Bundles reduce anastomosis leak in patients undergoing elective colorectal surgery. A propensity score-matched study.

Background: anastomosis leak still being a handicap in colorectal surgery. Bowel mechanical preparation and oral antibiotics are not a practice recommended in many clinical practice guides. The aim is to analyse the decrease in frequency and severity of postoperative complications, mainly related to anastomotic leak, after the establishment of a bundle. Methods: Single-center, before-after study. A bundle was implemented to reduce anastomotic leaks and their consequences. The Bundle group were matched to Pre-bundle group by propensity score matching. Mechanical bowel preparation, oral and intravenous antibiotics, inflammatory markers measure and early diagnosis algorithm were included at the bundle. Results: The bundle group shown fewer complications, especially in Clavien Dindós Grade IV complications (2.3% vs. 6.2% p < 0.01), as well as a lower rate of anastomotic leakage (15.5% vs. 2.2% p < 0.01). A significant decrease in reinterventions, less intensive unit care admissions, a shorter hospital stay and fewer readmissions were also observed. In multivariate analysis, the application of a bundle was an anastomotic leakage protective factor (OR 0.121, p > 0.05). Conclusions: The implementation of our bundle in colorectal surgery which include oral antibiotics, mechanical bowel preparation and inflammatory markers, significantly reduces morbidity adjusted to severity of complications, the anastomotic leakage rate, hospital stay and readmissions. Register study: The study has been registered at clinicaltrials.gov Code: nct04632446.

De la cabina al quirófano / From the cockpit to the operating room

No disponible

Recommendations of «not-to-do¼: Proposals of the Spanish Association of Surgeons to the project «Commitment to quality of scientific societies¼ / Recomendaciones de «no hacer¼: propuestas de la Asociación Española de Cirujanos al proyecto de «Compromiso por la calidad de las sociedades científicas¼

"INTRODUCTION: The initiative of the Spanish Ministry of Health «Commitment to quality of scientific societies¼, aims to reduce unnecessary interventions of healthcare professionals. METHODS: The Spanish Association of Surgeons has selected 22 experts from the different sections that have participated in the identification of 26 proposals «do not do¼ to be ordered by the expected impact its implementation would have according to the GRADE methodology. From these proposals, the Delphi technique was used to select 5 recommendations presented in more detail in this article. RESULTS: The 5 selected recommendations are: Do not perform cholecystectomy in patients with asymptomatic cholelithiasis; do not keep bladder catheterization more than 48hours; do not extend antibiotic prophylaxis treatments more than 24hours after a surgical procedure; do not perform routine antibiotic prophylaxis for uncomplicated clean and no prosthetic surgery; and do not use antibiotics postoperatively after uncomplicated appendicitis. CONCLUSION: The Spanish Association of Surgeons's participation in this campaign has allowed a reflection on those activities that do not add value in the field of surgery and it is expected that the spread of this process serves to reduce its performance."

"Introducción La iniciativa del Ministerio de Sanidad «Compromiso por la calidad de las sociedades científicas¼ tiene como objetivo disminuir las intervenciones innecesarias de los profesionales sanitarios. Métodos La Asociación Española de Cirujanos ha seleccionado a 22 expertos de las diferentes secciones que han participado en la identificación de 26 propuestas de «no hacer¼ que se ordenaron por el impacto esperado que tendría su puesta en marcha según la metodología GRADE. A partir de estas propuestas, se ha utilizado una técnica de Delphi para seleccionar las 5 recomendaciones más importantes en relación con el impacto potencial que tendría su aplicación. Resultados Las 5 recomendaciones seleccionadas son: no realizar colecistectomía en pacientes con colelitiasis asintomática; no mantener sondaje vesical más de 48 h; no prolongar más de 24 h, tras un procedimiento quirúrgico, los tratamientos de profilaxis antibiótica; no realizar profilaxis antibiótica de rutina para la cirugía no protésica limpia y no complicada, y no emplear tratamiento antibiótico postoperatorio tras apendicitis no complicada. Conclusión La participación de la Asociación Española de Cirujanos en esta campaña ha permitido una reflexión sobre aquellas actuaciones que no aportan valor en el ámbito de nuestra especialidad y es esperable que la difusión de este proceso sirva para reducir su realización."

