Cómo afrontar con éxito el Examen Clínico Objetivo Estructurado (ECOE) / How to successfully confront the Objective Structured Clinical Examination (OSCE)

La prueba ECOE está diseñada para evaluar el desempeño de los estudiantes ante situaciones clínicas específicas, donde se ponen a prueba sus conocimientos teóricos, razonamiento clínico, habilidades y destrezas, así como su actitud y capacidad de comunicación interpersonal. Este trabajo presenta medidas sobre cómo un estudiante puede afrontar un ECOE con éxito antes, durante y después de la prueba

The OSCE is designed to assess student performance in specific clinical situations, in which their theoretical knowledge, clinical reasoning, skills and abilities are tested, as well as their attitude and interpersonal communication skills. This paper presents measures on how a student can successfully confront the OSCE before, during, and after the test

Evaluación: Resultados a 16 años de las dos técnicas más comunes de hernioplastía inguinal abierta / Assessment: Results at 16 years of the two most common techniques used in open inguinal hernioplasty

Objetivo: Evaluar los resultados obtenidos durante 16 años en los pacientes sometidos a reparación abierta, con las dos técnicas más comunes: Lichtenstein y Mesh Plug. Sede: Hospital regional 2do nivel de atención. Diseño: Estudio observacional, descriptivo, comparativo, retrospectivo. Análisis estadístico: t de Student y Chi cuadrada. Material y métodos: Se valoraron 1,293 procedimientos de Lichtenstein y 5,889 de Mesh-Plug, realizados de julio de 1993 a junio de 2002, seguidos hasta 2009 con promedio de 132 meses. Ambos procedimientos estandarizados de acuerdo a las técnicas originales, efectuadas por cirujanos generales no especialistas en hernia. Variables evaluadas: tiempo quirúrgico, estancia hospitalaria, ahorro en días cama, días de incapacidad, recurrencias, morbilidad y dolor crónico. Resultados: La media de tiempo quirúrgico en el procedimiento de Lichtenstein fue de 59 minutos, y con ''Mesh-Plug'' 25 minutos. Permanencia hospitalaria de 7.5 horas con Lichtenstein contra 3.5 horas de ''Mesh-Plug''. Ahorro de 26,573 días cama y 201,096 días de incapacidad laboral. Morbilidad de 1.04%. Recurrencia de 0.59% y 9 pacientes con inguinodinia crónica que requirieron retiro de material protésico. Conclusiones: Ambos procedimientos son seguros con pocas consecuencias nocivas. Mesh-Plug fue más rápida en su conformación hasta en un 50%, la estancia hospitalaria corta favoreció ahorros sustanciales en días de incapacidad y días-cama.

Objective: To evaluate the results obtained during 16 years in patients subjected to open hernia repair with the two most common techniques: Lichtenstein and Mesh-Plug. Setting: Second health care level hospital. Design: Observational, retrospective, descriptive, comparative study. Statistical analysis: Student's t and square chi tests. Material and methods: We assessed 1,293 Lichtenstein and 5,889 Mesh-Plug procedures, performed from July 1993 to June 2002, followed for an average of 132 months. Both procedures were standardized according to the original techniques and performed by general surgeons, not specializing in hernia. Assessed variables were: surgical time, hospital stay, savings in bed-days, working incapacity days, recurrences, morbidity, and chronic pain. Results: The mean of surgical time for the Lichtenstein procedures was of 59 min, and 25 min for the Mesh-Plug, Length of in-hospital stay with Lichtenstein was 7.5 h versus 3.5 h with the Mesh-Plug. Savings in bed-days amounted to 26,573 and 201,098 days of working incapacity days. Morbidity of 1.04%. Recurrence of 0.59%, and nine patients coursed with chronic inguinodynia and required retrieval of the prosthetic material. Conclusions: Both procedures are safe and have few noxious consequences. The mesh plug technique was faster in 50%, the shorter in-hospital stay favored substantial savings in working incapacity and bed days.

