Evaluación económica del tratamiento quirúrgico de la obesidad / Economic evaluation of surgical treatment of obesity

INTRODUCCIÓN: La cirugía bariátrica es el mejor tratamiento de la obesidad mórbida a largo plazo. El ahorro generado por la mejoría de las comorbilidades podría justificar el empleo de más recursos sanitarios. MÉTODOS: Estudio observacional, descriptivo, longitudinal y retrospectivo, de pacientes a los que se les realizó un bypass gástrico, en el Hospital Universitario Central de Asturias entre 2003 y 2012. El seguimiento mínimo se estableció en dos años. Calculamos de manera individualizada el coste para cada uno de los pacientes intervenidos (bottom-up), así como según el grupo relacionado por el diagnóstico (GRD) (top-down). RESULTADOS: De los 307 pacientes del estudio, el coste medio del ingreso calculado por GRD fue de 6.545,9€ y el calculado por paciente de 10.572,2€. El GRD 288 representa al 91% de la serie con un valor de 4.631€. El cálculo estimativo del ahorro que supuso en nuestro entorno sanitario la disminución del número de fármacos de 2,86 a 0,78 por paciente medicado, representó 4.433€ por paciente intervenido si padecía todas las comorbilidades analizadas. CONCLUSIONES: El bypass gástrico en el Hospital Universitario Central de Asturias a los dos años de la cirugía, en pacientes con pluripatología consiguió un ahorro solo en fármacos que podría compensar los gastos inherentes al tratamiento quirúrgico. El coste por proceso mediante GRD se mostró insuficiente a la hora de hacer una correcta evaluación económica, por lo que recomendamos un método de evaluación de coste por paciente

INTRODUCTION: Obesity surgery is the best treatment for extreme obesity, with demonstrated long-term positive outcomes. The potential cost-savings generated by the improvement of comorbidities after surgery can justify the allocation of more resources in the surgical treatment of obesity. METHODS: This was an observational, descriptive, longitudinal and retrospective study. Eligible patients underwent Roux-en-Y gastric bypass surgery at the Hospital Universitario Central de Asturias between 2003 and 2012. The established minimum follow-up period was two years. We calculated the individualized cost per patient treated (bottom-up) as well as per Diagnosis-Related Group (DRG) codes (top-down). RESULTS: Our study included 307 patients. The average cost per hospitalization calculated by DRG codes was €6,545.90, and the average cost per patient was €10,572.20. DRG 288 represented 91% of the series, with a value of €4,631. The number of medications also decreased during this period, from 2.86 to 0.78 per medically treated patient, representing a cost reduction of €4,433 per patient with all the obesity-related comorbidities analyzed. CONCLUSIONS: Two years after Roux-en-Y gastric bypass conducted at Hospital Universitario Central de Asturias, the savings in drug costs for patients with multiple pathologies would compensate the inherent costs of the surgical treatment itself. Our results showed that DRG-related costs was insufficient to make a correct economic evaluation, so we recommend an individualized cost calculating method

Economic evaluation of surgical treatment of obesity. / Evaluación económica del tratamiento quirúrgico de la obesidad.

INTRODUCTION: Obesity surgery is the best treatment for extreme obesity, with demonstrated long-term positive outcomes. The potential cost-savings generated by the improvement of comorbidities after surgery can justify the allocation of more resources in the surgical treatment of obesity. METHODS: This was an observational, descriptive, longitudinal and retrospective study. Eligible patients underwent Roux-en-Y gastric bypass surgery at the Hospital Universitario Central de Asturias between 2003 and 2012. The established minimum follow-up period was two years. We calculated the individualized cost per patient treated (bottom-up) as well as per Diagnosis-Related Group (DRG) codes (top-down). RESULTS: Our study included 307 patients. The average cost per hospitalization calculated by DRG codes was €6,545.90, and the average cost per patient was €10,572.20. DRG 288 represented 91% of the series, with a value of €4,631. The number of medications also decreased during this period, from 2.86 to 0.78 per medically treated patient, representing a cost reduction of €4,433 per patient with all the obesity-related comorbidities analyzed. CONCLUSIONS: Two years after Roux-en-Y gastric bypass conducted at Hospital Universitario Central de Asturias, the savings in drug costs for patients with multiple pathologies would compensate the inherent costs of the surgical treatment itself. Our results showed that DRG-related costs was insufficient to make a correct economic evaluation, so we recommend an individualized cost calculating method.

