Global benchmarks in primary robotic bariatric surgery redefine quality standards for Roux-en-Y gastric bypass and sleeve gastrectomy.

BACKGROUND: Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks. METHODS: Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years. RESULTS: A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass. CONCLUSION: The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.

Metas internacionales de seguridad del paciente en centro de salud: un artículo de revisión bibliográfica / International goals of patient safety in health centers: a bibliographic review article

Las metas internacionales de seguridad del paciente fueron implementadas por la Joint Commision International (JCI), a nivel mundial, con la finalidad de reducir los eventos adversos en los centros de salud. El objetivo de esta revisión bibliográfica fue identificar las metas internacionales de seguridad del paciente (MISP) incorporadas en centros de salud en el marco de la cultura de seguridad y calidad de la atención. Se realizó una revisión bibliográfica narrativa sistematizada utilizando las bases de datos de PubMed y EBSCO Host, utilizando criterios de inclusión y exclusión para la selección de los artículos para análisis. Los ámbitos evaluados relacionados a las metas internacionales de seguridad, identificados en los artículos seleccionados fueron: i) cultura de seguridad, ii) calidad de la atención, iii) comunicación efectiva, iv) cirugía de alto riesgo, v) medicamentos de alto riesgo. Las metas internacionales de calidad están incorporadas en los diferentes centros de salud, algunos de ellos definidos explícitamente en los sistemas de evaluación de calidad y otros de manera implícita en ámbitos generales en los sistemas de evaluación.

The Joint Commission International (JCI) implemented international patient safety goals worldwide to reduce adverse events in health centers. The objective of this literature review was to identify the international patient safety goals (MISP) incorporated in healthcare facilities within the framework of safety culture and quality of care. A systematized narrative literature review was carried out using PubMed and EBSCO Host databases, using inclusion and exclusion criteria to select articles for analysis. The areas evaluated related to the international safety goals identified in the selected articles were: i) safety culture, ii) quality of care, iii) effective communication, iv) high-risk surgery, v) high-risk drugs. International quality goals are incorporated in the different health centers, explicitly defined in the quality evaluation systems and others in general areas in the evaluation systems.

Valoración de parámetros clínicos y analíticos preoperatorios en apendicitis aguda complicada. Score para predecir apendicitis complicada / Evaluation of Preoperative Clinical and Serological Determinations in Complicated Acute Appendicitis: A Score for Predicting Complicated Appendicitis

Introducción: Los parámetros clínicos y analíticos de la apendicitis aguda (AA) son la base diagnóstica. Se analiza la diferencia de sus valores según la histología para distinguir las AA simples de las complicadas. Métodos: Análisis observacional retrospectivo que incluye pacientes (>14 años) que ingresan con diagnóstico de AA desde el 1 abril 2014 al 31 julio 2016. Histopatológicamente se dividen en AA complicada (perforada y/o gangrenada) y AA no complicada (flemonosa). Entre los 2 grupos se compara sexo, edad, temperatura al ingreso, duración de sintomatología, recuento leucocitario preoperatorio (WBC), porcentaje de neutrófilos, volumen plaquetario medio (VPM), índice de distribución de plaquetas (PDW), proteína C-reactiva (PCR) y estancia hospitalaria. Resultados: Se analizan 335 pacientes y se incluyen 284, de los cuales 194 (68,3%) tienen AA no complicada (AAnc) y 90 (31,7%) AA complicada (AAc). La edad, la duración de sintomatología, el porcentaje de neutrófilos, la PCR y la estancia hospitalaria son mayores en la AAc (p<0,05). Las diferencias de las medias entre AAnc y AAc son: edad 13,2 años (IC 95%: 8,2-18,2), duración de sintomatología 14,1h (IC 95%: 6,3-21,9), porcentaje de neutrófilos 5,0% (IC 95%: 3,2-6,8), PCR 73,6mg/l (IC 95%: 50,0-97,2) y estancia hospitalaria 2,2 días (IC 95%: 1,4-3,0), con p<0,05. Un modelo basado en parámetros preoperatorios (edad, duración de sintomatología, porcentaje de neutrófilos y PCR) se calcula para predecir la posibilidad de AAc. El área bajo la curva del modelo es 0,80 (IC 95%: 0,75-0,85). Conclusiones: El modelo predice la posibilidad de desarrollar AAc, pero debe validarse de manera prospectiva. (AU)

