[National project for the clinical management of healthcare processes. The surgical treatment of cholelithiasis. Development of a clinical pathway]. / Proyecto Nacional para la gestión clínica de procesos asistenciales. Tratamiento quirúrgico de la colelitiasis. Desarrollo de la vía clínica.

INTRODUCTION: Because surgical treatment of gallstones is highly prevalent, this topic is particularly suitable for a national study aimed at determining the most important indicators and developing a clinical pathway. OBJECTIVES: To analyze the results obtained during the hospital phase of the process. To define the key indicators of the process. To design a clinical pathway for laparoscopic cholecystectomy. PATIENTS AND METHODS: A multicenter, prospective, cross-sectional, descriptive study was performed of patients who consecutively underwent surgery for gallstones in 2002. The sample size calculated with data provided by the National Institute of Statistics was 304 patients, which was increased by 45% to compensate for possible losses. Inclusion criteria consisted of elective cholecystectomy for gallstones, without preoperative findings suggestive of common duct stones. A database was designed (Microsoft Access 2000) with 76 variables analyzed in each patient. RESULTS: Completed questionnaires were obtained from 37 hospitals with 426 patients. The mean age was 55.69 years, with a predominance of women (68.3%). The most frequent symptom was biliary colic (23%). A total of 20.3% of the patient had prior episodes of cholecystitis and 18% had a history of mild pancreatitis. Diagnosis was given by ultrasonography in 93.2% of the patients. Informed consent was provided by 93.2%. The intervention was performed on an inpatient basis in 96.1% and in the ambulatory setting in the remainder. Antibiotic and antithrombotic prophylaxis was administered in 78.9% and 75.1% of the patients respectively. The laparoscopic approach was used in 84.6%, with a conversion rate of 4.9%. Intraoperative cholangiography was performed in 17.8% of the patients and common duct stones were found in 7 patients. The most frequent complication was surgical wound infection (1.1%). Possible accidental lesion of the biliary tract occurred in 0.7% of the patients and was described as biliary fistula. There were four reinterventions: biliary fistula (1), hemoperitoneum (2) and cause unknown (1). The mean surgical time was 73.17 minutes, with a median of 60 minutes. Postoperative length of stay was 4.75 days in open surgery and 2.67 days in laparoscopic surgery. Ninety-nine percent of the patients were satisfied or highly satisfied with the healthcare received. CONCLUSIONS: Analysis of the process and review of the literature identified a series of areas requiring improvement, which were gathered in the clinical pathway developed. These areas consisted of increasing the number of patients with correctly indicated antibiotic and antithrombotic prophylaxis, increasing the percentage of patients providing informed consent and undergoing adequate preoperative tests, limiting intraoperative cholangiography to selected patients, and reducing the number of patients with an overall stay of 3 days.

Proyecto Nacional para la Gestión Clínica de Procesos Asistenciales. Tratamiento quirúrgico de la colelitiasis. Desarrollo de la vía clínica / National Project for the Clinical Management of Healthcare Processes. The surgical treatment of gallstones.Development of a clinical pathway

Introducción. La alta prevalencia del tratamiento quirúrgico de la colelitiasis ofrece un gran interés para la realización de un estudio a escala nacional dirigido a conocer los indicadores más importantes y desarrollar una vía clínica. Objetivos. Analizar los resultados obtenidos durante la etapa hospitalaria del proceso. Definir los indicadores clave del proceso. Elaborar una vía clínica para la colecistectomía laparoscópica. Pacientes y métodos. Estudio multicéntrico, prospectivo, transversal y descriptivo, de pacientes intervenidos quirúrgicamente de forma consecutiva por presentar colelitiasis durante el año 2002. El tamaño muestral calculado con los datos suministrados por el Instituto Nacional de Estadística fue de 304 pacientes, que se incrementó en un 45% para compensar posibles pérdidas. Los criterios de inclusión fueron: colecistectomía programada por colelitiasis, sin sospecha preoperatoria fundamentada de litiasis de la vía biliar principal. Se diseñó una base de datos (Microsoft Access 2000®) con 76 variables analizadas en cada paciente. Resultados. Se obtuvieron los cuestionarios de 37 hospitales con 426 pacientes. La edad media fue de 55,69 años, con predominio del sexo femenino (68,3%). La sintomatología más frecuente fue el cólico biliar (23%), con un 20,3% de pacientes con antecedentes de colecistitis y un 18% con pancreatitis leve. Al diagnóstico se llegó con la ecografía en un 93,2% de los casos. El consentimiento informado se completó en un 93,2%. En un 96,1% de los pacientes la intervención se realizó en régimen hospitalario y en el resto, de forma ambulatoria. Se realizó tratamiento antibiótico en el 78,9% y antitrombótico en el 75,1% de los casos. La intervención se realizó de forma laparoscópica en el 84,6%, con un porcentaje de reconversión del 4,9%. En un 17,8% de los pacientes se realizaron colangiografías peroperatorias, y se encontró coledocolitiasis en 7 pacientes. La complicación más frecuente fue la infección de la herida quirúrgica (1,1%). La posible lesión accidental de la vía biliar se produjo en un 0,7% de los casos, descrita como fístula biliar. Hubo 4 reintervenciones: fístula biliar (1), hemoperitoneo (2) y no se informó causa (1). La duración media de la intervención fue de 73,17 min, con una mediana de 60 min. La estancia postoperatoria de los pacientes intervenidos por laparotomía fue de 4,75 días, y 2,67 días la de los pacientes intervenidos por vía laparoscópica. El 99% de los pacientes se mostró satisfecho o muy satisfecho con la atención hospitalaria. Conclusiones. Con el análisis del proceso y la revisión de la literatura médica se ha identificado una serie de indicadores de mejora recogidos en la vía clínica que se desarrolla: porcentaje de pacientes con uso de tratamiento antibiótico y antitrombótico correctamente indicada, porcentaje de pacientes con consentimiento informado y pruebas preoperatorias adecuadas, porcentaje de pacientes con colangiografía peroperatoria correctamente adecuada y porcentaje de pacientes intervenidos con una estancia global de 3 días (AU)

