Análisis del tratamiento quirúrgico más apropiado para la colecistitis aguda mediante aplicación del método RAND/UCLA / Analysis of the most appropriate surgical treatment for acute cholecystitis by applying the RAND/UCLA method

Introducción: La colecistitis aguda (CA) constituye una indicación frecuente de colecistectomía. Las circunstancias locales y ciertas características de los pacientes provocan unas altas tasas de fracaso y complicaciones de la colecistectomía laparoscópica (CL) y, a pesar de la experiencia ganada, aún no disponemos de una lista de indicaciones pormenorizada que permita minimizarlas. Material y método Empleamos el análisis de la adecuación RAM para evaluar 2 opciones, la CL y la colecistectomía abierta (OC). Un panel de expertos analizó su idoneidad tras una revisión de la bibliografía, una reunión de consenso y 2 rondas de puntuaciones sobre diferentes situaciones clínicas. Se analizó la puntuación sobre cada escenario para establecer el grado de adecuación de cada opción. Resultados Tras la reunión presencial quedaron definidos 64 escenarios, lográndose un acuerdo en las indicaciones en el 67,18% de ellos. En el 86,04% de los escenarios el acuerdo fue por adecuación de las indicaciones. Cuando la colecistectomía estuvo indicada siempre lo fue por laparoscopia, mientras que solo en ocasiones lo fue por laparotomía. En pacientes con menos de 72 h de evolución se consideró apropiada siempre la CL cuando se presentasen con sepsis, o bien sin ella pero con datos ecográficos de CA complicada. Conclusiones Sigue existiendo incertidumbre respecto al manejo de la CA, en especial respecto al momento de la intervención y la vía de abordaje, particularmente en pacientes frágiles y con evoluciones de la clínica superiores a las 72 h. El método RAND puede ayudar a tomar decisiones sobre la adecuación de distintas opciones terapéuticas (AU)

Introduction: Acute cholecystitis (AC) is a common indication for cholecystectomy. Local circumstances and certain patient characteristics lead to high failure rates and complications in laparoscopic cholecystectomy (LC), and despite the experience gained, we still do not have a detailed list of indications which could minimise them. Material and method: We used the RAND/UCLA Appropriateness Method (RAM) to evaluate2 options, LC and open cholecystectomy (OC). An expert panel analysed its suitability after a literature review, a consensus meeting, and 2 rounds of scores on different clinical situations. The score of each scenario was analysed to establish the appropriateness level of each option. Results: At the end of the meeting there were 64 defined scenarios, with an agreement being reached on the indications in 67.18% of them. In 86.04% of the scenarios, the agreement was due to the appropriateness of the indications. When cholecystectomy was indicated, it was always by laparoscopy, while it was only occasionally by laparotomy. In patients with less than 72 h of onset, LC was always considered appropriate when there was sepsis, or even without this if the ultrasound data showed complicated AC. Conclusions: There is still uncertainty as regards the management of AC, especially as regards the timing of the operation and the surgical approach, particularly in frail patients and with a clinical onset greater than 72 h. The RAND method can help to make decisions on the appropriateness of different therapeutic options (AU)

[Analysis of the most appropriate surgical treatment for acute cholecystitis by applying the RAND/UCLA method]. / Análisis del tratamiento quirúrgico más apropiado para la colecistitis aguda mediante aplicación del método RAND/UCLA.

INTRODUCTION: Acute cholecystitis (AC) is a common indication for cholecystectomy. Local circumstances and certain patient characteristics lead to high failure rates and complications in laparoscopic cholecystectomy (LC), and despite the experience gained, we still do not have a detailed list of indications which could minimise them. MATERIAL AND METHOD: We used the RAND/UCLA Appropriateness Method (RAM) to evaluate 2 options, LC and open cholecystectomy (OC). An expert panel analysed its suitability after a literature review, a consensus meeting, and 2 rounds of scores on different clinical situations. The score of each scenario was analysed to establish the appropriateness level of each option. RESULTS: At the end of the meeting there were 64 defined scenarios, with an agreement being reached on the indications in 67.18% of them. In 86.04% of the scenarios, the agreement was due to the appropriateness of the indications. When cholecystectomy was indicated, it was always by laparoscopy, while it was only occasionally by laparotomy. In patients with less than 72 h of onset, LC was always considered appropriate when there was sepsis, or even without this if the ultrasound data showed complicated AC. CONCLUSIONS: There is still uncertainty as regards the management of AC, especially as regards the timing of the operation and the surgical approach, particularly in frail patients and with a clinical onset greater than 72 h. The RAND method can help to make decisions on the appropriateness of different therapeutic options.

Appropriate management of common bile duct stones: a RAND Corporation/UCLA Appropriateness Method statistical analysis.

