Alexis Luna Aufroy

Libro informático del residente de cirugía : Un paso adelante

INTRODUCTION The surgical electronic logbook (surgical e-logbook) aims to: simplify registration of the training activities of surgical residents, and to obtain reliable and detailed reports about these activities for resident evaluation. METHODS The surgical e-logbook is a unique and shared database. Residents prospectively record their activities in 3 areas: surgical, scientific and teaching. We can access activity reports that are constantly updated. RESULTS Study period using the surgical e-logbook: Between June 2011 and May 2013. Number of surgeries reported: 4,255. Number of surgical procedures reported: 11,907. Number of surgeries per resident per year reported: 250. Number of surgical procedures per resident per year reported: 700. Surgical activity as a primary surgeon during the first year of residency is primarily in emergency surgery (68,01%) and by laparotomy (97,73%), while during the fifth year of residency 51,27% is performed in elective surgery and laparoscopy is used in 23,10% of cases. During this period, residents participated in a total of 11 scientific publications, 75 conference presentations and 69 continuing education activities. CONCLUSIONS The surgical e-logbook is a useful tool that simplifies the recording and analysis of data about surgical and scientific activities of the residents. It is a step forward in the evaluation of the training of surgical residents, however, is only an intermediate step towards the development of a larger Spanish registry.INTRODUCTION The surgical electronic logbook (surgical e-logbook) aims to: simplify registration of the training activities of surgical residents, and to obtain reliable and detailed reports about these activities for resident evaluation. METHODS The surgical e-logbook is a unique and shared database. Residents prospectively record their activities in 3 areas: surgical, scientific and teaching. We can access activity reports that are constantly updated. RESULTS Study period using the surgical e-logbook: Between June 2011 and May 2013. Number of surgeries reported: 4,255. Number of surgical procedures reported: 11,907. Number of surgeries per resident per year reported: 250. Number of surgical procedures per resident per year reported: 700. Surgical activity as a primary surgeon during the first year of residency is primarily in emergency surgery (68,01%) and by laparotomy (97,73%), while during the fifth year of residency 51,27% is performed in elective surgery and laparoscopy is used in 23,10% of cases. During this period, residents participated in a total of 11 scientific publications, 75 conference presentations and 69 continuing education activities. CONCLUSIONS The surgical e-logbook is a useful tool that simplifies the recording and analysis of data about surgical and scientific activities of the residents. It is a step forward in the evaluation of the training of surgical residents, however, is only an intermediate step towards the development of a larger Spanish registry.

Validación de un modelo de riesgo de evisceración

INTRODUCTION The aim of this study is to determine the usefulness of the risk model developed by van Ramshorst et al., and a modification of the same, to predict the abdominal wound dehiscences risk in patients who underwent midline laparotomy incisions. MATERIALS AND METHODS Observational longitudinal retrospective study. SAMPLE Patients who underwent midline laparotomy incisions in the General and Digestive Surgery Department of the Sabadells Hospital-Parc Taulís Health and University Corporation-Barcelona, between January 1, 2010 and June 30, 2010. Dependent variable: Abdominal wound dehiscence. INDEPENDENT VARIABLES Global risk score, preoperative risk score (postoperative variables were excluded), global and preoperative probabilities of developing abdominal wound dehiscence. RESULTS SAMPLE 176 patients. Patients with abdominal wound dehiscence: 15 (8.5%). The global risk score of abdominal wound dehiscence group (mean: 4.97; IC 95%: 4.15-5.79) was better than the global risk score of No abdominal wound dehiscence group (mean: 3.41; IC 95%: 3.20-3.62). This difference is statistically significant (P<.001). The preoperative risk score of abdominal wound dehiscence group (mean: 3.27; IC 95%: 2.69-3.84) was better than the preoperative risk score of No abdominal wound dehiscence group (mean: 2.77; IC 95%: 2.64-2.89), also a statistically significant difference (P<.05). The global risk score (area under the ROC curve: 0.79) has better accuracy than the preoperative risk score (area under the ROC curve: 0.64). CONCLUSION The risk model developed by van Ramshorst et al. to predict the abdominal wound dehiscences risk in the preoperative phase has a limited usefulness. Additional refinements in the preoperative risk score are needed to improve its accuracy.