Background: To analyze whether clinical and analytical parameters differ according to histopathology in cases of acute appendicitis (AA). Methods: This is a retrospective, observational study including patients (>14 years of age) admitted for suspicion of AA from 1 April 2014 to 31 July 2016. Histopathology was divided into complicated (including perforated and gangrenous AA) and uncomplicated appendicitis (phlegmonous). Sex, age, temperature of patients on admission to the Emergency Department, symptom duration, preoperative white blood cell (WBC) count, neutrophil percentage, mean platelet volume (MPV), platelet distribution width (PDW), C-reactive protein (CRP) and hospital stay were compared in the two groups. Results: Three hundred and thirty-five patients were analyzed, and 284 were included. Appendicitis was uncomplicated in 194 (68.3%) and complicated in 90 (31.7%). Age, symptom duration, neutrophil percentage, CRP and hospital stay were higher in the complicated AA group (P < .05). The mean differences between uncomplicated and complicated AA were: age 13.2 years (95% CI: 8.2-18.2), symptom duration 14.1hours (95% CI: 6.3-21.9), neutrophil percentage 5.0% (95% CI: 3.2-6.8), CRP 73.6mg/l (95% CI: 50.0-97.2) and hospital stay 2.2 days (95% CI: 1.4-3.0), with p<0.05 for all these variables. A model based on the preoperative parameters (age, symptom duration, neutrophil percentage and CRP) was calculated to predict the likelihood of complicated AA. The receiver operating characteristic (ROC) of the model had an area under the curve of 0.80 (95% CI 0.75-0.85). Conclusion: This model is able to diagnose complicated AA without the need for imaging techniques, although it must be validated with prospective analysis. (AU)

Evaluation of Preoperative Clinical and Serological Determinations in Complicated Acute Appendicitis: A Score for Predicting Complicated Appendicitis. / Valoración de parámetros clínicos y analíticos preoperatorios en apendicitis aguda complicada. Score para predecir apendicitis complicada.

BACKGROUND: To analyze whether clinical and analytical parameters differ according to histopathology in cases of acute appendicitis (AA). METHODS: This is a retrospective, observational study including patients (>14 years of age) admitted for suspicion of AA from 1 April 2014 to 31 July 2016. Histopathology was divided into complicated (including perforated and gangrenous AA) and uncomplicated appendicitis (phlegmonous). Sex, age, temperature of patients on admission to the Emergency Department, symptom duration, preoperative white blood cell (WBC) count, neutrophil percentage, mean platelet volume (MPV), platelet distribution width (PDW), C-reactive protein (CRP) and hospital stay were compared in the two groups. RESULTS: Three hundred and thirty-five patients were analyzed, and 284 were included. Appendicitis was uncomplicated in 194 (68.3%) and complicated in 90 (31.7%). Age, symptom duration, neutrophil percentage, CRP and hospital stay were higher in the complicated AA group (P < .05). The mean differences between uncomplicated and complicated AA were: age 13.2 years (95% CI: 8.2-18.2), symptom duration 14.1hours (95% CI: 6.3-21.9), neutrophil percentage 5.0% (95% CI: 3.2-6.8), CRP 73.6mg/l (95% CI: 50.0-97.2) and hospital stay 2.2 days (95% CI: 1.4-3.0), with p<0.05 for all these variables. A model based on the preoperative parameters (age, symptom duration, neutrophil percentage and CRP) was calculated to predict the likelihood of complicated AA. The receiver operating characteristic (ROC) of the model had an area under the curve of 0.80 (95% CI 0.75-0.85). CONCLUSION: This model is able to diagnose complicated AA without the need for imaging techniques, although it must be validated with prospective analysis.

Clinical Validation of the Comprehensive Complication Index as a Measure of Postoperative Morbidity at a Surgical Department: A Prospective Study.

OBJECTIVE: Using clinical outcomes, to validate the comprehensive complication index (CCI) as a measure of postoperative morbidity in all patients undergoing surgery at a general surgery department. BACKGROUND: The Clavien-Dindo classification (CDC) is the most widely used system to assess postoperative morbidity. The CCI is a numerical scale based on the CDC. Once validated, it could be used universally to establish and compare the real postoperative complications of each surgical procedure. METHODS: Observational prospective cohort study. All patients who underwent surgery during the 1-year study period were included. All the complications graded with the CDC and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. Surgical procedures were classified according to the operative severity score (OSS) as minor, moderate, major, or major+. The clinical validation of the CCI was performed by assessing its correlation with 4 different clinical outcomes. RESULTS: A total of 1850 patients were included: 513 (27.7%) presented complications and 101 (5.46%) were readmitted. In the multivariate analysis, the CCI and CDC were associated with postoperative stay, prolongation of postoperative stay, readmission, and disability in all OSS groups (P < 0.001). The CCI was superior to the CDC in all models except for prolongation of stay for OSS moderate and major+. CONCLUSIONS: The CCI can be applied in all the procedures carried out at general surgery departments. It is able to determine the morbidity and allows the comparison of the outcomes at different services.