Type II intrapancreatic choledochal malignant cyst in adults: duodenopancreatectomy.

A 62-year-old female patient was admitted for abdominal pain and vomiting. Imaging tests revealed a solid-cystic lesion at the head of the pancreas communicating with the distal bile duct. A Todani type II choledochal cyst was diagnosed with neoplastic degeneration after cytological diagnosis with endoscopic ultrasound-guided puncture. The patient was treated with a cephalic duodenopancreatectomy with curative intention.

[Spontaneous pneumomediastinum: descriptive study of our experience with 36 cases]. / Neumomediastino espontáneo: estudio descriptivo de nuestra experiencia basada en 36 casos.

Spontaneous pneumomediastinum is defined as a primary process characterized by the presence of air or gas in the mediastinum. We report all the cases of spontaneous pneumomediastinum diagnosed in our hospital between January 1996 and December 2004. We developed a protocol for data collection that included the following: medical history, triggers, signs, radiology, treatment, hospital stay, and complications. During this period we diagnosed 36 cases--25 men (69.4%) and 11 women (27.5%)--with a mean age of 36.8 years (range, 11-90 years) and a mean hospital stay of 8.56 days (range, 1-53 days). The most common clinical presentation was chest pain, either isolated (27%) or with associated dyspnea (19.4%). A triggering factor was identified for 14 patients (38.8%). There was no associated morbidity or mortality. In view of our findings, we concluded that spontaneous pneumomediastinum is an uncommon entity with considerable clinical variability and that correct diagnosis requires a high level of suspicion. Radiography provides the best evidence for diagnosis.

[Computed tomographic colonography: applications, advantages and disadvantages]. / Colonografía tomográfica computarizada: aplicaciones, ventajas e inconvenientes.

INTRODUCTION: Complete preoperative study of the colon is required in the management of colorectal cancer, due to the frequent association of primary colonic neoplasms with colonic adenomas (28%) and/or synchronous carcinomas (5%) of the colon. We present a series of patients who underwent computed tomographic colonography, the indications for this procedure, and the results. PATIENTS AND METHODS: We performed a descriptive prospective study. Between May 2003 and August 2004, 50 computed tomographic colonographies were performed in 50 patients with suspected stenosing colorectal cancer and incomplete conventional colonoscopy. RESULTS: Fifty computed tomographic colonographies were performed. The findings were as follows: three were normal (6%), and in the remainder, one was a false positive for a suspected neoplastic pelvic mass (3.125%) and two were false positives (11.7%) for colonic polyps. Fifty percent of the findings (n = 32) were related to peritoneal metastases and colonic neoplasms. There were 12 technical complications [lack of cleaning of the colon (5), lack of distension (2), little air insufflation (5)]. Patient complications included vegetative manifestations in one (vomiting) and rectal bleeding in another. The overall complication rate was 27.4% (23.4% corresponded to technical complications and the remaining 4% were patient-related). There was no mortality related to the procedure. CONCLUSION: Because computed tomographic colonography is safe, effective and well tolerated by the patient, it should be considered as a technical alternative in the study of stenosing neoplasms of the proximal colon with incomplete colonoscopy. In addition, it allows other associated findings, both intra- and extracolonic, to be obtained and improves the diagnostic and therapeutic management of the patient.