Objectives. To analyze the results obtained during the hospital phase of the process. To define the key indicators of the process. To design a clinical pathway for laparoscopic cholecystectomy. Patients and methods. A multicenter, prospective, cross-sectional, descriptive study was performed of patients who consecutively underwent surgery for gallstones in 2002. The sample size calculated with data provided by the National Institute of Statistics was 304 patients, which was increased by 45% to compensate for possible losses. Inclusion criteria consisted of elective cholecystectomy for gallstones, without preoperative findings suggestive of common duct stones. A database was designed (Microsoft Access 2000®) with 76 variables analyzed in each patient. Results. Completed questionnaires were obtained from 37 hospitals with 426 patients. The mean age was 55.69 years, with a predominance of women (68.3%). The most frequent symptom was biliary colic (23%). A total of 20.3% of the patient had prior episodes of cholecystitis and 18% had a history of mild pancreatitis. Diagnosis was given by ultrasonography in 93.2% of the patients. Informed consent was provided by 93.2%. The intervention was performed on an inpatient basis in 96.1% and in the ambulatory setting in the remainder. Antibiotic and antithrombotic prophylaxis was administered in 78.9% and 75.1% of the patients respectively. The laparoscopic approach was used in 84.6%, with a conversion rate of 4.9%. Intraoperative cholangiography was performed in 17.8% of the patients and common duct stones were found in 7 patients. The most frequent complication was surgical wound infection (1.1%). Possible accidental lesion of the biliary tract occurred in 0.7% of the patients and was described as biliary fistula. There were four reinterventions: biliary fistula (1), hemoperitoneum (2) and cause unknown (1). The mean surgical time was 73.17 minutes, with a median of 60 minutes. Postoperative length of stay was 4.75 days in open surgery and 2.67 days in laparoscopic surgery. Ninety-nine percent of the patients were satisfied or highly satisfied with the healthcare received. Conclusions. Analysis of the process and review of the literature identified a series of areas requiring improvement, which were gathered in the clinical pathway developed. These areas consisted of increasing the number of patients with correctly indicated antibiotic and antithrombotic prophylaxis, increasing the percentage of patients providing informed consent and undergoing adequate preoperative tests, limiting intraoperative cholangiography to selected patients, and reducing the number of patients with an overall stay of 3 days (AU)

Efecto protector de la vagotomía sobre la mucosa gástrica en un modelo de estrés en la rata / Protective effect of vagotomy on the gastric mucosa in a stress model in rats

