A scoring system to predict complex transanal endoscopic surgery.

BACKGROUND: Since the introduction of screening for colorectal cancer, the use of transanal endoscopic surgery (TEM) has become increasingly popular. However, the technical difficulty of this surgery varies widely. The few studies of learning curve in TEM have produced very disparate results. The aim of this study is to distinguish between straightforward and complex procedures, in order to refer more difficult cases to centers with greater experience. METHOD: Observational study with prospective data collection and retrospective analysis was carried out between June 2004 and January 2019. All TEMs performed on rectal tumors were included. The complexity of the procedure was defined according to the weighted mean surgical time for each surgeon. A predictive model of complexity was established, with a score higher than 5 indicating a complex lesion. RESULTS: During the study period, 773 TEMs were performed, 708 of which met the study's inclusion criteria. One hundred and three tumors were defined as complex. Predictors of complexity were as follows: male sex (OR: 1.78, 95% CI 1.1-2.9, score: 1), tumor size > 5 cm (OR: 5.1, 95% CI 3.2-8.2, score: 4), TEM for recurrence (OR: 6.3, 95% CI 2.3-16.7, score: 5), and distance from the upper margin of the tumor to the anal verge > 15 cm (OR: 1.6, 95% CI 0.96-2.7, score: 1). CONCLUSIONS: Rather than establishing the learning curve merely in terms of the number of TEM procedures performed, it is important to consider the surgical difficulty of the interventions. To this end, it is essential to differentiate simple TEMs from the complex ones.

Aplicación de la revisión terciaria en el manejo inicial del paciente politraumatizado / Tertiary survey in the management of patients with multiple injuries

Objetivo: La revisión terciaria puede disminuir la incidencia de lesiones inadvertidas y de lesiones inadvertidas clínicamente relevantes y puede reducir la morbi-mortalidad de los pacientes politraumatizados. Método: Estudio prospectivo que incluye pacientes politraumatizados mayores de 16años ingresados en una área de pacientes críticos, excluidos los que murieron en las primeras 24 h. Comparación de un grupo a quien se aplicó la revisión terciaria, con un grupo control a quién no se aplicó. Hemos registrado la incidencia de lesiones inadvertidas y de lesiones inadvertidas clínicamente relevantes. Hemos analizado los principales errores asociados a la aparición de lesiones inadvertidas y los factores de riesgo inevitables. Se estudió la mortalidad de ambos grupos y sus complicaciones. Resultados: Se ha protocolizado la revisión terciaria en 119 pacientes frente a 117 en los que no se realizó. Con la aplicación de la revisión terciaria, la incidencia de lesiones inadvertidas se ha reducido de un 40,2% a un 15,1%, y la incidencia de lesiones inadvertidas clínicamente relevantes de un 17,1% a un 3,4%. La mortalidad ha disminuido de un 10,2% a un 4,2%, y desaparecieron las muertes causadas por fracaso multiorgánico. Ha disminuido el error radiológico han desaparecido los errores de comunicación y quirúrgicos. Los principales factores asociados a la detección de lesiones inadvertidas y de lesiones inadvertidas clínicamente relevantes son la presión arterial, el número de lesiones y, como factor más relevante, la aplicación de la revisión terciaria. Conclusiones: La aplicación de la revisión terciaría debería ser obligada en el manejo inicial de los pacientes politraumatizados (AU)

Background: Implementing tertiary trauma surveys can reduce the incidence of clinically significant missed injury, thereby reducing morbidity and mortality in patients with multiple injuries. Methods: Prospective study of patients admitted to the critical care unit with multiple injuries. The patients were over the age of 16 years and survived at least 24 hours. Patients undergoing tertiary examination were compared to a historical control group that did not undergo additional assessment. We recorded missed injuries and clinically significant missed injuries in both groups. Also analyzed were the main errors associated with the appearance of missed injuries, avoidable risk factors, mortality, and complications in both groups. Results: A total of 119 patients underwent tertiary examination and their data were compared to those of 117 in the historical control group. The incidence of missed injuries was lower in the test period (15.13%) than the control period(40.17%). The incidence of clinically significant missed injuries was also lower in the test period (3.36% vs 17.09 in the control period). Mortality fell to 4.25% with tertiary examination (vs 10.25% in the control period), and mortality due to multiorgan failure was 0% in the test period. Radiologic errors were fewer with implementation of tertiary trauma surveys and communication and surgical errors disappeared. The main risk factors for detecting clinically significant missed injuries were to blood pressure, the number of injuries and, particularly, the inclusion of a tertiary examination or not. Conclusion: Tertiary trauma surveys should be considered an obligatory component of the initial management of patients with multiple injuries (AU)