Reduction in diabetic amputations over 15 years in a defined Spain population. Benefits of a critical pathway approach and multidisciplinary team work.

OBJECTIVE: To assess changes in diabetic lower-extremity amputations (LEA) rates in a defined population over a 15-year period, following a multidisciplinary approach including a critical pathway in an inpatient setting with standardized preoperative and postoperative care, as well as in an outpatient setting through the establishment of a diabetic foot clinic. METHODS: This is a study of the incidence and types of LEAs performed in patients with diabetic foot disease complicated admitted to Morales Meseguer Hospital (Murcia, Spain), a large district general hospital, before (1998-2000) and after (2001-2012) of the introduction of better organized diabetes foot care. Hospital and clinic characteristics to the success of the programme are described. All cases of LEA in diabetic patients (1998-2012) within the area were identified by ICD-9-Clinical modification (CM) diagnostic codes. A chi square test was used to compare the frequency and level of amputations. RESULTS: Over all inpatients with diabetes admitted with foot infections and gangrene, there was a significant decrease in the proportion of total major amputations (47%) and elective major amputations (66%) (p<0.001). The incidence of total major amputations rates per 100.000 of the general population fell with statistical significance (p=0.009). The biggest improvement in LEA incidence was seen in the reduction of major elective amputation with fell 60%, from 7.6 to 3.1 per 100,000 (p<0.001). CONCLUSIONS: Significant reductions in total and major amputations rates occurred over the 15-year period following improvements in foot care services included multidisciplinary teamwork (critical pathway and diabetic foot clinic).

Bariatric surgery, a risk factor for rhabdomyolysis

La rabdomiolisis tras cirugía bariatrica es una complicación rara pero posible. Presentamos un caso de rabdomiolisis y fallo renal agudo tras by-pass gástrico laparoscópico en paciente con obesidad mórbida. Su conocimiento puede ayudar a predecir y manejar esta complicación infradiagnosticada cuyo diagnostico precoz mejora el tratamiento de estos pacientes y previene las complicaciones posteriores (AU)

Rhabdomyolysis has been increasingly recognized as a complication of bariatric surgery. We report a case of this complication and its consequences, in a patient who had undergone bariatric surgery, with a very high creatine kinase (CK) concentration, and whose renal function failed. Obesity causes a range of effects on all major organ systems. Knowledge of these effects and issues specific to the intensive care unit care of bariatric patients can help to predict and manage this underestimated complication in this population in which early diagnosis can alter the outcome (AU)

Bariatric surgery, a risk factor for rhabdomyolysis.

Rhabdomyolysis has been increasingly recognized as a complication of bariatric surgery. We report a case of this complication and its consequences, in a patient who had undergone bariatric surgery, with a very high creatine kinase (CK) concentration, and whose renal function failed. Obesity causes a range of effects on all major organ systems. Knowledge of these effects and issues specific to the intensive care unit care of bariatric patients can help to predict and manage this underestimated complication in this population in which early diagnosis can alter the outcome.

Adult intussusception - 14 case reports and their outcomes.

AIMS: To analyze diagnostic and therapeutic options depending on the clinical symptoms, location, and lesions associated with intussusception, together with their follow-up and complications. PATIENTS AND METHODS: Patients admitted to the Morales Meseguer General University Hospital (Murcia) between January 1995 and January 2009, and diagnosed with intestinal invagination. Data related to demographic and clinical features, complementary explorations, presumptive diagnosis, treatment, follow-up, and complications were collected. RESULTS: There were 14 patients (7 males and 7 females; mean age: 41.9 years-range: 17-77) who presented with abdominal pain. The most reliable diagnostic technique was computed tomography (8 diagnoses from 10 CT scans). A preoperative diagnosis was established in 12 cases. Invaginations were ileocolic in 8 cases (the most common), enteric in 5, and colocolic in 2 (coexistence of 2 lesions in one patient). The etiology of these intussusceptions was idiopathic or secondary to a lesion acting as the lead point for invagination. Depending on the nature of this lead point, the cause of the enteric intussusceptions was benign in 3 cases and malignant in 2. Ileocolic invaginations were divided equally (4 benign and 4 malignant), and colocolic lesions were benign (2 cases). Conservative treatment was implemented for 4 patients and surgery for 10 (7 in emergency). Five right hemicolectomies, 3 small-bowel resections, 2 left hemicolectomies, and 1 ileocecal resection were performed. Surgical complications: 3 minor and 1 major (with malignant etiology and subsequent death). The lesion disappeared after 3 days to 6 weeks in patients with conservative management. Mean follow-up was 28.25 months (range: 5-72 months). CONCLUSIONS: A suitable imaging technique, preferably CT, is important for the diagnosis of intussusception. Surgery is usually necessary but we favor conservative treatment in selected cases.

Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Nuestra experiencia con 62 pacientes / Gastrojejunal anastomosis stricture after laparoscopic gastric bypass. Our experience with 62 patients

Objetivo: la estenosis de la anastomosis gastroyeyunal representauna complicación nada desdeñable en la cirugía bariátricapor laparoscopia, llegándose, en algunas series, a alcanzar el15%. Presentamos nuestra casuística en una serie de 62 casosconsecutivos y el manejo realizado.Pacientes y método: desde enero-2004 a septiembre-2006hemos realizado de manera consecutiva 62 bypass gástricos porlaparoscopia según técnica de Wittgrove modificada. La anastomosisgastroyeyunal se realiza con material de autosutura tipoCEAA nº 21 término-lateral (ILS; Ethicon) y después de comprobarla estanqueidad anastomótica se dan dos puntos de válvulatipo Hoffmeister a cada lado de la anastomosis. En 4 casos(6,45%) se reconvirtió a laparotomía, realizándose la anastomosisde la misma manera. El seguimiento tiene un rango de 3-35 meses,realizado en 61 enfermos, pues un paciente falleció por tromboembolismopulmonar en el postoperatorio inmediato tras reintervención,a las dos semanas del bypass gástrico, por necrosis deun pequeño fragmento del remanente gástrico.En todos los pacientes con intolerancia persistente a la alimentaciónse realizó tránsito baritado y/o gastroscopia. Cuando seevidenció estenosis gastroyeyunal se procedió a dilatación neumáticaendoscópica (recomendando dilatar la anastomosis hastacomo máximo 1,5 cm).Resultados: en 5 casos (8,1%) se desarrolló una estenosisgastroyeyunal, en 4 de estos casos el diagnóstico inicial fue portránsito baritado y en 1 caso por endoscopia. Dos pacientes teníanantecedentes de HDA que precisaron esclerosis endoscópicade la lesión sangrante (esclerosis circunferencial a las 48 horas dela cirugía y esclerosis de puntos sangrantes). Todos los casos seresolvieron mediante dilatación endoscópica, precisando en doscasos dos sesiones de dilatación y el resto una. En el seguimientono se han detectado re-estenosis...(AU)

Objective: gastrojejunal stricture (GYS), not only is a commoncomplication after laparoscopic gastric bypass (LGBP), butits frequency is about 15% according to bibliography. Our aim isto present our experience after 62 LGBP.Patients and method: from January 2004 to September-2006, we performed 62 consecutive laparoscopic gastric bypass(Wittgrove´s technique). The gastrojejunal anastomosis is performedwith auto suture material type CEAA No 21 termino-lateral(ILS, Ethicon). In 4 cases (6.45%) was converted to laparotomy,perform the anastomosis in the same way. Monitoring has arange of 3-35 months, conducted in 61 patients because one patientdied of pulmonary thromboembolism in the immediate postoperativeperiod after reoperation, after two weeks of gastric bypass,by necrosis of a small fragment of the remnant gastric. In allpatients with persistent feeding intolerance were performed bariumtransit and/or gastroscopy. When gastrojejunal strictureshowed proceeded to endoscopic pneumatic dilation (recommendingdilate the anastomosis to a maximum 1.5 cm).Results: five cases (8.1%) developed a gastrojejunal stricture,in 4 of these cases the initial diagnosis was made by barium transitand in 1 case by endoscopy. Two patients had a history of digestivebleeding that required endoscopic sclerosis of the bleeding lesion(circumferentially sclerosis within 48 hours of surgery andsclerosis of bleeding points). All cases were resolved by endoscopicdilatation. At follow-up has not been detected re-stricture.Conclusion: Clinically, gastrojejunal stricture results in a progressiveoral intolerance, revealing stenosis between 1 and 3months postoperatively. The situations of sclerosis of the bleedinglesions favor, especially in cases of extensive sclerosis. In cases ofsuspected barium transit offers us a high diagnostic yield. Endoscopicdilatation resolved, so far, all cases(AU)

Intususcepción en el adulto. Revisión de 14 casos y su seguimiento / Adult intussusception - 14 case reports and their outcomes

