Relationship between the anatomical location and the selective non-operative management of penetrating stab wounds in the abdomen.

INTRODUCTION: The relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. METHODS: Retrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. RESULTS: We identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RH, followed by the LH and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70.5% of lumbar, 66.5% of epigastric, 62% of flank, and 59% of RH penetrating SW could have been managed without a laparotomy. CONCLUSIONS: SNOM of penetrating SW in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RH regions.

Relación entre la localización anatómica y el manejo selectivo no operatorio de las heridas por arma blanca penetrantes en abdomen / Relationship between the anatomical location and the selective non-operative management of penetrating stab wounds in the abdomen

Introducción: La localización anatómica de las heridas por arma blanca (HAB) penetrantes en abdomen y su relación con el manejo selectivo no operatorio (MSNO) tiene escaso reflejo en la literatura especializada. Nuestro objetivo principal ha sido valorar la tasa de MSNO en función de esa localización anatómica, y sus resultados. Métodos: Revisión retrospectiva del registro prospectivo de trauma abdominal desde abril de 1993 hasta junio de 2020. Los dos grupos a estudio fueron manejo operatorio (MO) y MSNO, incluyendo en este último grupo el uso de laparoscopias exploradoras como método diagnóstico. Se clasificaron las HAB penetrantes en abdomen en función de su localización anatómica. Resultados: Identificamos 259 pacientes que cumplían los criterios de inclusión. El MSNO se aplicó en el 31% de los pacientes, con una tasa de éxito del 96,5%. En las HAB de las regiones lumbares, flancos y toracoabdominales fue donde se optó más frecuentemente por este manejo; y en el abdomen anterior fue más aplicable en el hipocondrio derecho (HD), seguido del hipocondrio izquierdo (HI) y epigastrio. Se realizó una laparotomía innecesaria en el 21%, con la cifra más alta en el epigastrio. Teniendo en cuenta los porcentajes de MSNO y laparotomías evitables en cada región, el 70,5% de las HAB lumbares, el 66,5% de las epigástricas, el 62% de flancos y el 59% de HD se podrían haber manejado con éxito sin laparotomía. Conclusiones: El MSNO de las HAB penetrantes en abdomen ha resultado más seguro y aplicable en las localizadas en las regiones lumbares, flancos, epigastrio e HD (AU)

Introduction: The relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. Methods: Retrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. Results: We identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RUQ, followed by the LUQ and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70,5% of lumbar, el 66,5% of epigastric, 62% of flank, and 59% of RUQ penetrating SWs could have been managed without a laparotomy. Conclusions: SNOM of penetrating SWs in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RUQ regions (AU)

Are Spanish surgeons prepared to treat trauma patients? Multicentre descriptive observational study.

PURPOSE: Specific training in the management of trauma patients is beneficial for surgeons. Training through specific courses in this area has a direct impact on the care of these patients. The aim of this work is to understand the participation and specific training in the care of trauma patients by Spanish surgeons. METHODS: A national survey was conducted and administered to all members of the Spanish Association of Surgeons. The survey assessed their degree of participation in emergency surgery, and therefore the probability of attending trauma patients, their assessment of the initial care of trauma patients in their centre, and their specific training in this field. RESULTS: The survey was completed by 510 surgeons from 47 Spanish provinces, with Catalonia and Andalusia being the most represented regions. In total, 456 (89.41%) of those surveyed work in the emergency department on a routine basis. Only 171 (33.53%) refer to having a registry of trauma patients in their hospital. While 79.02% of surgeons reported that general surgeons are not involved in care of severe trauma from the outset, only 66.47% have completed the ATLS course, 40.78% the DSTC course and 18.82% the MUSEC course. Despite this, 85.69% believe that the ATLS course should be compulsory during residency and 43.33% believe that severe trauma care in their hospital is poor or very poor. CONCLUSION: Only 40% have received specific training in definitive surgical management of severe trauma. Despite this, a large percentage of surgeons work in the emergency department on a routine basis and potentially face the challenge of managing these patients.

Multicentre cohort study of acute cholecystitis management during the COVID-19 pandemic.