Emergency surgery in chronic intestinal pseudo-obstruction due to mitochondrial neurogastrointestinal encephalomyopathy: case reports.

Chronic intestinal pseudo-obstruction (CIPO) is a syndrome characterized by recurrent clinical episodes of intestinal obstruction in the absence of any mechanical cause occluding the gut. There are multiple causes related to this rare syndrome. Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is one of the causes related to primary CIPO. MNGIE is caused by mutations in the gene encoding thymidine phosphorylase. These mutations lead to an accumulation of thymidine and deoxyuridine in blood and tissues of these patients. Toxic levels of these nucleosides induce mitochondrial DNA abnormalities leading to an abnormal intestinal motility.Herein, we described two rare cases of MNGIE syndrome associated with CIPO, which needed surgical treatment for gastrointestinal complications. In one patient, intra-abdominal hypertension and compartment syndrome generated as a result of the colonic distension forced to perform emergency surgery. In the other patient, a perforated duodenal diverticulum was the cause that forced to perform surgery. There is not a definitive treatment for MNGIE syndrome and survival does not exceed 40 years of age. Surgery only should be considered in some selected patients.

Pseudocarcinoma de colon / Pseudo-carcinoma of the colon

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¿Mejora la incorporación de un simulador virtual las capacidades en cirugía endoscópica adquiridas con simuladores inanimados? / Does the incorporation of a virtual simulator improve abilities in endoscopic surgery acquired with an inanimate simulator?

Se ha generalizado la realización de cursos y programas de formación en cirugía endoscópica en centros de entrenamiento. Además de una adecuada planificación de las actividades, se deben introducir sistemas de simulación para el aprendizaje y monitorizar la progresión. Se valoró la mejor adquisición de capacidades en un programa de formación en cirugía endoscópica al incorporar un simulador virtual a la práctica con cajas de entrenamiento. Material y método Se incluyó a 17 médicos residentes con un registro basal: grupo control. Se constituyeron 2 grupos: el grupo A, con 6h de entrenamiento con simulador inanimado, y el grupo B, con lo mismo más 4h de prácticas con LapSim. Se planificaron ejercicios de movilización-desplazamiento de objetos, corte y sutura-anudado en el simulador simple y en el virtual. Se evaluó el tiempo (medias e intervalos de confianza del 95%) empleado en cada ejercicio sobre el simulador inanimado, antes y después del entrenamiento. ResultadosEjercicio de movilización: el tiempo del grupo control fue de 223,6s, el del grupo A fue de 103,7s y el del grupo B fue de 89,9s (grupo control frente al grupo A, p<0,05). Ejercicio de corte: el tiempo del grupo control fue de 317,72s, el del grupo A fue de 232,8s y el del grupo B fue de 163,6s, (grupo control frente al grupo B, p<0,05). En el ejercicio de sutura todos consiguen dar un punto tras el entrenamiento. El tiempo del grupo control fue de 518,4s, el de A fue de 309,4s y el de B fue de 189,5s (grupo control frente al grupo A, p<0.05).Conclusiones El entrenamiento con simulador inanimado consiguió mejorar tanto el tiempo de movilización como el de sutura-anudado con respecto al grupo control. La incorporación del simulador virtual ha logrado superar los resultados obtenidos, sobre todo en el corte (AU)

Introduction The carrying out of training courses in surgical endoscopy for surgeons in training centres, is becoming more common. In addition to adequately planning activities, simulation systems are used to improve learning and monitor progression. Inanimate models and virtual reality programs increase psychomotor skills and assessment of performance. In this work we tried to improve our training program, basically in training boxes by introducing a virtual simulator. Material and method Seventeen surgical residents, with a basic training were chosen as the control group. Two additional groups were established, group A: with 6 hours of training with inanimate simulator. Group B: the same training system plus 4h of practice with LapSim. Exercises in the endotrainer and virtual simulator with moving-replacing objects, cutting and suturing-knotting were planned. End-point was time (mean with 95% confidence interval) in every exercise in box trainer, before and after the training period. Results Movement exercises: Time in control group was 223.6s, A:103.7s, and B:89.9s (Control vs. A, p<0,05). Cutting exercises: Time in control group was 317.7s, group A: 232.8s and in the B: 163.6s, (Control vs. B, p<0.05). In the suture/knot exercise everyone was able to carry out a stitch after the training period. Time in control group was 518.4s, in group A: 309.4s, p<0.05, and in B:189.5s (Control vs. A, p<0.05).Conclusions Training in inanimate boxes was able to improve the skills of students, particularly for moving and suture/knots. The incorporation of a virtual simulator increased the learning capabilities, mainly in cutting exercises (AU)