Introducción: la utilización de la vagotomía se ha basado clásicamente en sus efectos inhibidores sobre la secreción ácida. La sección vagal provoca modificaciones celulares y endocrinas que podrían estar implicadas en sus acciones protectoras. Nuestro objetivo es estudiar los cambios morfológicos que provoca la vagotomía sobre la mucosa gástrica y su relación con la protección frente al estrés a corto, medio y largo plazo. Material y métodos: se ha empleado un modelo de estrés de inmovilización y frío y 80 ratas Wistar divididas en dos grupos, control (con y sin estrés) y vagotomía (a 7, 30 y 120 días). Se han estudiado los cambios provocados en la mucosa gástrica por el estrés, con y sin vagotomía, así como la relación entre estos cambios y la acción protectora frente al mismo. Resultados: el sangrado tuvo una relación muy significativa con el estrés (p< 0,0001). La incidencia de sangrado tuvo una diferencia significativa entre ratas vagotomizadas y no vagotomizadas (p< 0,0001) lo que ocurrió a corto, medio y largo plazo (la vagotomía fue protectora frente al estrés). Los signos de regeneración se relacionaban significativamente con la vagotomía (p< 0,0001) y no se relacionaban con el estrés (p= 0,208). Sin embargo, no había relación significativa entre la acción protectora y la presencia de signos de regeneración (p= 1). Conclusiones: la vagotomía tiene efectos tróficos sobre la mucosa gástrica y es protectora frente al estrés. Esta acción protectora se mantiene a corto, medio y largo plazo. Sin embargo, estos cambios no son suficientes para explicar la protección. En esta acción podría estar implicado un fenómeno de adaptación mediado por factores hormonales y peptídicos. (AU)

Hacer lo correcto y hacerlo correctamente / Doing the right thing and doing it correctly

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Protective effect of vagotomy on the gastric mucosa in a stress model in rats.

INTRODUCTION: The use of vagotomy is classically based on its inhibiting effects on acid secretion. Vagotomy induces both cellular and endocrine changes that may be involved in protective actions. Our aim was to study morphologic changes induced by vagotomy on the gastric mucosa and their relation to stress protection in the short, medium and long term. MATERIAL AND METHODS: An immobilization and cold stress model was used with 80 Wistar rats divided into two groups--control (with and without stress) and vagotomy (at 7, 30 and 120 days). Changes induced in the gastric mucosa by stress were studied with and without vagotomy, as well as relationship between these changes and the intended protective action. RESULTS: Bleeding showed a very significant relation to stress (p < 0.0001). Bleeding incidence exhibited a significant difference between vagotomised and non-vagotomised rats (p < 0.0001) in the short, medium and long term (vagotomy was protective against stress). Regeneration signs related significantly to vagotomy (p < 0.0001) but not stress (p = 0.208). However, no significant relationship was found between the protective action and the presence of regeneration signs (p = 1). CONCLUSIONS: Vagotomy has tropic effects on the gastric mucosa and is protective against stress. This protective action is maintained in the short, medium and long term. However, these changes are not sufficient to explain protection. An adaptation phenomenon mediated by hormonal and peptidic factors may be involved in this action.

Buena cirugía es buena economía / Good surgery is good economy

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¿TIPS/DPPI, cuál es su papel? / What role for transjugular intrahepatic portosystemic shunt?

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Octreotide: effects in experimental severe acute pancreatitis. Analysis of survival, biochemical findings and histomorphometry.

OBJECTIVE: The effect of octreotide in acute experimental pancreatitis was examined. EXPERIMENTAL DESIGN: Acute pancreatitis was induced in 70 male Wistar rats by retrograde injection of 5% sodium taurocholate into the pancreatic duct. Octreotide (50 micrograms = 0.5 ml) or isotonic saline was administered subcutaneously every six hours for 24 hours, beginning at the time of induction of pancreatitis (groups 1 and 2) or 12 hours later (groups 3 and 4). Six hours after the last dose of octreotide or saline, the rats were sacrificed. Ten additional rats were used for basal biochemical determination. For the analysis of survival, another 10 rats were included. The survival rate, serum concentrations of amylase, lipase and lactate dehydrogenase (LDH) and morphometric studies (total area of the pancreas and percentage necrosis) were examined. Statistical analysis involved Student's t test, ANOVA and the Mantel-Haenszel test. RESULTS: No significant differences existed among the groups with respect to survival, morphometric analysis or biochemical determinations, except for a minor increase in LDH levels in the group treated with octreotide at the time of induction. CONCLUSIONS: Octreotide administration has almost no impact on mortality in experimental severe acute pancreatitis. Biochemical and morphometric changes are minimal. Therefore, according to the present study, the efficacy of octreotide administration is very low.

Evaluation of scolicidal agents in an experimental hydatid disease model.

