Correction to: Quantifying the extent of fistulotomy. How much sphincter can we safely divide? A three-dimensional endosonographic study.

In the Fig. 1 of the original published version of this article the numbers were switched as well as in the text of Results section, lines 5 and 6. The revised figure and the corrected text are now presented correctly in this article.

Evaluación del gastrointestinal quality of life index como sistema de selección para la priorización de pacientes en lista de espera de colecistectomía laparoscópica / Evaluation of the gastrointestinal quality of life index as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy

Introducción Evaluación prospectiva de la calidad de vida relacionada con la salud (CVRS) mediante el gastrointestinal quality of life index (GIQLI) como sistema de priorización de pacientes en lista de espera para el proceso colecistectomía laparoscópica (CL) y su correlación con un sistema lineal de priorización (SP) desarrollado en el Instituto de Cirugía General y Aparato Digestivo (ICAD) de la Clínica Quirón de Valencia. Material y métodos Un total de 100 pacientes consecutivos a los que se les realizó CL electiva ambulatoria. Principales medidas de resultados 1) repercusión de la enfermedad mediante el GIQLI; 2) evaluación de un sistema objetivo basado en criterios científico-técnicos; 3) evaluación del valor de la CL en términos de CVRS mediante el GIQLI analizando la utilidad esperable y la obtenida en términos de change ratio (CR) y 4) análisis de la correlación entre el sistema objetivo lineal, la CVRS y la utilidad. Resultados El GIQLI es útil en la evaluación de la repercusión. La CL obtiene un beneficio en CVRS significativo en pacientes tanto oligosintomáticos como sintomáticos. Los factores objetivos o clínicos no permiten evaluar la percepción sobre el proceso ni medir o inferir la repercusión en CVRS. Un SP basado en tramos de puntuación del GIQLI permite una selección en función de la utilidad de la CL esperable (deterioro en CVRS) y obtenida (ganancia en CVRS).Conclusiones Un SP debe incluir la utilidad para garantizar la equidad. El GIQLI objetiva la repercusión sobre el paciente mientras que los factores clínicos-objetivos no tienen relación con las expectativas de priorización. Un SP debe incluir ambos a fin de mantener el equilibrio repercusión/adecuada indicación (AU)

Introduction We prospectively evaluated health-related quality of life (HRQoL) through the gastrointestinal quality of life index (GIQLI) as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy (LC) and its correlation with a linear prioritization system developed in the General and Gastrointestinal Surgery Institute of Clínica Quirón in Valencia. Material and methods There were 100 consecutive patients who underwent elective outpatient LC. The main outcome measures consisted of: 1) assessment of the impact of the disease, measured through the GIQLI; 2) evaluation of an objective system based on technical scientific criteria; 3) evaluation of the utility of LC in improving HRQoL through the GIQLI by analyzing expected and obtained utility through the change ratio, and 4) analysis of the correlation between the objective linear system, HRQoL and utility. Results The GIQLI was useful in evaluating the impact of the disease. LC significantly improved HRQoL in both oligosymptomatic and symptomatic patients. The objective or clinical factors did not allow perceptions of the process to be evaluated or the impact on HRQoL to be measured or inferred. A prioritization system based on GIQLI scores allows patients to be selected according to the expected utility (worsening of HRQoL) and obtained utility (improvement in HRQoL) of CL.Conclusions Prioritization systems should include utility to guarantee equity. The GIQLI shows the impact of the disease on the patient while the clinical/objective factors are unrelated to the expectation of prioritization. Prioritization systems should include both elements to maintain the balance between impact and appropriate indication (AU)

Colecistectomía laparoscópica ambulatoria. Estudio de cohortes de 1.600 casos consecutivos / Ambulatory laparoscopic cholecystectomy. A cohort study of 1, 600 consecutive cases