[Does the incorporation of a virtual simulator improve abilities in endoscopic surgery acquired with an inanimate simulator?]. / ¿Mejora la incorporación de un simulador virtual las capacidades en cirugía endoscópica adquiridas con simuladores inanimados?

INTRODUCTION: The carrying out of training courses in surgical endoscopy for surgeons in training centres, is becoming more common. In addition to adequately planning activities, simulation systems are used to improve learning and monitor progression. Inanimate models and virtual reality programs increase psychomotor skills and assessment of performance. In this work we tried to improve our training program, basically in training boxes by introducing a virtual simulator. MATERIAL AND METHOD: Seventeen surgical residents, with a basic training were chosen as the control group. Two additional groups were established, group A: with 6 hours of training with inanimate simulator. Group B: the same training system plus 4h of practice with LapSim. Exercises in the endotrainer and virtual simulator with moving-replacing objects, cutting and suturing-knotting were planned. End-point was time (mean with 95% confidence interval) in every exercise in box trainer, before and after the training period. RESULTS: Movement exercises: Time in control group was 223.6s, A:103.7s, and B:89.9s (Control vs. A, P < 0.05). Cutting exercises: Time in control group was 317.7s, group A: 232.8s and in the B: 163.6s, (Control vs. B, P < 0.05). In the suture/knot exercise everyone was able to carry out a stitch after the training period. Time in control group was 518.4s, in group A: 309.4s, P < 0.05, and in B:189.5s (Control vs. A, P < 0.05). CONCLUSIONS: Training in inanimate boxes was able to improve the skills of students, particularly for moving and suture/knots. The incorporation of a virtual simulator increased the learning capabilities, mainly in cutting exercises.

[Obesity in the history of surgery]. / La obesidad en la historia de la cirugía.

Obesity is a problem that is reaching epidemic proportions throughout the world and bariatric surgery is now a rapidly growing technique. However existence of obesity in humans has been recognized for thousands of years, as statues dating from the Stone Age period appear to provide the earliest depictions. Hippocrates (466-355 b.C.) and Galen (131-201 a.C.) had a clear understanding of the condition, its consequences and medical treatment. On the other hand bariatric surgery was a xx century treatment, but at the end of the xix century it was known that the massive loss of small bowel or gastric resection after ulcer surgery resulted in persistent weight loss. Malabsorption and gastric restriction in isolation, or more commonly in combination, remain the main options to surgical control of weight. Unfortunately surgery as a non etiological treatment is an imperfect model to treat an incurable disease: morbid obesity. Prevention and better knowledge of disease would allow a tailored medical or surgical approach.

La obesidad en la historia de la cirugía / Obesity in the history of surgery

La obesidad ha alcanzado dimensiones epidémicas mundiales y la cirugía bariátrica, prácticamente desconocida, ha logrado un desarrollo difícil de imaginar hace pocas décadas. No obstante, no puede decirse que la obesidad no existiese en la antigüedad o sea una patología de conocimiento reciente. Ya en la Edad de Piedra hay testimonios de su existencia y los grandes maestros de la medicina Hipócrates (460-355 a.C.) y Galeno (131-201 d.C.) conocían perfectamente la enfermedad y sus consecuencias e incluso los tratamientos médicos actuales remedan los que ellos prescribían. La cirugía comienza esencialmente a mediados del siglo xx, aunque al final del xix ya se dan los primeros pasos experimentales en la comprensión de la fisiopatología de la hipoabsorción intestinal como base del adelgazamiento, o el auge de la resección gástrica por úlcera péptica permite observar que la restricción de la capacidad del estómago promueve la pérdida de peso. Hipoabsorción y restricción gástrica, solas o combinadas, han llegado a nuestros días como principios quirúrgicos inalterables. Sin embargo, como todo tratamiento no etiológico, la cirugía bariátrica es una solución imperfecta para una enfermedad incurable, la obesidad mórbida. Prevención y conocimientos genéticos o moleculares, entre otros, permitirán un tratamiento integral, médico o quirúrgico, adaptado a cada situación clínica del paciente (AU)