BACKGROUND: Bile duct stones affect 10% of patients who undergo a cholecystectomy and therefore represent a major health problem. Laparoscopic common bile duct exploration, endoscopic sphincterotomy, and open surgical choledocholithotomy are the three available methods for dealing with choledocholithiasis. Though many trials and reviews have compared all three strategies, a list of indications for defined patient profiles is lacking. METHODS: We employed the RAND Corporation/UCLA Appropriateness Method (RAM) to evaluate the three procedures for bile duct stone clearance. An expert panel judged appropriateness after a comprehensive bibliography review, a first-round private rating of 108 different clinical situations, a consensus meeting, and a second round of definitive rating. A list of indications for each procedure was statistically calculated. RESULTS: A consensus was reached for 41 indications (38%). The endoscopic approach was always appropriate for preoperatively diagnosed bile duct stones and inappropriate for patients with single intraoperative detected stones causing cholangitis and bile duct dilatation. Laparoscopic bile duct exploration was appropriate for preoperatively diagnosed choledocholithiasis if patients had not undergone a previous cholecystectomy and no signs of cholangitis were detected. The laparoscopic approach was also appropriate for intraoperatively incidentally detected stones, except for septic patients with poor performance status and multiple calculi. Laparoscopic bile duct clearance was judged inappropriate for septic patients with poor performance status and absence of bile duct dilatation. Open surgery was appropriate in all patients with intraoperative diagnosis of choledocholithiasis and cholangitis and in septic patients with bile duct dilatation. There was no clinical situation in which open surgery was appropriate when bile duct stones were preoperatively diagnosed. CONCLUSIONS: There is still uncertainty with respect to the management of choledocholithiasis, showing the need for further investigation. The RAM helps to elucidate appropriateness for the different treatment options in specific clinical settings.

Reconstrucción tridimensional de metástasis mandibular en adenocarcinoma prostático / Three-dimensional reconstruction of mandibular metastasis in prostatic adenocarcinoma

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[Experience with the Bogota bag technique for temporary abdominal closure]. / Experiencia con la técnica de la bolsa de Bogotá para el cierre temporal del abdomen.

INTRODUCTION: The Bogota bag technique is a reliable method for open abdominal closure. The aim of this study was to describe our experience with this technique. MATERIAL AND METHOD: We retrospectively evaluated our experience with the Bogota Bag technique between January 2000 and March 2006. Descriptive statistical techniques were applied and percentages and means were calculated. RESULTS: The Bogota bag technique was applied in 12 patients. The technique was the preferred closure system to prevent abdominal compartment syndrome in 11 patients (91.66%) and was required to treat abdominal compartment syndrome in one patient (8.34%). No complications occurred in relation to placement or withdrawal of the Bogota bag. There were no intestinal fistulas or intra-abdominal abscesses. The mean length of hospital stay was 46.33 days and the mean length of stay in the intensive care unit was 16.58 days. The survival rate was 41.66%. CONCLUSIONS: In our experience, the Bogota bag is a useful technique and is the preferred closure system to prevent or treat abdominal compartment syndrome. The high mortality rates described are due to the underlying diseases leading to open abdominal closure and not directly to the Bogota bag technique itself.

Experiencia con la técnica de la bolsa de Bogotá para el cierre temporal del abdomen / Experience with the Bogota bag technique for temporary abdominal closure

Introducción. La bolsa de Bogotá es uno de los dispositivos que se han descrito para el cierre temporal del abdomen. El objetivo de este trabajo ha sido describir nuestra experiencia con la técnica de la bolsa de Bogotá. Material y método. Analizamos retrospectivamente nuestra experiencia entre enero de 2000 y marzo de 2006. Se aplicó estadística descriptiva con cálculo de porcentajes y medias. Resultados. En un total de 12 pacientes se empleó la bolsa de Bogotá. En 11 (91,66%) se colocó de forma preventiva por presentar riesgos de hipertensión intraabdominal y síndrome compartimental abdominal. En un paciente (8,34%) la descompresión con bolsa de Bogotá se realizó una vez el síndrome compartimental se había instaurado. No hemos tenido ninguna complicación en relación con la colocación ni la retirada de la bolsa de Bogotá. En ningún caso aparecieron fístulas intestinales ni colecciones infectadas intraabdominales. La estancia media hospitalaria fue de 46,33 días y en la unidad de cuidados intensivos, de 16,58 días. En la actualidad 7/12 (58,34%) han fallecido y 5/12 (41,66%) viven. Conclusiones. La bolsa de Bogotá para el open abdomen en nuestra serie ha sido un método útil para evitar o tratar el síndrome compartimental abdominal. La gran mortalidad descrita viene dada por el proceso inicial que presentan los pacientes y no por las complicaciones derivadas de la colocación de la bolsa de Bogotá (AU)

Introduction. The Bogota bag technique is a reliable method for open abdominal closure. The aim of this study was to describe our experience with this technique. Material and method. We retrospectively evaluated our experience with the Bogota Bag technique between January 2000 and March 2006. Descriptive statistical techniques were applied and percentages and means were calculated. Results. The Bogota bag technique was applied in 12 patients. The technique was the preferred closure system to prevent abdominal compartment syndrome in 11 patients (91.66%) and was required to treat abdominal compartment syndrome in one patient (8.34%). No complications occurred in relation to placement or withdrawal of the Bogota bag. There were no intestinal fistulas or intra-abdominal abscesses. The mean length of hospital stay was 46.33 days and the mean length of stay in the intensive care unit was 16.58 days. The survival rate was 41.66%. Conclusions. In our experience, the Bogota bag is a useful technique and is the preferred closure system to prevent or treat abdominal compartment syndrome. The high mortality rates described are due to the underlying diseases leading to open abdominal closure and not directly to the Bogota bag technique itself (AU)