PURPOSE: To analyse acute cholecystitis (AC) management during the first pandemic outbreak after the recommendations given by the surgical societies estimating: morbidity, length of hospital stay, mortality and hospital-acquired SARS-CoV-2 infection rate. METHODS: Multicentre-combined (retrospective-prospective) cohort study with AC patients in the Community of Madrid between 1st March and 30th May 2020. 257 AC patients were involved in 16 public hospital. Multivariant binomial logistic regression (MBLR) was applied to mortality. RESULTS: Of COVID-19 patients, 30 were diagnosed at admission and 12 patients were diagnosed during de admission or 30 days after discharge. In non-COVID-19 patients, antibiotic therapy was received in 61.3% of grade I AC and 40.6% of grade II AC. 52.4% of grade III AC were treated with percutaneous drainage (PD). Median hospital stay was 5 [3-8] days, which was higher in the non-surgical treatment group with 7.51 days (p < 0.001) and a 3.25% of mortality rate (p < 0.21). 93.3% of patients with SARS-CoV-2 infection at admission were treated with non-surgical treatment (p = 0.03), median hospital stay was 11.0 [7.5-27.5] days (p < 0.001) with a 7.5% of mortality rate (p > 0.05). In patients with hospital-acquired SARS-CoV-2 infection, 91.7% of grade I-II AC were treated with non-surgical treatment (p = 0.037), with a median hospital stay of 16 [4-21] days and a 18.2% mortality rate (p > 0.05). Hospital-acquired infection risk when hospital stay is > 7 days is OR 4.7, CI 95% (1.3-16.6), p = 0.009. COVID-19 mortality rate was 11.9%, AC severity adjusted OR 5.64 (CI 95% 1.417-22.64). In MBLR analysis, age (OR 1.15, CI 95% 1.02-1.31), SARS-CoV-2 infection (OR 14.49, CI 95% 1.33-157.81), conservative treatment failure (OR 8.2, CI 95% 1.34-50.49) and AC severity were associated with an increased odd of mortality. CONCLUSION: In our population, during COVID-19 pandemic, there was an increase of non-surgical treatment which was accompanied by an increase of conservative treatment failure, morbidity and hospital stay length which may have led to an increased risk hospital-acquired SARS-CoV-2 infection. Age, SARS-CoV-2 infection, AC severity and conservative treatment failure were mortality risk factors.

Relationship between the anatomical location and the selective non-operative management of penetrating stab wounds in the abdomen. / Relación entre la localización anatómica y el manejo selectivo no operatorio de las heridas por arma blanca penetrantes en abdomen.

INTRODUCTION: The relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. METHODS: Retrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. RESULTS: We identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RUQ, followed by the LUQ and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70,5% of lumbar, el 66,5% of epigastric, 62% of flank, and 59% of RUQ penetrating SWs could have been managed without a laparotomy. CONCLUSIONS: SNOM of penetrating SWs in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RUQ regions.

Emergency surgery and trauma care during COVID-19 pandemic. Recommendations of the Spanish Association of Surgeons / Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients

La infección por el nuevo coronavirus SARS-COV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados

Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos / Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons

La infección por el nuevo coronavirus SARS-CoV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons]. / Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos.

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients.

Fracturas de pelvis con hematoma retroperitoneal asociado: tiempo hasta la angioembolización y resultados / Pelvic fractures with associated retroperitoneal hematoma: time until angioembolization and results

Introducción: El tratamiento de las fracturas de pelvis con hematoma retroperitoneal (HRP) es controvertido. Especialmente la necesidad de angioembolización (AE) cuando no hay extravasación de contraste (EC) en la tomografía computarizada (TC) o angiografía. Otro aspecto relevante es el retraso hasta la misma. Nuestro objetivo ha sido determinar si existen diferencias en el tiempo hasta la AE entre los pacientes admitidos durante el horario laboral y los admitidos fuera del mismo y durante los fines de semana y festivos. Nuestra hipótesis era que la angiografía y AE serían más frecuentes en el horario laboral, y el tiempo hasta las mismas sería superior fuera del horario laboral habitual, con una mortalidad mayor en este grupo para una gravedad global similar. Un objetivo secundario ha sido valorar la correlación entre EC en la TC y la angiografía. Métodos: Análisis retrospectivo de 2 cohortes de pacientes con HRP por fractura de pelvis. Se estudia la realización de angiografía dividiendo a los pacientes según su hora de llegada a lo largo de un periodo de 24 años (grupo A: horario laboral, y grupo B: fuera del mismo). La indicación de angiografía y AE fue realizada por la guardia de cirugía general, en consenso con el radiólogo intervencionista. Se han analizado variables demográficas, mecanismo lesivo, lesiones asociadas, gravedad fisiológica y anatómica, EC en la TC y la angiografía, necesidad de AE, estancia en unidad de cuidados intensivos (UCI) y mortalidad. Resultados: Se admitió a 104 pacientes con diagnóstico de HRP por fractura pélvica. Se realizó angiografía, con AE en 63 casos (61%). Los grupos eran comparables en las variables analizadas. En el 70% de los pacientes del grupo A se realizó angiografía, frente al 57% del grupo B, sin diferencias en tiempo hasta la AE. Se demostró EC en la TC en 53 de los 96 pacientes en los que se hizo, lo que se confirmó mediante angiografía en el 85%. No hubo diferencias estadísticamente significativas de mortalidad entre ambos grupos. Conclusiones: Se demuestra un tiempo corto entre la admisión en Urgencias y la AE, sin relación con el momento del ingreso durante el día, y una buena correlación entre la EC en la TC y la angiografía