Neumomediastino espontáneo: estudio descriptivo de nuestra experiencia basada en 36 casos / Spontaneous pneumomediastinum: descriptive study of our experience with 36 cases

El neumomediastino espontáneo se define como la presencia de aire o gas en el mediastino de forma primaria. Presentamos todos los casos de neumomediastino espontáneo hallados en nuestro hospital entre enero de 1996 y diciembre de 2004. Para ello, elaboramos un protocolo de recogida de datos que incluyó: antecedentes personales, desencadenantes, semiología, radiología, tratamiento, estancia y complicaciones. En este período diagnosticamos 36 casos --25 varones (69,4%) y 11 mujeres (27,5%)--, con una edad media de 36,8 años (rango: 11-90) y estancia media de 8,56 días (rango: 1-53). El cuadro clínico más habitual fue el dolor torácico, aislado (27%) o asociado a disnea (19,4%). En 14 pacientes (38,8%) hubo factor desencadenante. No hubo morbimortalidad asociada al proceso. Por todo ello, se concluye que el neumomediastino espontáneo es una entidad infrecuente, con gran variabilidad clínica, cuyo diagnóstico correcto exige un alto índice de sospecha, y la radiografía de tórax es la prueba idónea para ello

Spontaneous pneumomediastinum is defined as a primary process characterized by the presence of air or gas in the mediastinum. We report all the cases of spontaneous pneumomediastinum diagnosed in our hospital between January 1996 and December 2004. We developed a protocol for data collection that included the following: medical history, triggers, signs, radiology, treatment, hospital stay, and complications. During this period we diagnosed 36 cases--25 men (69.4%) and 11 women (27.5%)--with a mean age of 36.8 years (range, 11-90 years) and a mean hospital stay of 8.56 days (range, 1-53 days). The most common clinical presentation was chest pain, either isolated (27%) or with associated dyspnea (19.4%). A triggering factor was identified for 14 patients (38.8%). There was no associated morbidity or mortality. In view of our findings, we concluded that spontaneous pneumomediastinum is an uncommon entity with considerable clinical variability and that correct diagnosis requires a high level of suspicion. Radiography provides the best evidence for diagnosis

Colonografía tomográfica computarizada: aplicaciones, ventajas e inconvenientes / Computed tomographic colonography: applications, advantages and disadvantages

Introducción: El estudio preoperatorio completo del colon es necesario para el tratamiento del cáncer colorrectal, debido a la frecuente asociación de la neoplasia primaria de colon con adenomas colónicos (28%) y/o carcinomas sincrónicos (5%) de colon. El objetivo de este trabajo es presentar nuestra serie de pacientes a los que se ha realizado colonografía tomográfica computarizada, sus indicaciones y sus resultados.Pacientes y métodos: Estudio descriptivo y prospectivo. Entre mayo de 2003 y agosto de 2004, se llevaron a cabo 50 colonografías tomográficas computarizadas en 50 pacientes con sospecha de cáncer colorrectal estenosante y colonoscopia preoperatoria incompleta. Resultados: Se realizaron 50 colonografías tomográficas computarizadas. Los hallazgos fueron los siguientes: 3 de ellas fueron normales (6%) y en las restantes se encontró un falso positivo para masa pelviana sospechosa de neoplasia (3,125%) y 2 falsos positivos (11,7%) para pólipos colónicos. El 50% de los hallazgos (n = 32) estuvo en relación con metástasis peritoneales y neoplasias de colon. Hubo 12 casos de complicación técnica (5 falta de limpieza del colon, 2 falta de distensión, 5 escasa insuflación de aire) y 2 del paciente (1 manifestación vegetativa [vómitos], 1 sangrado rectal). La tasa global de complicaciones fue del 27,4% (el 23,4% debidas a complicaciones técnicas y el 4% restante a los pacientes). No hubo mortalidad relacionada con el procedimiento. Conclusión: La colonografía tomográfica computarizada, por su seguridad, eficacia y buena tolerancia por parte del paciente, debe considerarse una técnica alternativa de estudio del colon proximal ante una neoplasia estenosante con colonoscopia incompleta. Además, permite obtener otros hallazgos asociados, intra y extracolónicos, así como mejorar el manejo diagnóstico y terapéutico del paciente