Triple afectación pancreática en una paciente con Von Hippel-Lindau / Triple pancreatic lesion in a patient with Von Hippel-Lindau disease

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Elevated parathyroid hormone levels after successful parathyroidectomy for primary hyperparathyroidism: a clinical review.

INTRODUCTION: Surgery for primary hyperparathyroidism (PHPT) is traditionally deemed to be successful if serum calcium levels return to normal 6 months after parathyroidectomy. Regular monitoring of serum calcium and parathyroid hormone (PTH) in the follow-up of patients after parathyroidectomy for PHPT has drawn attention to the presence of a normocalcemic group of patients with elevated PTH (NCePTH) during the post-operative period. The etiological factors and mechanisms underlying this condition, its consequences, and the possibility of treatment are the object of this study. MATERIALS AND METHODS: We conducted an unlimited PubMed search updated on March 31, 2017, which yielded 1628 results. We selected 37 articles, 33 of which included cases of NCePTH in their series and 23 performed statistical studies to assess factors associated with NCePTH. RESULTS: The maximum mean prevalence of NCePTH in the various series was 23.5%, ranging from 3 to 46%. Many factors were associated with NCePTH. The most important were higher pre-operative PTH, low pre-operative 25 (OH) D3, lower pre-operative creatinine clearance and greater adenoma weight. The origin of NCePTH may be multifactorial, since several factors were implicated in the etiology. NCePTH does not seem to be related to an increase in PHPT recurrence, although this possibility should not be dismissed. Vitamin D deficiency should be corrected. Treatment with calcium supplements seems to be clearly beneficial. CONCLUSION: The prevalence of NCePTH is high. The causes of secondary hyperparathyroidism should be investigated carefully. Patients require treatment and long-term follow-up.

Predictive Value of Gut Peptides in T2D Remission: Randomized Controlled Trial Comparing Metabolic Gastric Bypass, Sleeve Gastrectomy and Greater Curvature Plication.

BACKGROUND: Our aim was to determine the predictive value of gut hormone changes for the improvement of type 2 diabetes (T2D) following metabolic Roux-en-Y gastric bypass (mRYGB), sleeve gastrectomy (SG), and greater curvature plication (GCP) in a randomized controlled trial. Contradictory results have been obtained regarding the role of gastrointestinal hormones (in particular GLP-1) in beneficial metabolic bariatric surgery outcomes. METHODS: Forty-five patients with T2D (mean BMI 39.4 ± 1.9 kg/m2) were randomly assigned to mRYGB, SG, or GCP. Anthropometric and biochemical parameters, fasting concentrations of PYY, ghrelin, glucagon, and area under the curve (AUC) of GLP-1 after a standard meal test were determined prior to and at months 1 and 12 after surgery. RESULTS: Twelve months after surgery, total weight loss percentage was higher and HbA1c lower in the mRYGB group than in the SG and GCP groups (-35.2 ± 8.1 and 5.1 ± 0.6% vs. -27.8 ± 5.4 and 6.2 ± 0.8% vs. -20.5 ± 6.8 and 6.6 ± 1.3%; p = 0.007 and p < 0.001, respectively). Moreover, GLP-1 AUC at months 1 and 12 was greater and T2D remission was higher in mRYGB (80 vs. 53.3 vs. 20%, p < 0.001). Insulin treatment (odds ratio (OR) 0.025, p = 0.018) and the increase in GLP-1 AUC from baseline to month 1 (OR 1.021, p = 0.013) were associated with T2D remission. CONCLUSIONS: mRYGB achieves a superior rate of weight loss and T2D remission at month 12. Enhanced GLP-1 secretion 1 month after surgery was a determinant of glucose metabolism improvement. Registration number ( http://www.clinicaltrials.gov ): NCT14104758.