Introduction: Two areas of controversy in the management of bleeding pelvic fractures are the need to perform angioembolization (AE) in patients with a retroperitoneal hematoma (RPH) but no contrast extravasation (CE) on Computerized Tomography (CT) and/or angiography, and the delay to AE. Our main objective was to assess whether there had been differences in the percentage and delay to AE between patients admitted on weekdays versus off-hours (weekends and admission after 3pm) at our hospital. Our hypothesis was that angiography and AE would be more frequent on weekdays, and the time delay would be longer during off-hours, with a higher mortality in this latter group for a similar overall severity. A secondary objective was to assess the correlation between CE on CT scan and angiography. Methods: Retrospective review of two cohorts of patients with RPH from a pelvic fracture during a period of 24 years. Patients were divided depending on the time of arrival (Group A: weekdays, and Group B: off-hours). The decision to perform angiography and AE was made by the general surgeons on call, in consensus with the interventional radiologist. We analyzed demographics, mechanism of injury, associated injuries, physiologic and anatomic trauma scores, CE on CT scan, need of AE, Intensive Care Unit (ICU) stay and mortality. Results: 104 patients were admitted with RPH from a pelvic fracture. We performed AE in 63 cases (61%). The groups were comparable in the variables analyzed. In 70% of patients in group A, angiography was done, vs 57% in group B, with the same median time delay. CE on CT scan was seen in 53 out of 96 patients and confirmed by angiography in 45 (85%) of them. No significant differences were found in mortality between the two groups. Conclusions: There was a short delay from admission to AE, even during off-hours, and a good correlation of CE on CT scan and angiography

Pelvic fractures with associated retroperitoneal hematoma: time until angioembolization and results. / Fracturas de pelvis con hematoma retroperitoneal asociado: tiempo hasta la angioembolización y resultados.

INTRODUCTION: Two areas of controversy in the management of bleeding pelvic fractures are the need to perform angioembolization (AE) in patients with a retroperitoneal hematoma (RPH) but no contrast extravasation (CE) on Computerized Tomography (CT) and/or angiography, and the delay to AE. Our main objective was to assess whether there had been differences in the percentage and delay to AE between patients admitted on weekdays versus off-hours (weekends and admission after 3pm) at our hospital. Our hypothesis was that angiography and AE would be more frequent on weekdays, and the time delay would be longer during off-hours, with a higher mortality in this latter group for a similar overall severity. A secondary objective was to assess the correlation between CE on CT scan and angiography. METHODS: Retrospective review of two cohorts of patients with RPH from a pelvic fracture during a period of 24 years. Patients were divided depending on the time of arrival (Group A: weekdays, and Group B: off-hours). The decision to perform angiography and AE was made by the general surgeons on call, in consensus with the interventional radiologist. We analyzed demographics, mechanism of injury, associated injuries, physiologic and anatomic trauma scores, CE on CT scan, need of AE, Intensive Care Unit (ICU) stay and mortality. RESULTS: 104 patients were admitted with RPH from a pelvic fracture. We performed AE in 63 cases (61%). The groups were comparable in the variables analyzed. In 70% of patients in group A, angiography was done, vs 57% in group B, with the same median time delay. CE on CT scan was seen in 53 out of 96 patients and confirmed by angiography in 45 (85%) of them. No significant differences were found in mortality between the two groups. CONCLUSIONS: There was a short delay from admission to AE, even during off-hours, and a good correlation of CE on CT scan and angiography.

Tasa de conversión y morbilidad en el abordaje laparoscópico en pacientes seleccionados con obstrucción intestinal adherencial / Morbidity and Conversion Rate in Laparoscopy Approach in Selected Patients with Adhesive Intestinal Obstruction