Measurement of lactic acid in multiple injury patients and its usefulness as a predictor of multiorgan failure and mortality

INTRODUCTION The use of lactic acid as marker of occult hyperfusion and its relationship with multiorgan failure (MOF) and/or mortality is a subject of debate. MATERIAL AND METHOD A prospective study was conducted on multiple injury patients over 16 years of age in critical care areas. The lactic acid was measured at the beginning and at 24 hours of the trauma and associating it with the patient morbidity and mortality. RESULTS A total of 342 patients, with a mean injury severity score of 24.1, were included. The patients who survived had an initial, and 24 hours after the trauma, lactic acid of 27.8 mg/dl and 17.9 mg/dl, respectively, (normal values less than 22 mg/dl), increasing to 36.5mg/dl and 40.2mg/dl, respectively, in those who died. There were no differences between the initial lactic acid in patients with and without MOF, being increased at 24 hours in those who had MOF (17.8 vs 26.7). The patients with a lactic acid that got worse or remained abnormal at 24 hours had a higher mortality than those in which it remained the same or improved (25% - 17.1% vs 6.3% - 0.8%), with the percentage of patients with MOF also increasing (40.6% - 32.8% vs 14.9% - 11.1%). In haemodynamically stable patients, there was also a higher mortality when the lactic acid got worse or remained abnormal in the first 24 hours (23.8% - 19.2% vs 8.8% - 0%), as well as a higher percentage of MOF (38.1% - 26.9% vs 10.9% - 7.6%). CONCLUSIONS The lactic acid results in the first 24 hours of the multiple injury patient are associated with mortality and MOF, even when the patient is haemodynamically stable.

Medición del ácido láctico en pacientes politraumatizados y su utilidad como factor predictor de mortalidad y fallo multiorgánico

INTRODUCTION The use of lactic acid as marker of occult hyperfusion and its relationship with multiorgan failure (MOF) and/or mortality is a subject of debate. MATERIAL AND METHOD A prospective study was conducted on multiple injury patients over 16 years of age in critical care areas. The lactic acid was measured at the beginning and at 24 hours of the trauma and associating it with the patient morbidity and mortality. RESULTS A total of 342 patients, with a mean injury severity score of 24.1, were included. The patients who survived had an initial, and 24 hours after the trauma, lactic acid of 27.8 mg/dl and 17.9 mg/dl, respectively, (normal values less than 22 mg/dl), increasing to 36.5mg/dl and 40.2mg/dl, respectively, in those who died. There were no differences between the initial lactic acid in patients with and without MOF, being increased at 24 hours in those who had MOF (17.8 vs 26.7). The patients with a lactic acid that got worse or remained abnormal at 24 hours had a higher mortality than those in which it remained the same or improved (25% - 17.1% vs 6.3% - 0.8%), with the percentage of patients with MOF also increasing (40.6% - 32.8% vs 14.9% - 11.1%). In haemodynamically stable patients, there was also a higher mortality when the lactic acid got worse or remained abnormal in the first 24 hours (23.8% - 19.2% vs 8.8% - 0%), as well as a higher percentage of MOF (38.1% - 26.9% vs 10.9% - 7.6%). CONCLUSIONS The lactic acid results in the first 24 hours of the multiple injury patient are associated with mortality and MOF, even when the patient is haemodynamically stable.