Trombosis portal y necrosis hepática: complicación excepcional de la pancreatitis aguda / Portal thrombosis and liver necrosis: Exceptional complication of acute pancreatitis

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Establishment of Mimosa biuncifera (Fabaceae) inoculated with arbuscular mycorrhizal fungi in greenhouse and field drought conditions / Establecimiento de Mimosa biuncifera (Fabaceae) inoculada con hongos micorrízicos arbusculares en invernadero y campo, en condiciones de sequía

AbstractMexico is dominated by arid or semi-arid ecosystems, predominantly characterized as xeric shrublands. These areas are frequently deteriorated due to agriculture or over-grazing by livestock (sheep and goats). The vegetation type mainly consists of thorny plant species, and among these, the dominant one in overgrazed areas is catclaw (Mimosa biuncifera). This is a nurse plant that facilitates establishment of other vegetation and promotes plant succession. Catclaw plants form a mutualistic association with arbuscular mycorrhizal fungi (AMF), which improves uptake of nutrients and water. The objective of this study was to determine the effect of inoculating catclaw plants with native AMF and starting their growth under a low water availability treatment in a greenhouse, and later transplanting them to field conditions of drought and deterioration. Field plants were evaluated according to their survivorship and growth. The seeds of catclaw plants and soil with AMF spores were collected in the Mezquital Valley of Hidalgo State, in Central Mexico. Seedlings were grown in individual pots in a greenhouse. The experimental design consisted of two levels of pot irrigation, wet (W) and dry (D), as well as the presence (M+) or absence (M-) of AMF inoculum, with 20 replicates for each treatment. The following plant parameters were recorded every week: height, number of leaves and pinnae, and mean diameter of coverage. After 20 weeks in the greenhouse, determination was made of fresh and dry biomass, relative growth rate (RGR), root/shoot ratio, real evapotranspiration (RET), water-use efficiency (WUE), and percentage of mycorrhizal colonization. The remaining plants growing under the dry treatment (M+ and M-) were then transplanted to a semi-arid locality in the Mezquital Valley. During one year, monthly records were kept of their height, number of leaves, mean diameter of coverage and survival. Results showed that compared to greenhouse plants under other treatments, those under the wet mycorrhizal (WM+) treatment were taller, had more pinnae, and were characterized by greater coverage, faster RGR, and greater fresh and dry biomass. Moreover, inoculated plants (WM+ and DM+) showed higher WUE than those uninoculated (WM- and DM-, respectively). After one year in field conditions, there was a higher survival rate for previously inoculated versus uninoculated plants. Hence, mycorrhization of M. biuncifera with native AMF inoculum increased plant efficiency in biomass production, thus favoring establishment and survival in field conditions. We concluded that inoculation of catclaw plants is recommendable for revegetation programs in deteriorated semi-arid zones. Rev. Biol. Trop. 64 (2): 791-803. Epub 2016 June 01.

ResumenMás de la mitad del territorio mexicano está dominado por ecosistemas áridos y semiáridos. El principal tipo de vegetación de estos ambientes son matorrales xerófilos y normalmente están deteriorados por agricultura y sobrepastoreo de ovejas y cabras inducido por la actividad humana. Las plantas espinosas dominan en estas zonas, como el gatuño (Mimosa biuncifera Benth., Fabaceae), que es una planta nodriza que promueve la sucesión vegetal. Las plantas de gatuño forman junto con hongos micorrizógenos arbusculares (HMA), una asociación mutualista llamada micorriza arbuscular que mejora la captación vegetal de nutrimentos y agua. El objetivo de este trabajo fue determinar el efecto de la inoculación con HMA nativos en plantas de gatuño, para evaluar su crecimiento y establecimiento bajo un tratamiento de baja disponibilidad hídrica, tanto en condiciones de invernadero como de campo. Para esto, se recolectaron semillas de Mimosa biuncifera y suelo con esporas de HMA en el Valle del Mezquital, estado de Hidalgo, en el Centro de México. Las plántulas fueron cultivadas en macetas individuales en condiciones de invernadero bajo un diseño experimental que consistió en dos tratamientos de riego de las macetas, húmedo (W) y seco (D), y dos tratamientos de inoculación: con y sin inóculo de HMA (M+, M-). Cada tratamiento tuvo 20 repeticiones. Semanalmente se registró altura, diámetro medio de la cobertura y número de hojas y pinnas de las plantas. Después de 20 semanas, se determinaron biomasa húmeda y seca, tasa relativa de crecimiento (TRC), proporción raíz vástago, evapotranspiración real, eficiencia en el uso del agua (WUE) y porcentaje de colonización micorrícica. Posteriormente, los individuos del tratamiento seco (M+ y M-) fueron trasplantados a una localidad semiárida en el Valle del Mezquital, donde la altura, número de hojas y supervivencia fueron registrados mensualmente durante un año. Los resultados muestran que las plantas en el tratamiento húmedo y micorrizado (WM+) tuvieron una mayor altura, cobertura vegetal, biomasa húmeda y seca, TRC y más pinnas que las plantas de los otros tratamientos; también los tratamientos micorrizados (WM+ y DM+) tuvieron mayor WUE que la plantas sin inóculo (M-). En condiciones de campo, después de un año, la supervivencia de las plantas M+ fue mayor que en los testigos. Se concluyó que la micorrización de M. biuncifera con inóculo nativo incrementa su eficiencia en la producción de biomasa y favorece el establecimiento y supervivencia en condiciones de campo. Finalmente, se recomienda la inoculación de plantas de gatuño con HMA en programas de revegetación de zonas semiáridas deterioradas.