Introducción: El síndrome adherencial es la causa más frecuente de obstrucción de intestino delgado. La laparotomía es el abordaje estándar. El avance de la cirugía mínimamente invasiva hace posible la resolución de cuadros obstructivos por laparoscopia. Objetivo: Analizar el abordaje laparoscópico de la obstrucción intestinal y compararlo con la vía abierta. Método: Análisis retrospectivo de los pacientes tratados de obstrucción intestinal aguda mediante laparoscopia en nuestro hospital desde 2012 hasta 2016. Se utilizó como referencia un grupo de pacientes tratados desde 2002 hasta 2005, cuando sólo se usaba el abordaje abierto. Se analizaron datos demográficos, riesgo quirúrgico, comorbilidades, métodos diagnósticos y complicaciones (Clavien). Resultados: De los 134 pacientes intervenidos de obstrucción intestinal aguda, se inició un abordaje laparoscópico en 47 (35 pr ciento). Por esta vía sólo se completaron 32 pacientes (68 por ciento). La tasa de conversión fue del 32 por ciento, estos pacientes fueron eliminados del estudio. En el grupo de referencia se analizaron al azar 32 pacientes. Ambos grupos son comparables. El grupo tratado con abordaje laparoscópico tuvo un 9 por ciento de complicaciones y un 3 por ciento de reintervenciones, con una sola lesión inadvertida. El grupo laparoscópico tuvo un 12,5 por ciento de reintervenciones, todas por evisceración, pero tuvo una lógica mayor tasa de resecciones intestinales. No hubo mortalidad hospitalaria. Conclusión: Los resultados en los pacientes en que se ha completado la cirugía por laparoscopia se comparan favorablemente con los del abordaje abierto en un grupo histórico homogéneo de referencia, y sin el riesgo añadido de evisceración(AU)

Introduction: Adherence syndrome is the most frequent cause of small bowel obstruction. Laparotomy is the standard approach. The progress of minimally invasive surgery makes it possible to resolve obstructive frames by laparoscopy. Objective: To analyze the laparoscopic approach for intestinal obstruction and compare it with the open pathway. Method: Retrospective analysis of patients treated for acute intestinal obstruction by laparoscopy in our hospital, from 2012 to 2016. A group of patients treated from 2002 to 2005 were used as reference, when only the open approach was used. We analyzed demographic data, surgical risk, comorbidities, diagnostic methods and complications (Clavien). Results: Within the 134 patients operated for acute intestinal obstruction, a laparoscopic approach was started in 47 (35 percent). Only 32 patients (68 percent) were completed in this way. The conversion rate was 32 percent, these patients were eliminated from the study. In the reference group, 32 patients were randomly analyzed. Both groups are comparable. The group treated with laparoscopic approach had 9 por ciento complications and 3 percent reoperations, with a single unexpected lesion. The laparoscopic group had 12.5 of reintervention, all due to evisceration, but had a higher rate of intestinal resections. There was no hospital mortality. Conclusion: In patients who have completed laparoscopic surgery, the results are compared favorably with those of the open approach in a homogeneous historical reference group, and without the added risk of evisceration(AU)

Tasa de conversión y morbilidad en el abordaje laparoscópico en pacientes seleccionados con obstrucción intestinal adherencial / Morbidity and Conversion Rate in Laparoscopy Approach in Selected Patients with Adhesive Intestinal Obstruction

Introducción: El síndrome adherencial es la causa más frecuente de obstrucción de intestino delgado. La laparotomía es el abordaje estándar. El avance de la cirugía mínimamente invasiva hace posible la resolución de cuadros obstructivos por laparoscopia. Objetivo: Analizar el abordaje laparoscópico de la obstrucción intestinal y compararlo con la vía abierta. Método: Análisis retrospectivo de los pacientes tratados de obstrucción intestinal aguda mediante laparoscopia en nuestro hospital desde 2012 hasta 2016. Se utilizó como referencia un grupo de pacientes tratados desde 2002 hasta 2005, cuando sólo se usaba el abordaje abierto. Se analizaron datos demográficos, riesgo quirúrgico, comorbilidades, métodos diagnósticos y complicaciones (Clavien). Resultados: De los 134 pacientes intervenidos de obstrucción intestinal aguda, se inició un abordaje laparoscópico en 47 (35 pr ciento). Por esta vía sólo se completaron 32 pacientes (68 por ciento). La tasa de conversión fue del 32 por ciento, estos pacientes fueron eliminados del estudio. En el grupo de referencia se analizaron al azar 32 pacientes. Ambos grupos son comparables. El grupo tratado con abordaje laparoscópico tuvo un 9 por ciento de complicaciones y un 3 por ciento de reintervenciones, con una sola lesión inadvertida. El grupo laparoscópico tuvo un 12,5 por ciento de reintervenciones, todas por evisceración, pero tuvo una lógica mayor tasa de resecciones intestinales. No hubo mortalidad hospitalaria. Conclusión: Los resultados en los pacientes en que se ha completado la cirugía por laparoscopia se comparan favorablemente con los del abordaje abierto en un grupo histórico homogéneo de referencia, y sin el riesgo añadido de evisceración(AU)