Isquemia mesenterica aguda: utilidad de las tecnicas de revascularizacion endovascular §

INTRODUCTION Acute mesenteric ischemia (AMI) has a high mortality. Early diagnosis and treatment are very important. In our institution there is a therapeutic protocol that includes endovascular techniques (ET) in patients with AMI without peritoneal irritation at diagnosis. The aim of this study was to evaluate the use of ET in conjunction with conventional surgery in the management of potentially reversible IMA diagnosed by computed tomography (CT-angiography). METHODS Observational, descriptive and retrospective study that evaluated the use of ET in patients with AMI (arterial origin) in 2 periods (before and after the application of a protocol that includes ET), between 2009-2013. All patients were diagnosed by a CT-angiography, as the diagnostic technique of choice, because of the clinical and analytical suspicion. RESULTS Our series included 73 patients with IMA diagnosed by CT-angiography (45: 2009-2011; 28: 2012-2013). Leukocytosis was common (82%), high lactate levels are less frequent (47% vs. 53%). There were 49 patients with IMA without peritoneal irritation. In 51% bowel resection surgery was performed (44% survival); 18%: revascularization by ET (survival 67%); 31%: palliative treatment (0% survival). 33% of patients undergoing first-line RVI needed a surgical rescue (bowel resection). The overall mortality was 67% (2009-2011) vs. 62% (2012-2013). CONCLUSIONS Since the protocol application, there is a higher indication of ET in patients with AMI without peritoneal irritation, showing a decreased mortality. With ET application, there is a higher survival in these patients. In our experience, the use of ET in cases of AMI without peritoneal irritation at diagnosis, may increase survival.INTRODUCTION Acute mesenteric ischemia (AMI) has a high mortality. Early diagnosis and treatment are very important. In our institution there is a therapeutic protocol that includes endovascular techniques (ET) in patients with AMI without peritoneal irritation at diagnosis. The aim of this study was to evaluate the use of ET in conjunction with conventional surgery in the management of potentially reversible IMA diagnosed by computed tomography (CT-angiography). METHODS Observational, descriptive and retrospective study that evaluated the use of ET in patients with AMI (arterial origin) in 2 periods (before and after the application of a protocol that includes ET), between 2009-2013. All patients were diagnosed by a CT-angiography, as the diagnostic technique of choice, because of the clinical and analytical suspicion. RESULTS Our series included 73 patients with IMA diagnosed by CT-angiography (45: 2009-2011; 28: 2012-2013). Leukocytosis was common (82%), high lactate levels are less frequent (47% vs. 53%). There were 49 patients with IMA without peritoneal irritation. In 51% bowel resection surgery was performed (44% survival); 18%: revascularization by ET (survival 67%); 31%: palliative treatment (0% survival). 33% of patients undergoing first-line RVI needed a surgical rescue (bowel resection). The overall mortality was 67% (2009-2011) vs. 62% (2012-2013). CONCLUSIONS Since the protocol application, there is a higher indication of ET in patients with AMI without peritoneal irritation, showing a decreased mortality. With ET application, there is a higher survival in these patients. In our experience, the use of ET in cases of AMI without peritoneal irritation at diagnosis, may increase survival.

Abscesos esplénicos múltiples

pondencia. co: jhermoso@tauli.cat (J. Hermoso Bosch) Varon de 59 anos con antecedente de exodoncia hace un mes sin complicaciones. Presenta fiebre, astenia y dolor abdominal, se lo trata con analgesia y antibioticos sin mejoria, por lo que ingresa para completar estudio. Se realiza una ecocardiografia transtor acica por sospecha confirmada de endocarditis que muestra fraccion de eyeccion del 40%. En la TC de abdomen (fig. 1) se observan abscesos espl enicos multiples, que se puncionan con cultivo positivo para Streptococcus mitis. Debido a empeoramiento clinico con insuficiencia cardiaca, hipotension e insuficiencia renal se le practica esplenectomia, sin identificacion de germen en pieza quirurgica (fig. 2). Tiene una evolucion torpida por patologia cardiaca, y se le da el alta hospitalaria al mes de la intervencion.