Routine administration of antibiotics to patients suffering accidental gallbladder perforation during laparoscopic cholecystectomy is not necessary.

INTRODUCTION: Accidental rupture of the gallbladder is an event which occurs in up to 20% of laparoscopic cholecystectomies, mainly in those where dissection is difficult, or during extraction when the gallbladder is withdrawn directly through the laparoscope port. It has been commonly assumed that contamination by bile in the abdominal cavity could be a cause of infection and lead to the formation of a residual abscess or even to surgical wound infection. It is common practice, therefore, for the surgeon to prescribe the application of an antibiotic at the moment when gallbladder perforation occurs. OBJECTIVE: To compare 2 groups of similar patients, to determine whether administration of antibiotics, started during surgery, is actually useful in reducing the risk of residual abscess or infection in the surgical wound. PATIENTS AND METHOD: The study considered a total of 166 patients who had suffered accidental perforation of the gallbladder during elective laparoscopic cholecystectomy. This total was divided at random into 2 groups: group A (80 patients) who received a dose of 1 g of Cefotaxime at the moment of gallbladder rupture, followed by 2 more doses at intervals of 8 hours in the immediate postoperative period; and group B (86 patients) who did not receive any antibiotic treatment at all. The dependent variables observed were surgical wound infection and residual abscess: and the control variables were age, sex, length of operation time, intercurrent illnesses, and American Society of Anesthesiologists (ASA) classification. RESULTS: Two patients (2.5%) in group A developed a surgical wound infection, against 3 cases (3.4%) in group B, the result having no statistical significance. No patients developed residual abscess. In a multivariant analysis, the following were identified as independent factors significantly associated with the onset of surgical wound infection (P<0.001): diabetes mellitus, being over 60 years of age, operation time lasting longer than 70 minutes, and ASA 3. CONCLUSIONS: Routine application of an antibiotic to patients experiencing accidental perforation of the gallbladder during laparoscopic cholecystectomy is not necessary. In the case of patients with diabetes mellitus, those who are older than 60, or who have an ASA classification of 3 or more, or if the operation itself is likely to last more than 70 minutes, the recommendation is to start antibiotic therapy in the preoperative phase immediately before surgery.

Parastomal hernia-repair using mesh and an open technique.

INTRODUCTION: Parastomal hernia occurs in 35%-50% of patients who have had a stoma formed, whether for the digestive tract or the urinary tract. There are many repair techniques including primary repair and repair using different types of mesh prosthesis, and the surgical approach may be open or laparoscopic. However, all techniques suffer the disadvantage of a high index of hernia recurrence. PATIENTS AND METHODS: This study included 125 patients from the stoma clinic at our hospital. Hernia repair was performed on 25 of these patients who had a terminal colostomy because of either cancer or inflammatory disease. Preoperative colon preparation involved a cathartic, an evacuating enema, and antibiotic therapy in the preoperative period. The repair was conducted via an anterior approach, dissecting the skin around the stoma in the way a plastic surgeon handles an umbilical scar during abdominoplasty, in order to enter the hernia site. The hernial sac was left intact to form a bed on which to lay a lightweight polypropylene mesh, and this was then fixed to the deep face of the aponeurosis all around the stoma, with sutures placed in a U-shape with 1/0 or 2/0 non-absorbent material. The mesh was also fixed to the external surface of the colon with simple sutures of 3/0 polyglycocolic acid. A closed supra-aponeurotic drain was left in situ, and the skin was closed with 3/0 nylon. RESULTS: Of the corpus, 50 patients presented with parastomal hernia (40%), and 25 of them underwent surgery. These patients were followed for a period of 12 months, on average (range: 8-24 months). After operation, 2 patients (8%) experienced hernia recurrence and underwent further surgery to reinforce the abdominal wall with a new insertion of mesh prosthesis; 2 patients (8%) suffered surgical wound infection; and 2 patients (8%) developed a seroma. There was no rejection of the mesh, erosion of the colon, or fistula formation. CONCLUSIONS: Inserting a mesh prosthesis by this technique is a safe effective treatment for parastomal hernia, adding another option to the available repair solutions. Prospective and comparative studies are required to reinforce this study, and they should ideally include a greater number of patients in the study corpus.