Introduction: Adherence syndrome is the most frequent cause of small bowel obstruction. Laparotomy is the standard approach. The progress of minimally invasive surgery makes it possible to resolve obstructive frames by laparoscopy. Objective: To analyze the laparoscopic approach for intestinal obstruction and compare it with the open pathway. Method: Retrospective analysis of patients treated for acute intestinal obstruction by laparoscopy in our hospital, from 2012 to 2016. A group of patients treated from 2002 to 2005 were used as reference, when only the open approach was used. We analyzed demographic data, surgical risk, comorbidities, diagnostic methods and complications (Clavien). Results: Within the 134 patients operated for acute intestinal obstruction, a laparoscopic approach was started in 47 (35 percent). Only 32 patients (68 percent) were completed in this way. The conversion rate was 32 percent, these patients were eliminated from the study. In the reference group, 32 patients were randomly analyzed. Both groups are comparable. The group treated with laparoscopic approach had 9 por ciento complications and 3 percent reoperations, with a single unexpected lesion. The laparoscopic group had 12.5 of reintervention, all due to evisceration, but had a higher rate of intestinal resections. There was no hospital mortality. Conclusion: In patients who have completed laparoscopic surgery, the results are compared favorably with those of the open approach in a homogeneous historical reference group, and without the added risk of evisceration(AU)

Linfoma no Hodgkin suprarrenal primario / Primary Non Hodgkin´s Lymphoma of the Adrenal Gland

El linfoma no Hodgkin primario de la glándula suprarrenal es una patología muy poco común. Su diagnóstico inicial es difícil siendo este histológico. El linfoma B difuso de células grandes es el tipo histológico más frecuente. Se presenta el caso mujer de 62 años a la que se le realiza tomografía axial computarizada abdominal que muestra una masa de 18 cms dependiente de la glándula suprarrenal y con características de carcinoma. Se realiza exéresis de la tumoración, siendo la anatomía patológica linfoma difuso de célula grande B. Este tipo de linfoma tiene mal pronóstico describiéndose supervivencias medias en torno a los 13 meses. No existe un régimen terapéutico bien definido; aunque el tratamiento más aceptado es el esquema R-CHOP. El papel de la radioterapia y de la exéresis tumoral no está claramente establecido. El linfoma suprarrenal primario debe tenerse en cuenta en el diagnóstico diferencial de pacientes que presentan una masa suprarrenal. Ante la sospecha de esta patología es preferible realizar una biopsia con aguja guiada por prueba de imagen para evitar una intervención quirúrgica innecesaria(AU)

Primary non- Hodgkin`s lymphoma of the adrenal gland is very rare. Its initial diagnosis is difficult and needs to be histological. Diffuse large B- cell lymphoma is the most common histological type. This is the report of a 62 years old woman, who was performed abdominal tomography to disclose a 18 cm tumor in the adrenal gland with carcinoma characteristics. The tumor was removed and the final pathologic diagnosis was diffuse large B-cell lymphoma. This type of lymphoma has poor prognosis since the average survival rates are roughly 13 months. There is no well-defined therapeutic regimen, although the most widely accepted treatment is R-CHOP scheme. The roles of radiotherapy and tumor resection are not clearly established. Primary adrenal lymphoma should be considered in the differential diagnosis of patients presenting with an adrenal mass. When this condition is suspected, then it is advisable to perform a imaging-guided needle biopsy to avoid unnecessary surgery(AU)

Utilización de adhesivos biológicos a base de fibrina en la prevención de fugas anastomóticas en anastomosis del tubo digestivo de alto riesgo: resultados preliminares del ensayo clínico fase iv multicéntrico, prospectivo, aleatorizado y controlado simple ciego: Protissucol001 / Use of fibrin based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract: preliminary results of the multicentre, prospective, randomised, controlled, and simple blind phase IV clinical trial: Protissucol001

Introducción: Con el objetivo de demostrar la eficacia de los adhesivos biológicos a base de fibrina en la prevención de fugas anastomóticas, en enero de 2007 iniciamos un estudio multicéntrico, prospectivo, aleatorizado, controlado, simple ciego, sobre la prevención de fugas anastomóticas en anastomosis del tubo digestivo de alto riesgo mediante la utilización de adhesivos biológicos a base de fibrina. Material y métodos En enero de 2007 iniciamos un ensayo clínico multicéntrico en el que participan los hospitales Gregorio Marañón, Universitario de San Carlos y Hospital del Sureste, de Madrid sobre la prevención de defectos de cicatrización anastomótica mediante la aplicación de adhesivos biológicos a base de fibrina en la linea de sutura. Los pacientes reclutados se aleatorizan asignando al paciente en función de esta aleatorización a uno de los 2 grupos: grupo de estudio en el que se aplica adhesivo en la línea de sutura y grupo control en el que no se aplica. La variable principal del estudio es la presencia o ausencia de fugas. El ensayo ha sido aprobado por los correspondientes Comités de Ética e Investigación Clínica, por la Agencia Española del Medicamento y registrado en www.clinicaltrials.gov (NCT01306851). Ninguno de los autores manifiesta tener conflicto de interés con la empresa Baxter, que comercializa el producto en España. Resultados Desde enero de 2007 hasta noviembre de 2010, se ha reclutado a 104 pacientes que han sido asignados tras aleatorización, 52 al grupo de estudio y 52 al grupo control. Se han registrado 22 fugas anastomóticas de las cuales 7 en el grupo de estudio (13, 4%) y 15 en el grupo control (28, 8%) con un valor de la P de 0,046. El índice de riesgo de fugas fue de 0,384, es decir, se produce una reducción del 61% en las fugas de los pacientes a los que se aplica adhesivo biológico a (..) (AU)