Introduction: Complete preoperative study of the colon is required in the management of colorectal cancer, due to the frequent association of primary colonic neoplasms with colonic adenomas (28%) and/or synchronous carcinomas (5%) of the colon. We present a series of patients who underwent computed tomographic colonography, the indications for this procedure, and the results. Patients and methods: We performed a descriptive prospective study. Between May 2003 and August 2004, 50 computed tomographic colonographies were performed in 50 patients with suspected stenosing colorectal cancer and incomplete conventional colonoscopy. Results: Fifty computed tomographic colonographies were performed. The findings were as follows: three were normal (6%), and in the remainder, one was a false positive for a suspected neoplastic pelvic mass (3.125%) and two were false positives (11.7%) for colonic polyps. Fifty percent of the findings (n = 32) were related to peritoneal metastases and colonic neoplasms. There were 12 technical complications [lack of cleaning of the colon (5), lack of distension (2), little air insufflation (5)]. Patient complications included vegetative manifestations in one (vomiting) and rectal bleeding in another. The overall complication rate was 27.4% (23.4% corresponded to technical complications and the remaining 4% were patient-related). There was no mortality related to the procedure. Conclusion: Because computed tomographic colonography is safe, effective and well tolerated by the patient, it should be considered as a technical alternative in the study of stenosing neoplasms of the proximal colon with incomplete colonoscopy. In addition, it allows other associated findings, both intra- and extracolonic, to be obtained and improves the diagnostic and therapeutic management of the patient

Role of appendectomy in training for laparoscopic surgery.

BACKGROUND: This study aimed to evaluate a program of training in laparoscopic surgery based on clinical practice in the emergency room, in which laparoscopic appendectomy is the first technique that residents perform as surgeons. METHODS: A prospective nonrandomized study was conducted involving all the laparoscopies performed in emergencies with a diagnosis of acute abdomen, appendicular in origin, during the period between June 1991 and December 1997. RESULTS: There were no statistically significant differences between residents and assistants in terms of conversion rates (22/242 vs 15/158), mean hospital stay for each type of surgeon (5.2 days for residents and 5.1 days for assistants), and complications (12.8% for residents and 13.7% for assistants). Operating time, was significantly longer (p < 0.05) for residents (52.2 min) than for assistants (48 min). CONCLUSIONS: Apprenticeship in laparoscopic appendectomy can be accomplished with gradual clinical training and without the need for resort to animal experimentation laboratories.

[Omental torsion: imaging techniques can prevent unnecessary surgical interventions]. / Torsión de epiplón: las técnicas de imagen pueden evitar intervenciones innecesarias.

INTRODUCTION: Segmentary infarction of the greater omentum produces a clinical profile of acute abdomen. To date, the cause has been discovered during surgery. Greater use of ultrasonography and computed tomography (CT) in the emergency department could lead to preoperative diagnosis. The aim of this study was to describe the advisability of avoiding surgery in selected patients. PATIENTS AND METHOD: A series of nine adult patients (six men and three women), aged between 18 and 50 years, with a final diagnosis of primary omental torsion were reviewed. The first three patients underwent surgery: two underwent laparotomy for suspected acute appendicitis and the third underwent laparoscopy with a diagnosis of non-specific acute abdomen. The six remaining patients, who received a diagnosis of primary omental torsion or infarction based on ultrasonography and CT, underwent conservative treatment. The patients who did not undergo surgery were subsequently evaluated with imaging techniques to confirm resolution. RESULTS: In the first three patients, symptoms were resolved by resection of the affected omental section. In the six remaining patients, a 3-6 cm mass of soft tissue in the paraumbilical region, between the rectal sheath and the transverse colon, was found. The lesions were hyperechoic or of mixed attenuation. These findings, together with the absence of other radiological and clinical signs, led to the preoperative diagnosis. Treatment was conservative and a fast recovery, observed both clinically and radiologically, was made. CONCLUSIONS: Surgery should be avoided in selected cases of acute abdomen diagnosed as primary omental torsion.