Objetivos: analizar las opciones terapéuticas en función de laclínica, localización y lesión asociada a la intususcepción, asícomo, su seguimiento y complicaciones.Pacientes y métodos: pacientes ingresados en el HGU MoralesMeseguer (Murcia) desde enero de 1995 hasta enero 2009,con diagnóstico de invaginación intestinal. Se recogieron datosdemográficos, clínicos, exploraciones complementarias, diagnósticopresuntivo, tratamiento, seguimiento y complicaciones.Resultados: 14 pacientes (edad media 41,9 años, rango: 17-77), 7 varones y 7 mujeres, que debutaron principalmente condolor abdominal. La exploración más fiable en el diagnóstico fuela tomografía computerizada, TC (8 diagnósticos, de 10 exploraciones).El diagnóstico preoperatorio se obtuvo en 12 casos, encontrando,invaginaciones ileocólicas en 8 casos (las más frecuentes),entéricas en 5 casos y colocólicas en 2, teniendo en cuentaque son 14 los pacientes y 15 las lesiones debido a la coexistenciade 2 invaginaciones en un mismo sujeto. La etiología de las intususcepcioneses idiopática o secundaria a una lesión que hace de cabeza de invaginación. Según la naturaleza de dichas lesiones lacausa de intususcepciones entéricas fue benigna en 3 casos y malignaen 2. De las ileocólicas, se repartieron equitativamente (4benignas y 4 malignas); y de las colocólicas, sus lesiones fueronbenignas (2 casos). Se realizó tratamiento conservador en 4 pacientesy quirúrgico en 10 (7 urgente). Con 5 hemicolectomías derechas,3 resecciones de intestino delgado, 2 hemicolectomías izquierdasy una resección ileocecal. Las complicacionesquirúrgicas: 3 menores y 1 mayor (de etiología maligna y consecuenteexitus). En los pacientes con manejo conservador desaparecióla lesión entre 3 días y 6 semanas. Se siguieron durante28,25 meses de media (rango 5-72 meses)...(AU)

Aims: to analyze diagnostic and therapeutic options dependingon the clinical symptoms, location, and lesions associated withintussusception, together with their follow-up and complications.Patients and methods: patients admitted to the MoralesMeseguer General University Hospital (Murcia) between January1995 and January 2009, and diagnosed with intestinal invagination.Data related to demographic and clinical features, complementaryexplorations, presumptive diagnosis, treatment, followup,and complications were collected.Results: there were 14 patients (7 males and 7 females; meanage: 41.9 years-range: 17-77) who presented with abdominal pain.The most reliable diagnostic technique was computed tomography(8 diagnoses from 10 CT scans). A preoperative diagnosis was establishedin 12 cases. Invaginations were ileocolic in 8 cases (themost common), enteric in 5, and colocolic in 2 (coexistence of 2 lesionsin one patient). The etiology of these intussusceptions was idiopathicor secondary to a lesion acting as the lead point for invagination.Depending on the nature of this lead point, the cause of theenteric intussusceptions was benign in 3 cases and malignant in 2.Ileocolic invaginations were divided equally (4 benign and 4 malignant),and colocolic lesions were benign (2 cases). Conservativetreatment was implemented for 4 patients and surgery for 10 (7 inemergency). Five right hemicolectomies, 3 small-bowel resections,2 left hemicolectomies, and 1 ileocecal resection were performed.Surgical complications: 3 minor and 1 major (with malignant etiologyand subsequent death). The lesion disappeared after 3 days to6 weeks in patients with conservative management. Mean follow-upwas 28.25 months (range: 5-72 months).Conclusions: a suitable imaging technique, preferably CT, isimportant for the diagnosis of intussusception. Surgery is usuallynecessary but we favor conservative treatment in selected cases(AU)

Evaluación y mejora del manejo del consentimiento informado en urgencias / Evaluation and improvement of the management of informed consent in the emergency department

