[Metástasis hepáticas sincrónicas de cáncer colorrectal. ¿Resección simultánea o diferida?] / Synchronous liver metastases from colorectal origin. Simultaneous or staged resection?

INTRODUCCIÓN: El 20-40% de las metástasis hepáticas de origen colorrectal son de tipo sincrónico. Actualmente existen tres estrategias quirúrgicas; dos de ellas proponen resecciones diferidas, y la otra, la resección simultánea. OBJETIVO: evaluar los resultados a corto y largo plazo de las resecciones simultáneas. MÉTODO: Evaluamos 212 metástasis hepáticas sincrónicas resecadas en dos centros y comparamos las intervenidas de forma simultánea con aquellas de manera diferida. Evaluamos las características demográficas, las resecciones hepáticas y las características de las metástasis. También evaluamos la morbimortalidad. RESULTADOS: Fueron resecados de manera simultánea con el tumor primario 63 pacientes, y no hubo diferencias significativas en las características demográficas. Hubo más resecciones mayores (p = 0.005) en el grupo de las diferidas. La morbimortalidad fue comparable. La insuficiencia hepática (p = 0.037) fue mayor en el grupo de las diferidas. La morbilidad fue del 33.2% en las diferidas y del 10.1% en las simultáneas (p = 0.256). La mortalidad fue del 2.83% en las diferidas y del 0.94% en las simultáneas (p = 0.508). CONCLUSIÓN: Los resultados a corto y largo plazo en ambos grupos son similares. Queda el interrogante de si la necesidad de una hepatectomía mayor favorecería la elección de un tratamiento diferido. INTRODUCTION: Between 20 and 40% of liver metastases from colorectal tumor are synchronous. Three types of surgical approaches are proposed; two of them propose a deferred resection and the other, simultaneous resection. The aim of this analysis is to assess the short- and long-term outcomes of simultaneous resections. METHOD: 212 synchronous liver metastases resected in two centers were evaluated. Comparison between those resected simultaneously with those that were in a deferred way was made. Demographics, liver resections and metastatic characteristics were evaluated. Morbidity and mortality of both alternatives are also evaluated. RESULTS: 63 patients were resected simultaneously with the primary tumor, there were no significant differences in demographic characteristics. There was a greater number of major resections (p = 0.005) in the deferred group. Morbidity and mortality was comparable in both groups. Liver failure (p = 0.037) was higher in the deferred group. Morbidity was 33.2% in the deferred and 10.1% for the simultaneous (p = 0.256). Mortality rate was 2.83% in the deferred and 0.94% in the simultaneous group (p = 0.508). CONCLUSION: Short and long-term outcomes for both groups are similar. A question remains to be answered: the need of a major hepatectomy will favor the election of a deferred treatment?

[Resultados a corto y largo plazo de las rehepatectomías como parte del tratamiento multimodal de las metástasis de origen colorrectal. Un estudio biinstitucional]. / Short and long-term outcomes of the re-hepatectomies as part of multi-modal treatment of hepatic metastases from colo-rectal origin. Bi-institutional study.

INTRODUCCIÓN: Un alto porcentaje de pacientes que reciben una hepatectomía por metástasis de cáncer colorrectal presentarán recidiva hepática, y en algunas será posible una nueva resección. La utilidad de las hepatectomías repetidas continúa siendo discutida. OBJETIVO: Evaluar los resultados obtenidos a corto y largo plazo. MÉTODO: Fueron analizadas 68 rehepatectomías de dos instituciones. Se analizaron datos demográficos y características de la enfermedad metastásica y de las resecciones hepáticas. Los tipos de complicaciones y la morbimortalidad también fueron analizados, al igual que la supervivencia y el tiempo libre de enfermedad. Se evaluaron algunos de los factores de mal pronóstico mencionados en la literatura. RESULTADOS: El análisis de los datos de corto plazo no mostró diferencias significativas entre los pacientes de primera hepatectomía y de hepatectomías repetidas, a excepción del porcentaje de fístulas biliares posoperatorias (p = 0.001). La supervivencia a 1 año es similar, mientras que a 3 y 5 años mostró diferencias significativas (p = 0.024 y 0.004, respectivamente). Los factores de mal pronóstico referidos en la literatura no fueron representativos en esta serie. CONCLUSIÓN: Los resultados a corto plazo de los pacientes con rehepatectomía son similares a los de aquellos resecados una vez. Los resultados a largo plazo de las rehepatectomías son inferiores a otros publicados. INTRODUCTION: A high percentage of patients undergoing hepatectomy for metastatic colorectal liver disease will have a recurrence. Of these, some can be subject to a new resection. The usefulness of repeated hepatectomy remains controversial. The aim of this study is to evaluate the results of short and long-term outcomes in repeated hepatectomies. METHODS: They were re-analyzed 68 repeated hepatectomies from two institutions. Demographics, characteristics of metastatic disease and hepatic resections were analyzed. Types of complications, morbidity and mortality were also analyzed as survival and disease-free time. Some of the factors of poor prognosis mentioned in the literature were evaluated. RESULTS: The analysis of short-term data showed no statistically significant differences between patients with first and repeated hepatectomy, except the percentage of postoperative biliary leakage (p = 0.001). The 1-year survival was similar while 3 and 5 years survival showed significant differences (p = 0.024 and 0.004, respectively). The factors of poor prognosis referred in the literature were not representative in this series. CONCLUSION: The short-term results of repeated hepatectomy are similar to those resected once. Long term result are inferior to other published series.