Objetivo Describir la experiencia de nuestro grupo en colecistectomía laparoscópica ambulatoria en una cohorte de 1.600 casos consecutivos realizados en el Instituto de Cirugía y Aparato (CLA) Digestivo (ICAD) en la Clínica Quirón de Valencia durante el período 1997-2010.Pacientes y método Estudio prospectivo, observacional de 1.601 pacientes consecutivos remitidos para colecistectomía laparoscópica, procedentes de la Agencia Valenciana de Salud (AVS) y compañías aseguradoras privadas (CAP).Principales medidas de resultados: se evalúan los resultados con el análisis de índice de sustitución, tasa de ingresos no planeados, reingresos, estancia postoperatoria, duración de intervención y factores demográficos. Resultados El índice de sustitución de la serie fue de 80,8% con un porcentaje de pacientes intervenidos en régimen de estancia over-night (EON) de 13,4% y un porcentaje de ingresos en hospitalización convencional de 4,6%. La mortalidad de la serie fue de 0,13%, 0,08 en el grupo de CLA y 0,5% en el grupo de CL con EON. El índice de reingresos fue de 2,1% en la serie global, 1,6% en los pacientes ambulatorios, 5,4% en los pacientes con EON y 4,2% en los pacientes ingresados. Conclusiones La CLA es un procedimiento seguro y fiable. La reducción en la necesidad de ingreso de los pacientes es fundamental en la optimización coste efectividad del procedimiento de colecistectomía. La CLA debería ser considerada como el patrón oro del tratamiento de la colelitiasis sintomática (AU)

Objective A descriptive analysis of day-case laparoscopic cholecystectomy (ALC) in a cohort of 1,600 consecutive patients performed in Instituto de Cirugía y Aparato Digestivo (ICAD), Clínica Quirón de Valencia in the period 1997-2010.Patients and methods Prospective observational study of 1,601 consecutive patients undergoing elective laparoscopic cholecystectomy (LC) provided by the regional health service and private health companies. Main measures Conversion rate, non-planned admissions, readmissions, surgery duration and demographics. Results ALC was successfully performed in 80.8% of cases. LC with over-night (ON) stay accounted for 13.4% of patients. Admission was necessary in 4.6%. Mortality was 0.13%, 0.08 in ALC and 0.5% in ON LC. Readmissions occurred in 2.1%, 1.6% in ALC group, 5.4% in ON stay and 4.2% in admission group. Conclusions ALC is a reliable and safe procedure. Minimization of admission rates is the key for cost-effective optimization in the management of cholelithiasis. ALC should be considered as the reference standard in gallbladder stone disease treatment (AU)

[Evaluation of the gastrointestinal quality of life index as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy]. / Evaluación del gastrointestinal quality of life index como sistema de selección para la priorización de pacientes en lista de espera de colecistectomía laparoscópica.

INTRODUCTION: We prospectively evaluated health-related quality of life (HRQoL) through the gastrointestinal quality of life index (GIQLI) as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy (LC) and its correlation with a linear prioritization system developed in the General and Gastrointestinal Surgery Institute of Clínica Quirón in Valencia. MATERIAL AND METHODS: There were 100 consecutive patients who underwent elective outpatient LC. The main outcome measures consisted of: 1) assessment of the impact of the disease, measured through the GIQLI; 2) evaluation of an objective system based on technical scientific criteria; 3) evaluation of the utility of LC in improving HRQoL through the GIQLI by analyzing expected and obtained utility through the change ratio, and 4) analysis of the correlation between the objective linear system, HRQoL and utility. RESULTS: The GIQLI was useful in evaluating the impact of the disease. LC significantly improved HRQoL in both oligosymptomatic and symptomatic patients. The objective or clinical factors did not allow perceptions of the process to be evaluated or the impact on HRQoL to be measured or inferred. A prioritization system based on GIQLI scores allows patients to be selected according to the expected utility (worsening of HRQoL) and obtained utility (improvement in HRQoL) of CL. CONCLUSIONS: Prioritization systems should include utility to guarantee equity. The GIQLI shows the impact of the disease on the patient while the clinical/objective factors are unrelated to the expectation of prioritization. Prioritization systems should include both elements to maintain the balance between impact and appropriate indication.

[Ambulatory laparoscopic cholecystectomy. A cohort study of 1,600 consecutive cases]. / Colecistectomía laparoscópica ambulatoria. Estudio de cohortes de 1.600 casos consecutivos.