Introduction: A multicentre, prospective, randomised, controlled, and simple blind clinicaltrial was started in January 2007, with the aim of demonstrating the eficacy of fibrin-based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract. Material and methods: A study on the prevention of anastomotic healing defects by applying biological adhesives along the suture line began in January 2007, and included the hospitals, Gregorio Marañón, Universitario de San Carlos, and Hospital del Sureste, in Madrid. The enrolled patients were randomised to one of 2 groups: the study group in which the adhesive was applied to the suture line, and a control group in which it was not applied. The primary outcome of the study was the presence or absence of leaks. The trial was approved by the corresponding Clinical Research Ethics Committees and the Spanish Medicines Agency(AEMPS) and registered www.clinicaltrials.gov (NCT01306851). The authors declared not to have any (..) (AU)

Complicaciones quirúrgicas en los body-packers: una urgencia infrecuente pero potencialmente letal / Surgical complications in drug body-packers: an uncommon but potentially lethal emergency

Introducción: El tráfico de drogas mediante la introducción de paquetes de sustancias ilícitas en cavidades corporales supone un riesgo de padecer una obstrucción gastrointestinal y/o intoxicación grave para la persona que las trasporta. Nuestro país está considerado como puerta de entrada a Europa para drogas, y algunos hospitales españoles tienen experiencia en el manejo de este tipo de pacientes. Dos hospitales en Madrid, entre ellos el Hospital General Universitario Gregorio Marañón (HGUGM), reciben estos potenciales pacientes desde el aeropuerto de Barajas. Objetivo Analizar los resultados del tratamiento conservador y de la necesidad de cirugía en los body-packers. Métodos Estudio retrospectivo observacional de pacientes ingresados entre enero de 2000 y diciembre de 2008 con el diagnóstico de body-packer. Son ingresados en la Unidad de Custodiados de nuestro centro aquellos con síntomas gastrointestinales, signos de intoxicación o tóxicos positivos. El (..) (AU)

Introduction: Drug flicking by means of introducing packets of illegal substances in body cavities carries a risk of suffering from a gastrointestinal obstruction and/or severe poisoning in the person who transports them. Spain is considered as the port of entry to Europe for drugs, and some Spanish hospitals have experience in managing these types of patients. Two hospitals in Madrid, including the Gregorio Marañón University General Hospital(HGUGM), received these potential patients from the Madrid Barajas airport. Objective: To analyse the results of the conservative treatment and the need for surgery in ‘‘body-packers’’. Material and methods: A retrospective, observational study of patients diagnosed as a body packer between January 2000 and December 2008. Those with gastrointestinal symptoms, signs of poisoning, or positive for drugs of abuse, were admitted to the Custodial Unit of our hospital. The conservative treatment consisted of digestive rest and imaging studies until expulsion from the body. Asymptomatic patients were discharged from the Emergency Department. Results: A total of 549 patients, with a median age of 31 years, and of whom 81% were males, were hospitalised during this period. Less than half (40%) showed positive for drugs in the urine, with cocaine in 80% of the cases (..) (AU)

[Use of fibrin based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract: preliminary results of the multicentre, prospective, randomised, controlled, and simple blind phase IV clinical trial: Protissucol001]. / Utilización de adhesivos biológicos a base de fibrina en la prevención de fugas anastomóticas en anastomosis del tubo digestivo de alto riesgo: resultados preliminares del ensayo clínico fase iv multicéntrico, prospectivo, aleatorizado y controlado simple ciego: Protissucol001.