Educational interventions to improve the effectiveness in clinical competence of general practitioners: problem-based versus critical reading-based learning.

BACKGROUND: Evidence suggests that continuing medical education improves the clinical competence of general practitioners and the quality of health care services. Thus, we evaluated the relative impact of two educational strategies, critical reading (CR) and problem based learning (PBL), on the clinical competence of general practitioners in a healthcare system characterized by excessive workload and fragmentation into small primary healthcare centers. METHODS: Clinical competence was evaluated in general practitioners assigned to three groups based on the educational interventions used: 1) critical reading intervention; 2) problem based learning intervention; and 3) no intervention (control group, which continued clinical practice as normal). The effect on the clinical competence of general practitioners was evaluated in three dimensions: the cognitive dimension, via a self-administered questionnaire; the habitual behavioral dimension, via information from patient's medical records; and the affective dimension, through interviews with patients. A paired Student´s t-test was used to evaluate the changes in the mean clinical competence scores before and after the intervention, and a 3 x 2 ANOVA was used to analyze groups, times and their interaction. RESULTS: Nine general practitioners participated in the critical reading workshop, nine in the problem-based learning workshop, and ten were assigned to the control group. The participants exhibited no significant differences in clinical competence measures at baseline, or in socio-demographic or job characteristics (p > 0.05). Significant improvements in all three dimensions (cognitive, 45.67 vs 54.89; habitual behavioral, 53.78 vs 82.33; affective, 4.16 vs 4.76) were only observed in the problem-based learning group after the intervention (p > 0.017). CONCLUSIONS: While no differences in post-intervention scores were observed between groups, we conclude that problem-based learning can be effective, particularly in a small-group context. Indeed, problem-based learning was the only strategy to induce a significant difference between pre- and post- intervention scores for all three CC dimensions.

[Analgesic effect of intra-artcular fentanyl in knee arthroscopy to treat patellofemoral lateral hyperpressure syndrome]. / Efecto analgésico del fentanyl intraarticular en artroscopía de rodilla para el síndrome de hiperpresión lateral patelofemoral.

INTRODUCTION: During arthroscopy for the treatment of patellofemoral lateral hyper-pressure syndrome (LHS), intra-articular morphine or its derivatives (fentanyl) may reduce postoperative pain when combined with anesthetics. We therefore decided to determine whether adding fentanyl to epinephrine and bupivacaine produced an increased analgesia. MATERIAL AND METHODS: We randomly distributed 40 patients into two groups. The experimental group (n=20) was given 0.5% bupivacaine (2 mg/kg), epinephrine (100 microg) and fentanyl (2.5 microg/kg). The control group (n=20) received 0.5% bupivacaine (2 mg/kg) and epinephrine (100 microg). Patients underwent chondroplasty and retinacular release, and we assessed pain, time of analgesia and postoperative range of motion at postoperative hours 6 and 24. RESULTS: The age and the grade of patellofemoral chondromalacia (PFC) were similar in both groups (p > 0.05). No differences were found in pain and ranges of motion intraoperatively and at postoperative hours 6 and 24 (p > 0.05) between both groups. The postoperative analgesia time was similar (p > 0.05). CONCLUSIONS: Adding intra-articular fentanyl to the combination of epinephrine plus bupivacaine did not decrease pain, and did not increase neither the analgesia time nor the range of motion in patients with LHS undergoing knee arthroscopy.