Complicaciones relacionadas con el tubo en "t" en cirugía biliar / "T"-tube-related complications in biliary surgery

El tubo en "T" de Kehr es un instrumento que se viene utilizando desde hace más de un siglo como drenaje biliar después de la cirugía sobre la vía biliar principal. Muchos cirujanos lo consideran una herramienta imprescindible después de hacer una coledocotomía supraduodenal, aunque otros asocian su uso con un alto índice de complicaciones. El objetivo del presente artículo de revisión consiste en estudiar las distintas complicaciones asociadas a la utilización del tubo en "T", así como las causas a las que se atribuyen, planteando las soluciones alternativas que publican los diversos autores que han trabajado sobre el tema. El artículo comienza con una introducción histórica de la utilización del tubo en "T"; a continuación se exponen las diversas complicaciones relacionadas con su utilización. Posteriormente se explican las causas que encuentran los diversos autores de estas complicaciones, y por último las alternativas que muchos autores plantean a la utilización sistemática del tubo en "T" (AU)

Evolución de la categoría del cirujano que realiza la apendicectomía laparoscópica en nuestro servicio / Changes in category of surgeons performing laparoscopic appendectomy in our service

Introducción. Desde que se introdujo la laparoscopia en nuestro hospital ha ido variando la categoría del cirujano que realiza la apendicectomía laparoscópica. El objetivo de nuestro trabajo es analizar la evolución de la categoría del cirujano que efectúa esta técnica. Pacientes y método. Hemos estudiado las 400 apendicecto mías laparoscópicas realizadas entre junio de 1991 y diciembre de 1997, dividiéndolas en 4 grupos de 100. Analizamos los hallazgos operatorios, el tiempo quirúrgico, la tasa de conversiones, las complicaciones, la estancia hospitalaria y la categoría del cirujano en cada grupo. Resultados. Inicialmente, los adjuntos realizaban casi la totalidad de intervenciones, siendo actualmente los residentes los que llevan a cabo más del 85 por ciento de las apendicectomías laparoscópicas. No existen diferencias en el tiempo quirúrgico, complicaciones y estancia hospitalaria en los 4 grupos. Ha aumentado de forma significativa la tasa de conversiones y ha disminuido el número de apendicitis perforadas conforme avanza la serie. Conclusiones. La apendicectomía laparoscópica es una técnica ampliamente asimilada por los residentes de nuestro servicio, que realizan en estos momentos la mayoría de intervenciones (AU)

El cirujano como factor pronóstico en la apendicectomía laparoscópica / The surgeon as a prognostic factor in laparoscopic appendectomy

Introducción. La apendicectomía laparoscópica se introdujo en nuestro servicio de manos de cirujanos con experiencia previa en colecistectomía laparoscópica. Progresivamente, los residentes se iniciaron en la técnica, realizando hoy día la mayor parte de estas intervenciones. El objetivo del estudio es analizar si el grado de experiencia del cirujano influye en el pronóstico del paciente con apendicitis aguda intervenido por laparoscopia. Pacientes y método. Se estudian 400 pacientes con sospecha de apendicitis aguda intervenidos por laparoscopia. Analizamos los hallazgos, el tiempo quirúrgico, las conversiones, las complicaciones y la estancia hospitalaria según el cirujano (adjunto o residente, y año de formación). Resultados. No existen diferencias en cuanto al tiempo quirúrgico, tasa de conversión, complicaciones y estancia hospitalaria entre los pacientes intervenidos por adjuntos o residentes. No obstante, los adjuntos han operado un mayor porcentaje de apendicitis complicadas que los residentes. Conclusión. Los residentes de cirugía deben iniciarse en laparoscopia a través de la apendicectomía laparoscópica, aunque las formas complicadas deben ser operadas por cirujanos con experiencia (AU)