OBJECTIVE: A descriptive analysis of day-case laparoscopic cholecystectomy (ALC) in a cohort of 1,600 consecutive patients performed in Instituto de Cirugía y Aparato Digestivo (ICAD), Clínica Quirón de Valencia in the period 1997-2010. PATIENTS AND METHODS: Prospective observational study of 1,601 consecutive patients undergoing elective laparoscopic cholecystectomy (LC) provided by the regional health service and private health companies. MAIN MEASURES: Conversion rate, non-planned admissions, readmissions, surgery duration and demographics. RESULTS: ALC was successfully performed in 80.8% of cases. LC with over-night (ON) stay accounted for 13.4% of patients. Admission was necessary in 4.6%. Mortality was 0.13%, 0.08 in ALC and 0.5% in ON LC. Readmissions occurred in 2.1%, 1.6% in ALC group, 5.4% in ON stay and 4.2% in admission group. CONCLUSIONS: ALC is a reliable and safe procedure. Minimization of admission rates is the key for cost-effective optimization in the management of cholelithiasis. ALC should be considered as the reference standard in gallbladder stone disease treatment.

Quantifying the extent of fistulotomy. How much sphincter can we safely divide? A three-dimensional endosonographic study.

PURPOSE: To quantify the longitudinal division of the internal anal sphincter (IAS) and external anal sphincter (EAS) after fistulotomy using three-dimensional endoanal ultrasound (3D-EAUS) and correlate the results with postoperative faecal incontinence. METHODS: A prospective, consecutive study was performed from December 2008 to October 2010. All patients underwent 3D-EAUS before and 8 weeks after surgery. Thirty-six patients with simple perianal fistula were included. Patients with an intersphincteric or low transphincteric fistula (<66% sphincter involved) without risk factors for incontinence underwent fistulotomy. The outcome measures were the longitudinal extent of division of the IAS and EAS in relation to total sphincter length and continence (Jorge and Wexner scores). RESULTS: One-year follow-up revealed a 0% recurrence rate. There was a strong correlation between preoperative 3D-EAUS measurement of fistula height with intraoperative and postoperative 3D-EAUS measurement of IAS and EAS division (p < 0.001). The relationship between the level of EAS division and faecal incontinence showed a significant difference in incontinence rates between fistulotomies limited to the lower two thirds of the EAS and those above this level. Five patients (13.9%) had worse anal continence after surgery, although this was mild in all patients (<3/20 Jorge and Wexner scale). There was no significant difference in continence scores before and after surgery (p > 0.05). CONCLUSIONS: In patients without risk factors, division of the EAS during fistulotomy limited to the lower two thirds of the EAS is associated with excellent continence and cure rates.

[Evaluation of three-dimensional endoanal endosonography of perianal fistulas and correlation with surgical findings]. / Evaluación de las fístulas perianales mediante ecografía endoanal tridimensional y correlación con los hallazgos intraoperatorios.

OBJECTIVE: This study aims to assess the accuracy of three-dimensional endoanal ultrasound (3D-US), two-dimensional ultrasound (2D-US) and physical examination (PE) for the diagnosis of perianal fistulas and correlate the results with intraoperative findings. MATERIALS AND METHODS: A prospective, observational study with consecutive inclusion of patients was performed between December 2008 and August 2009. Twenty-nine patients diagnosed with a perianal fistula due to undergo surgery were included. All patients underwent PE, 2D-US and 3D-US, and the results were compared to intraoperative findings. The examinations were repeated with hydrogen peroxide instilled through the external opening. RESULTS: Internal opening (IO): no significant differences with regards to the number of IO diagnosed by PE and 2D-US or 3D-US (P>0.05). Primary tract: good concordance between 3D US and surgery (k=0.61), and this was higher than any of the other techniques used (PE: k=0.41; 2D-US: k=0.56). Secondary tracts: both 2D and 3D-US show good concordance with surgery (86%, k=0.66; 90%, k=0.73, respectively). Abscesses/cavities: The ultrasound examinations showed a moderate concordance with surgery (k=0.438, k=0.540, respectively). CONCLUSIONS: 3D-US shows a higher diagnostic accuracy than 2D-US when compared with surgery to estimate primary fistula height in transphincteric fistulas. 3D-US shows good concordance with surgery for diagnosing primary and secondary tracts and a high sensitivity and specificity for diagnosis of the IO. There was a tendency to overestimate fistula height with 2D-US as shown by the lower specificity of 2D-US for the diagnosis of high transphincteric fistulas and lower sensitivity of 2D-US for low transphincteric fistulas.