Obesity is a problem that is reaching epidemic proportions throughout the world and bariatric surgery is now a rapidly growing technique. However existence of obesity in humans has been recognized for thousands of years, as statues dating from the Stone Age period appear to provide the earliest depictions. Hippocrates (466-355 b.C.) and Galen (131-201 a.C.) had a clear understanding of the condition, its consequences and medical treatment. On the other hand bariatric surgery was a xx century treatment, but at the end of the xix century it was known that the massive loss of small bowel or gastric resection after ulcer surgery resulted in persistent weight loss. Malabsorption and gastric restriction in isolation, or more commonly in combination, remain the main options to surgical control of weight. Unfortunately surgery as a non etiological treatment is an imperfect model to treat an incurable disease: morbid obesity. Prevention and better knowledge of disease would allow a tailored medical or surgical approach (AU)

[Complications of surgical resection of esophageal cancer]. / Complicaciones de la cirugía de exéresis del cáncer de esófago.

Esophageal resection has undergone refinements over recent years, with improved outcomes. However, in-hospital mortality remains above 10% in developed countries and is below 5% in only a select group of hospitals. Morbidity remains high even in high-volume hospitals. We reviewed risk factors in esophageal resection. Pulmonary complications occur mainly in older patients and in those with pulmonary dysfunction, especially %FEV1 or hypoxia. Liver cirrhosis, squamous cell cancer, low patient volume, and cervical anastomoses also increase complication rates. Neoadjuvant chemoradiotherapy, which may be effective in squamous cell tumors, can also increase morbidity. The main cause of morbidity and mortality are pleuropulmonary complications. Also significant are anastomotic leak and esophageal conduit necrosis. A complex procedure such as esophageal resection is better served in specialized teams.

Complicaciones de la cirugía de exéresis del cáncer de esófago / Complications of surgical resection of esophageal cancer

La cirugía del cáncer de esófago está más reglada, hecho que ha propiciado mejores resultados. No obstante, la mortalidad operatoria en países desarrollados supera el 10% y sólo un grupo selecto se acerca al 5%. La morbilidad es elevada incluso en centros experimentados. Hemos revisado factores de riesgo. Las complicaciones respiratorias son más habituales en presencia de edad avanzada y alteraciones de las pruebas respiratorias, sobre todo la de volumen máximo espirado en el primer segundo e hipoxia. Factores como la cirrosis hepática, tipo epidermoide, la poca casuística o la anastomosis cervical generan morbilidad adicional. La quimiorradioterapia neoadyuvante, quizás eficaz en tumores epidermoides, puede añadir más morbilidad. Las complicaciones pleuropulmonares ocupan el primer lugar de morbimortalidad operatoria, sin olvidar que la fístula anastomótica o la necrosis de la plastia obligan a tomar precauciones. La complejidad del tema hace concluir que la resección esofágica por cáncer debe restringirse a grupos con casuística suficiente (AU)

Esophageal resection has undergone refinements over recent years, with improved outcomes. However, in-hospital mortality remains above 10% in developed countries and is below 5% in only a select group of hospitals. Morbidity remains high even in high-volume hospitals. We reviewed risk factors in esophageal resection. Pulmonary complications occur mainly in older patients and in those with pulmonary dysfunction, especially %FEV1 or hypoxia. Liver cirrhosis, squamous cell cancer, low patient volume, and cervical anastomoses also increase complication rates. Neoadjuvant chemoradiotherapy, which may be effective in squamous cell tumors, can also increase morbidity. The main cause of morbidity and mortality are pleuropulmonary complications. Also significant are anastomotic leak and esophageal conduit necrosis. A complex procedure such as esophageal resection is better served in specialized teams (AU)