrasound diagnostic features of twin reversed arterial perfusion sequence.

Two cases of twin reversed arterial perfusion (TRAP) sequence with relevant ultrasound features that would help an accurate diagnosis are described. Available management options are proposed and discussed.