Objetivo: Evaluar la preparación preoperatoria del paciente quirúrgico en urgencias y mejorar así la calidad de la atención prestada a estos pacientes. Material y métodos: Para detectar las causas de incumplimiento se utilizó el diagrama de causa-efecto de Ishikawa, de forma que se elaboraron 8 criterios (C) de evaluación de la preparación preoperatoria en urgencias. La primera evaluación incluyó una muestra de 120 pacientes intervenidos de urgencia desde enero a abril de 2007. Se establecieron medidas correctoras consistentes en reuniones y charlas informativas con personal facultativo y enfermería, recordando la importancia del consentimiento informado (CI) como documento legal que debe ser firmado por el paciente y la obligación de proporcionar una copia de éste al paciente o a los familiares. La segunda evaluación incluye el período comprendido entre julio y octubre (n=120). Resultados: Se detectó un incumplimiento importante de la firma del CI de cirugía del C1 (C1: todo paciente deberá tener firmado el CI de cirugía correspondiente a la intervención realizada [27,5%]) y la entrega de la copia del consentimiento tanto por cirugía del C2 (C2: todo paciente debe haber recibido una copia del CI de cirugía correspondiente a la intervención realizada [72,5%]) como por parte de anestesia del C4 (C4: todo paciente debe haber recibido una copia del CI de anestesia correspondiente a la intervención realizada [90%]). Tras implantar las medidas correctoras se observó una mejora significativa en el cumplimiento del C2 y del C4. En el C1 se apreció mejora, pero sin significación estadística. Conclusiones: La realización de un ciclo de mejora ha permitido alcanzar el propósito fundamental de este trabajo: mejorar en un aspecto importante de nuestra actividad clínica como es el uso de los documentos del CI y, lo que es más importante, proporcionar una adecuada atención e información a nuestros pacientes (AU)

Objective: To assess the preoperative management in our emergency surgical service and to improve the quality of the care provided to patients. Material and methods: In order to find the causes of non-compliance, the Ishikawa Fishbone diagram was used and eight assessment criteria were chosen. The first assessment includes 120 patients operated on from January to April 2007. Corrective measures were implemented, which consisted of meetings and conferences with doctors and nurses, insisting on the importance of the informed consent as a legal document which must be signed by patients, and the obligation of giving a copy to patients or relatives. The second assessment includes the period from July to October 2007 (n=120). Results: We observed a high non-compliance of C1 signing of surgical consent (CRITERION 1: all patients or relatives have to sign the surgical informed consent for the operation to be performed [27.5%]) and C2 giving a copy of the surgical consent (CRITERION 2: all patients or relatives must have received a copy of the surgical informed consent for the Surgery to be performed [72.5%]) and C4 anaesthetic consent copy (CRITERION 4: all patients or relatives must have received a copy of the Anaesthesia informed consent corresponding to the operation performed [90%]). After implementing corrective measures a significant improvement was observed in the compliance of C2 and C4. In C1 there was an improvement without statistical significance. Conclusions: The carrying out of an improvement cycle enabled the main objective of this paper to be achieved: to improve the management of informed consent and the quality of the care and information provided to our patients (AU)

[Evaluation and improvement of the management of informed consent in the emergency department]. / Evaluación y mejora del manejo del consentimiento informado en urgencias.

OBJECTIVE: To assess the preoperative management in our emergency surgical service and to improve the quality of the care provided to patients. MATERIAL AND METHODS: In order to find the causes of non-compliance, the Ishikawa Fishbone diagram was used and eight assessment criteria were chosen. The first assessment includes 120 patients operated on from January to April 2007. Corrective measures were implemented, which consisted of meetings and conferences with doctors and nurses, insisting on the importance of the informed consent as a legal document which must be signed by patients, and the obligation of giving a copy to patients or relatives. The second assessment includes the period from July to October 2007 (n=120). RESULTS: We observed a high non-compliance of C1 signing of surgical consent (CRITERION 1: all patients or relatives have to sign the surgical informed consent for the operation to be performed [27.5%]) and C2 giving a copy of the surgical consent (CRITERION 2: all patients or relatives must have received a copy of the surgical informed consent for the Surgery to be performed [72.5%]) and C4 anaesthetic consent copy (CRITERION 4: all patients or relatives must have received a copy of the Anaesthesia informed consent corresponding to the operation performed [90%]). After implementing corrective measures a significant improvement was observed in the compliance of C2 and C4. In C1 there was an improvement without statistical significance. CONCLUSIONS: The carrying out of an improvement cycle enabled the main objective of this paper to be achieved: to improve the management of informed consent and the quality of the care and information provided to our patients.

Abordaje endoscópico en cirugía bariátrica. Papel de la enteroscopia de doble balón / No disponible

No disponible

Rotura de colon durante una colonoscopia secundaria a la torsión de un apéndice epiploico / Colonic perforation during a colonoscopy secondary to a torsión of an epiploic appendix

No disponible