Acute amebic appendicitis.

INTRODUCTION: Acute appendicitis of amebic origin is considered a rare cause of acute appendicitis. METHODS: The clinical notes for 4093 patients over the age of 16 who had undergone appendectomy were reviewed. Particular attention was paid to the histopathologic results, separating out those cases where trophozoites were seen in the appendix. These cases were considered to be of amebic origin. RESULTS: A total of 93 cases reported lesions suggestive of amebiasis (2.3%). This study analyzed 86 of these cases. Comparing the cases in this study against the cases of patients with acute appendicitis in general (excluding the cases of amebic origin), no differences were found in relation to the distribution or presentation according to sex or in the degree of inflammation of the appendix, the incidence of surgical wound infection, or general complications. By contrast, the study noted a statistically significant difference in the age at presentation: Acute appendicitis of amebic origin presents principally among those under 20 years of age and is accompanied by a higher frequency of fecal fistula (2.3%). CONCLUSIONS: Acute appendicitis of amebic origin is not seen frequently, and in general it does not behave any differently from other cases of acute appendicitis, except in its earlier presentation and its greater incidence of fecal fistula. The condition is suspected clinically whenever a cecum of hard, "cardboard-like" consistency is discovered.

Xanthogranulomatous cholecystitis in laparoscopic surgery.

Xanthogranulomatous cholecystitis (XGC) is one presentation of cholecystitis and can be a cause of difficulty in cholecystectomy. We reviewed the clinical files of 12,426 patients who had undergone cholecystectomy. In this group, there were 182 cases of XGC, and 41 of these patients had undergone laparoscopic surgery. Patients with XGC represented 1.46% of the cholecystectomies that were performed. Of the 41 patients who underwent laparoscopic surgery, 27 were men (66%) and 14 were women (34%) (average age, 52 years). A total of 36 patients (88%) presented with a chronic condition. XGC was found to be associated with lithiasis in 85%, with jaundice in 22%, and with cancer in 2.4% (one patient). A total of 33 patients (80%) required conversion to open surgery, because of technical difficulties; of these patients, 64% underwent partial cholecystectomy. We conclude that XGC creates difficulty at laparoscopy and therefore any preoperative suspicion of XGC should cause the clinician to consider open cholecystectomy.

Xanthogranulomatous cholecystitis: 15 years' experience.

The demographic and clinical aspects of xanthogranulomatous cholecystitis (XGC) over a period of 15 years are reviewed. The review entailed examining 12,426 clinical files of patients who had undergone cholecystectomy, including 182 patients with a histopathologic diagnosis of XGC. Altogether, 1.46% of the cholecystectomies performed were done on patients with a diagnosis of XGC. XGC presented in patients over the age of 32, with a male/female ratio of 2:1. Thickening of the gallbladder wall, seen on ultrasonography and computed tomography scans, was demonstrated in 100% of the cases. A total of 17% of the cases presented in acute form. Obstructive jaundice was observed in 23% of the patients, 11 of which cases were associated with choledocholithiasis (30% of these patients had jaundice) and the rest with extrinsic obstruction of the bile tract (Mirizzi syndrome). XGC was associated with lithiasis in 85% of the cases. A malignant lesion was suspected during operation in 30% of the cases, requiring histopathologic examination during surgery. Carcinomatous lesions were found in 3% of the cases. Surgical difficulty was reported in 65% of the cases, resulting in the performance of partial cholecystectomy in 35%. XGC is an infrequent form of chronic inflammation of the gallbladder, the clinical presentation of which is similar to that of cholecystitis; given the thickening of the gallbladder wall, it makes cholecystectomy difficult. As XGC may resemble adenocarcinoma, differentiation is essential by means of intraoperative histologic examination to ensure optimal surgical treatment.