INTRODUCTION: A multicentre, prospective, randomised, controlled, and simple blind clinical trial was started in January 2007, with the aim of demonstrating the efficacy of fibrin-based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract. MATERIAL AND METHODS: A study on the prevention of anastomotic healing defects by applying biological adhesives along the suture line began in January 2007, and included the hospitals, Gregorio Marañón, Universitario de San Carlos, and Hospital del Sureste, in Madrid. The enrolled patients were randomised to one of 2 groups: the study group in which the adhesive was applied to the suture line, and a control group in which it was not applied. The primary outcome of the study was the presence or absence of leaks. The trial was approved by the corresponding Clinical Research Ethics Committees and the Spanish Medicines Agency (AEMPS) and registered www.clinicaltrials.gov (NCT01306851). The authors declared not to have any conflict of interests with the company, Baxter, which markets the product in Spain. RESULTS: A total of 104 patients were recruited between January 2007 and November 2010, of whom 52 were randomised to the study group, and 52 to the control group. A total of 22 anastomotic leaks were recorded, of which 7 (13.4%) were in the study group, and 15 (28.8%) in the control group (P=.046). The leak risk index was 0.384, which means that there was a 61% reduction in leaks in the patients who had the fibrin-based biological adhesive applied. There were 3 (5.7%) further surgeries in the study group, compared to 12 (23%) in the control group (P=.12). On analysing the mortality, it was observed that 3 patients in the study group and 4 patients in the control group died (5.7% vs. 7.7%, P=.5). No other significant differences were found as regards the type of suture, surgical time, or pre-surgical history, except that the use of drainages appeared to be a protective factor of anastomotic leak (P=.041), although the use or not of a drainage was not a controlled factor, but at the discretion of each surgeon. CONCLUSIONS: Our study demonstrates, significantly, that in the 104 patients in the study that fibrin based biological adhesives are capable of preventing anastomotic leaks in the high risk digestive tract, reducing the risk of leaks by 61% and a further surgeries. This is the first clinical trial that shows these significant results. If our results are maintained at the end of the study, it will show that anastomotic leaks can be prevented with the application of these adhesives, thus their application may be recommended in all the anastomosis of the high risk digestive tract.

[Surgical complications in drug body-packers: an uncommon but potentially lethal emergency]. / Complicaciones quirúrgicas en los body-packers: una urgencia infrecuente pero potencialmente letal.

INTRODUCTION: Drug trafficking by means of introducing packets of illegal substances in body cavities carries a risk of suffering from a gastrointestinal obstruction and/or severe poisoning in the person who transports them. Spain is considered as the port of entry to Europe for drugs, and some Spanish hospitals have experience in managing these types of patients. Two hospitals in Madrid, including the Gregorio Marañón University General Hospital (HGUGM), received these potential patients from the Madrid Barajas airport. OBJECTIVE: To analyse the results of the conservative treatment and the need for surgery in "body-packers". MATERIAL AND METHODS: A retrospective, observational study of patients diagnosed as a body-packer between January 2000 and December 2008. Those with gastrointestinal symptoms, signs of poisoning, or positive for drugs of abuse, were admitted to the Custodial Unit of our hospital. The conservative treatment consisted of digestive rest and imaging studies until expulsion from the body. Asymptomatic patients were discharged from the Emergency Department. RESULTS: A total of 549 patients, with a median age of 31 years, and of whom 81% were males, were hospitalised during this period. Less than half (40%) showed positive for drugs in the urine, with cocaine in 80% of the cases. Of the 549 patients with initial conservative treatment, 27 (4.9%) had serious complications (16, bowel obstruction, and 11 with signs of poisoning). Of these, 23 required surgery (the 16 obstructions and 7 of the poisonings); 2 were successfully treated in ICU, and 2 died before surgery (0.4%) of the cases. The most frequent surgical treatment was enterotomy and/or gastrostomy to extract the packets. Thirteen (56%) of those operated on had associated morbidity (11 abdominal infections and 2 nosocomial infections). CONCLUSIONS: Conservative treatment is safe in 95% of the patients. A small percentage required surgical treatment, basically for gastrointestinal obstruction or severe poisoning.

Factores predictores de mortalidad en la colitis isquémica grave: análisis de 101 pacientes intervenidos / Predictive factors of mortality in severe ischaemic colitis: post-operative analysis of 101 patients

Introducción La colitis isquémica (CI) es la forma más frecuente de enfermedad isquémica digestiva y está infradiagnosticada. Objetivos Describir los resultados obtenidos en pacientes con CI que necesitaron de intervención quirúrgica en nuestro centro, y evaluar los factores predictores de mortalidad. Métodos Los datos fueron obtenidos de la base de CI del Hospital Gregorio Marañón. Las características demográficas, clínicas, los métodos diagnósticos, las técnicas quirúrgicas empleadas y la mortalidad fueron analizados estadísticamente empleando la prueba de la χ2 y la t de Student. Resultados Entre 1991 y 2006, se operó a 101 pacientes con CI. La mayoría de éstos tenían antecedentes cardiovasculares y 35 casos fueron diagnosticados durante su ingreso hospitalario por otra causa. Tanto los signos como los síntomas fueron inespecíficos en el 40% de los casos. La morbilidad y la mortalidad total fue del 39,6 y el 41,6%, respectivamente. En los casos de CI postoperatoria, la mortalidad se elevó hasta el 68% (p<0,01); el 93% de los paciente que fallecieron tenían necrosis transmural durante la cirugía (p<0,05) y el 69% tenía acidosis metabólica. Conclusiones La mortalidad en pacientes afectos de CI que necesitan intervención quirúrgica es alta, especialmente si el diagnóstico se hace en el postoperatorio de otra cirugía o si se evidencia necrosis transmural durante la intervención. Para mejorar estos resultados el diagnóstico precoz es la mejor arma, y debe basarse en un alto índice de sospecha(AU)