Garengeot's hernia: two case reports with CT diagnosis and literature review.

Garengeot's hernia (GH) is defined as the presence of the appendix inside a femoral hernia. It occurs in 0.9% of femoral hernias and is usually an incidental finding during surgery. Its treatment is controversial and the aim of this article is to review the diagnostic methods and surgical considerations. We report two cases diagnosed preoperatively by contrast-enhanced computed tomography (CT) and discuss the treatment options based on a review of the literature published in PubMed updated on 1 December, 2015. Fifty articles reporting 64 patients (50 women, mean age 70 years) with GH were included in the analysis. Diagnosis was performed by preoperative CT in only 24 cases, including our two. The treatment of GH is emergency surgery. Several options are available laparoscopic or open approach: insertion of a mesh or simple herniorrhaphy, with or without appendectomy. CONSLUSION: The preoperative diagnosis with CT can guide the choice of treatment. Appendectomy and hernioplasty should be performed via inguinotomy, if there is no perforation or abscess formation.

Establishment of Mimosa biuncifera (Fabaceae) inoculated with arbuscular mycorrhizal fungi in greenhouse and field drought conditions.

Mexico is dominated by arid or semi-arid ecosystems, predominantly characterized as xeric shrublands. These areas are frequently deteriorated due to agriculture or over-grazing by livestock (sheep and goats). The vegetation type mainly consists of thorny plant species, and among these, the dominant one in overgrazed areas is catclaw (Mimosa biuncifera). This is a nurse plant that facilitates establishment of other vegetation and promotes plant succession. Catclaw plants form a mutualistic association with arbuscular mycorrhizal fungi (AMF), which improves uptake of nutrients and water. The objective of this study was to determine the effect of inoculating catclaw plants with native AMF and starting their growth under a low water availability treatment in a greenhouse, and later transplanting them to field conditions of drought and deterioration. Field plants were evaluated according to their survivorship and growth. The seeds of catclaw plants and soil with AMF spores were collected in the Mezquital Valley of Hidalgo State, in Central Mexico. Seedlings were grown in individual pots in a greenhouse. The experimental design consisted of two levels of pot irrigation, wet (W) and dry (D), as well as the presence (M+) or absence (M-) of AMF inoculum, with 20 replicates for each treatment. The following plant parameters were recorded every week: height, number of leaves and pinnae, and mean diameter of coverage. After 20 weeks in the greenhouse, determination was made of fresh and dry biomass, relative growth rate (RGR), root/shoot ratio, real evapotranspiration (RET), water-use efficiency (WUE), and percentage of mycorrhizal colonization. The remaining plants growing under the dry treatment (M+ and M-) were then transplanted to a semi-arid locality in the Mezquital Valley. During one year, monthly records were kept of their height, number of leaves, mean diameter of coverage and survival. Results showed that compared to greenhouse plants under other treatments, those under the wet mycorrhizal (WM+) treatment were taller, had more pinnae, and were characterized by greater coverage, faster RGR, and greater fresh and dry biomass. Moreover, inoculated plants (WM+ and DM+) showed higher WUE than those uninoculated (WM- and DM-, respectively). After one year in field conditions, there was a higher survival rate for previously inoculated versus uninoculated plants. Hence, mycorrhization of M. biuncifera with native AMF inoculum increased plant efficiency in biomass production, thus favoring establishment and survival in field conditions. We concluded that inoculation of catclaw plants is recommendable for revegetation programs in deteriorated semi-arid zones.