Factores intraoperatorios predictivos del fracaso del régimen ambulatorio tras colecistectomía laparoscópica / Introsperative factors pedictive of failure of the ambulatory regimen after laparoscopic cholecysteroctomy

Objetivos. Establecer qué hechos intraoperatorios durante una colecistectomía laparoscópica con pretensión ambulatoria determinan su conversión en una operación con ingreso hospitalario. Material y método. Entre enero de 1999 y agosto de 2003 se realizaron 410 colecistectomías laparoscópicas consecutivas con pretensión de régimen ambulatorio. Se aplicaron análisis univariante y multivariante de variables intraoperatorias de los pacientes. Se aplicó un score intraoperatorio para determinar la probabilidad de régimen ambulatorio tras la colecistectomía laparoscópica en cada paciente. Resultados. El índice de sustitución de la serie global fue del 88,5%. Cuarenta y dos pacientes requirieron estancia nocturna en el hospital, la mayoría por causas sociales, y 5 precisaron ingreso después de 24-48 h. Los hechos intraoperatorios relacionados con el fracaso del pretendido régimen ambulatorio para la colecistectomía laparoscópica fueron el tiempo quirúrgico superior a 60 min (p = 0,011), la existencia de dificultad anatómica en la disección intraoperatoria de la vesícula biliar (p = 0,001) y la hemorragia de la arteria cística (p = 0,041). Variables como el acceso a la cavidad abdominal, la perforación vesicular, la hemorragia de las puertas de entrada o del lecho hepático, la intensidad o el grado de hemorragia, o la extracción vesicular no se comportaron como factores predictores. Conclusiones. La colecistectomía laparoscópica en régimen ambulatorio se puede realizar de manera segura y fiable. El tiempo operatorio, la correcta disección de estructuras hiliares y la hemorragia del hilio vesicular, especialmente de la arteria cística, desempeñan un papel importante en el éxito o el fracaso de la colecistectomía laparoscópica con pretensión ambulatoria (AU)

Objectives. To determine which intraoperative factors during ambulatory laparoscopic cholecystectomy predict postoperative admission. Material and method. Between January 1999 and August 2003, we attempted 410 consecutive laparoscopic cholecystectomies. Intraoperative variables were analyzed using univariate and multivariate methods. An intraoperative score was applied to determine the probability of successful ambulatory surgery in each patient. Results. A total of 88.5% of the patients were strictly ambulatory. Forty-two patients required overnight admission, mostly due to social factors, and five patients required admission after 24-48 hours. Intraoperative variables predictive of postoperative admission were an operating time of more than 60 minutes (p = 0.011), gallbladder dissection with anatomic difficulty (p = 0.001), and cystic artery hemorrhage (p = 0.041). Surgical access to the abdominal cavity, gallbladder perforation, trocar wound or hepatic bed bleeding, intensity or grade of hemorrhage, and gallbladder extraction were not predictive variables. Conclusions. Ambulatory laparoscopic cholecystectomy is a safe and effective procedure. Operating time, correct dissection of gallbladder structures and hemorrhage of the gallbladder hilus, especially of the cystic artery, play a major role in the success or failure of ambulatory laparoscopic cholecystectomy (AU)

[Intraoperative factors predictive of failure of the ambulatory regimen after laparoscopic cholecystectomy]. / Factores intraoperatorios predictivos del fracaso del régimen ambulatorio tras colecistectomía laparoscópica.

OBJECTIVES: To determine which intraoperative factors during ambulatory laparoscopic cholecystectomy predict postoperative admission. MATERIAL AND METHOD: Between January 1999 and August 2003, we attempted 410 consecutive laparoscopic cholecystectomies. Intraoperative variables were analyzed using univariate and multivariate methods. An intraoperative score was applied to determine the probability of successful ambulatory surgery in each patient. RESULTS: A total of 88.5% of the patients were strictly ambulatory. Forty-two patients required overnight admission, mostly due to social factors, and five patients required admission after 24-48 hours. Intraoperative variables predictive of postoperative admission were an operating time of more than 60 minutes (p = 0.011), gallbladder dissection with anatomic difficulty (p = 0.001), and cystic artery hemorrhage (p = 0.041). Surgical access to the abdominal cavity, gallbladder perforation, trocar wound or hepatic bed bleeding, intensity or grade of hemorrhage, and gallbladder extraction were not predictive variables. CONCLUSIONS: Ambulatory laparoscopic cholecystectomy is a safe and effective procedure. Operating time, correct dissection of gallbladder structures and hemorrhage of the gallbladder hilus, especially of the cystic artery, play a major role in the success or failure of ambulatory laparoscopic cholecystectomy.