IntroductionIschaemic colitis (IC) is the most common form of bowel ischaemia and is often under-diagnosed. Objectives To report the results obtained in patients with IC who required surgical intervention in our Hospital, and to evaluate the predictive factors of mortality. Methods The data were obtained from the Gregorio Marañon Hospital CI database. The demographic and clinical characteristics, diagnostic methods, surgical techniques employed and mortality were analysed statistically, using the χ2 and Student t test. Results One-hundred and one patients with CI were operated on between 1991 and 2006. The majority of them had cardiovascular histories and 35 cases were diagnosed during their hospital stay due to another cause. The signs and the symptoms were non-specific in 40% of the cases. Total morbidity and mortality was 39.6% and 41.6% respectively. In the post-operative IC cases, the death rate increased to 68% (p<0.01); 93% of the patients who died had transmural necrosis during the surgery (p<0.05) and 69% had a metabolic acidosis. Conclusions The death rate in patients with IC that requires surgery is high, particularly if the diagnosis is made in the post-operative period after surgery for another cause, or if there is evidence of transmural necrosis during the intervention. Early diagnosis is the best tool to improve these results (AU)

[Predictive factors of mortality in severe ischaemic colitis: post-operative analysis of 101 patients]. / Factores predictores de mortalidad en la colitis isquémica grave: análisis de 101 pacientes intervenidos.

INTRODUCTION: Ischaemic colitis (IC) is the most common form of bowel ischaemia and is often under-diagnosed. OBJECTIVES: To report the results obtained in patients with IC who required surgical intervention in our Hospital, and to evaluate the predictive factors of mortality. METHODS: The data were obtained from the Gregorio Marañon Hospital CI database. The demographic and clinical characteristics, diagnostic methods, surgical techniques employed and mortality were analysed statistically, using the chi(2) and Student t test. RESULTS: One-hundred and one patients with CI were operated on between 1991 and 2006. The majority of them had cardiovascular histories and 35 cases were diagnosed during their hospital stay due to another cause. The signs and the symptoms were non-specific in 40% of the cases. Total morbidity and mortality was 39.6% and 41.6% respectively. In the post-operative IC cases, the death rate increased to 68% (p<0.01); 93% of the patients who died had transmural necrosis during the surgery (p<0.05) and 69% had a metabolic acidosis. CONCLUSIONS: The death rate in patients with IC that requires surgery is high, particularly if the diagnosis is made in the post-operative period after surgery for another cause, or if there is evidence of transmural necrosis during the intervention. Early diagnosis is the best tool to improve these results.

[Safety and efficiency of ambulatory treatment of acute diverticulitis]. / Eficiencia y seguridad del tratamiento ambulatorio de la diverticulitis aguda.

INTRODUCTION: The treatment of acute diverticulitis is currently being modified, showing a tendency to limit surgical treatment and favor conservative management. OBJECTIVE: To analyze the safety and efficiency of ambulatory treatment of acute diverticulitis in a selected group of patients. METHODS: We performed a prospective study of domiciliary oral antibiotic therapy for acute diverticulitis in a cohort of patients in the Emergency Surgery Section of our hospital. Seventy-four patients (44 men and 30 women) were included between 2000 and 2006. Patients with Hinchey stage 1 diverticulitis and those with Hinchey stage 2 diverticulitis and abscesses of less than 3cm, who were clinically and biochemically stable, were selected. The patients were treated with oral ciprofloxacin and metronidazole for 7-10 days. Follow-up was performed in the outpatients unit with clinical evaluation at 10 days and an imaging test at 1 month. RESULTS: The mean age of the patients was 55 years. The most frequent clinical presentation was spontaneous abdominal pain associated with leukocytosis. The mean duration of treatment was 8.8 days. Four patients (5.4%) required subsequent hospital admission for intravenous antibiotic administration and 70 (94.6%) completed treatment without complications. During follow-up, two cases of colonic adenocarcinoma and six cases of polyposis were diagnosed. Only 13 patients underwent elective surgery. CONCLUSIONS: In most of the patients studied, ambulatory conservative management was safe and effective in the treatment of uncomplicated acute diverticulitis. Moreover, this approach reduces length of hospital stay and lowers costs.