INTRODUCTION: The treatment of hydatid disease is largely surgical, with medical treatment being reserved as coadjuvant treatment. The scolicidal agents have been, and are being used mainly during surgical manipulation of the cysts, with the object of avoiding relapses and peritoneal dissemination. OBJECTIVE: Evaluation of the scolicidal agents used in surgery in a hydatid disease model in the mouse. MATERIAL AND METHODS: We have used 85 Swiss OF1 mice, weighing more than 30 g, of 90 +/- 10 days of age, in which a picture of hydatid sowing was reproduced by means of intra-peritoneal inoculation with 0.2 ml of a suspension which contained approximately 1,200 viable protoscolex of Echinococcus granulosus which came from the livers of parasite-infested sheep. 24 h after the inoculation, the mice were subjected to a median laparotomy for the introduction of 1 ml of the scolicidal solution to be evaluated: physiologic saline (n = 10); 10% povidone iodine (n = 15); praziquantel (n = 15); 10% hydrogen peroxide (n = 15); 10% hypertonic saline (n = 15); simulated operation (n = 15). After 7 months of follow-up, the mice were sacrificed and the following was evaluated: number of isolated cysts, cyst masses, and total cysts. RESULTS: The number of isolated cysts which developed was significantly lower in the hydrogen peroxide group (tF 2.14 < RC 3.29). The number of cyst masses was significantly reduced in the hydrogen peroxide group (tF 2.14 < RC 2.18), in the povidone iodine group (tF 2.17 < RC 3), and in the hypertonic saline group (tF 2.11 < RC 2.77). The total number of cysts which developed decreased significantly in the hydrogen peroxide (tF 2.14 < RC 2.84) and the povidone iodine (tF 2.17 < RC 3.79) groups. CONCLUSIONS: Hydrogen peroxide and povidone iodine show a greater protoscolicidal effect than simple cleansing with physiological saline, hypertonic saline, or praziquantel.

[Experimental acute pancreatitis in the rat. The quantification of pancreatic necrosis after the retrograde ductal injection of sodium taurocholate]. / Pancreatitis aguda experimental en la rata. Cuantificación de la necrosis pancreática tras la inyección retrógrada ductal de taurocolato sódico.

Acute haemorrhagic pancreatitis was induced in rats by injecting 5% sodium taurocholate into the common biliopancreatic duct. The condition was associated with an increase in the serum amylase levels as well as progressive pancreatic necrosis resulting in 100% mortality before 36 hours. This experimental model was documented by quantifying nine different parameters of pancreatic necrosis and giving more information about the induced lesion. The extent of pancreatic necrosis was evaluated at different intervals, 5.77% at 12 hours, 14.9% at 24 hours, and the rats died before 36 hours of pancreatitis induction with an average percentual necrosis of 29.9%. This model seems suitable for more pathogenic as well as therapeutic studies on acute pancreatitis in the rat.

[Somatostatin in the treatment of established and severe acute pancreatitis in the rat]. / Somatostatina en el tratamiento de la pancreatitis aguda establecida y severa en la rata.

The effects of somatostatin (SS) on the treatment of acute pancreatitis were studied in rats. Acute pancreatitis was established by injecting 5% sodium taurocholate in the biliopancreatic duct. Previously, pancreatic necrosis was determined in this experimental model at several intervals without treatment. Treatment was started according different groups: at 12, 16 and 20 hours after induction of acute pancreatitis (IV bolus of 4 ug/kg body weight followed by a 24h continuous infusion of 4 ug/kg body wt/hour). When somatostatin was initiated at 12 or 16h a decrease in serum amylase and lactodehydrogenase was observed, as well as in pancreatic necrosis resulting in 0% mortality after 24h of treatment. When somatostatin was started at 20h there was no changes in the lethal outcome of the disease.

[Role of liver transplant in the treatment of hepatic hydatidosis]. / Papel del trasplante de hígado en el tratamiento de la hidatidosis hepática.

Three patients are reported who had liver hydatidosis that was not resolved by conventional surgery and who eventually underwent liver transplantation. In view of the satisfactory results obtained, with 100% postoperative survival, possible indications for liver transplant in this type of patients are discussed, fundamentally for secondary sclerosing cholangitis, secondary biliary cirrhosis and acute Budd-Chiari syndrome.

[Initial results of restoration of bile flow in liver transplant]. / Resultados iniciales en la restauración de la continuidad biliar en el trasplante hepático.

The initial results of biliary reconstruction in 72 liver transplants realized in 62 patients, 50 adults and 12 children, are presented. Three reconstruction techniques were used: end-to-end choledocho-choledochostomy on a Kehr tube in 44 transplants (61.1%); choledocho-jejunostomy on a Roux-en-Y loop in 24 transplants (33.3%); double derivation cholecysto-choledocho-jejunostomy in 2 transplants (2.7%). The number of early complications related to biliary reconstruction was 5 (7.14%): 3 fistulas in the choledocho-choledochostomy series (6.8%) and 2 fistulas among the choledocho-jejunostomies (8.3%). All complications required reoperation and mortality was nil. Thirty-two months after the onset of the program, no late complications of the biliary anastomosis have been registered.