Benito Flores Pastor

Endoscopia urgente por hemorragia digestiva tras cirugía bariátrica. Algoritmo terapéutico

OBJECTIVE Gastrointestinal bleeding (GB) is a potential complication after bariatric surgery and its frequency is around 2-4% according to the literature. The aim of this study is to present our experience with GB after bariatric surgery, its presentation and possible treatment options by means of an algorithm. PATIENTS AND METHOD From January 2004 to December 2012, we performed 300 consecutive laparoscopic bariatric surgeries. A total of 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of a gastrojejunal anastomosis using a circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. Demographics, clinical presentation, diagnostic evaluation and treatment were reviewed. A total of 20 patients underwent a sleeve gastrectomy. RESULTS Twenty-seven cases (9%) developed GB. Diagnosis and therapeutic endoscopy was required in 13 patients. The onset of bleeding occurred between the 1(st)-6(th) postop days in 10 patients, and the origin was at the gastrojejunostomy staple-lines, and 3 patients had bleeding from an anastomotic ulcer 15-20 days after surgery. All other patients were managed non-operatively. CONCLUSION Conservative management of gastrointestinal bleeding is effective in most cases, but endoscopy with therapeutic intent should be considered in patients with severe or recurrent bleeding. Multidisciplinary postoperative follow- up is very important for early detention and treatment of this complication.

Vía clínica de tiroidectomía

Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.

Es adecuado incluir el tratamiento convencional y laparoscópico de la hernia inguinal bilateral en un programa de cirugía mayor ambulatoria sin ingreso

Resumen Introduccion En nuestro entorno, el tratamiento de la hernia inguinal unilateral esta ampliamente incorporado a las unidades de cirugia mayor ambulatoria (CMA), al contrario que la hernia bilateral, que aun suele ser tratada en regimen de ingreso hospitalario. El objetivo de este estudio es analizar si ha sido adecuado realizar el tratamiento de la hernia inguinal bilateral, laparoscopico y con cirugia abierta, en nuestra unidad de CMA. Pacientes y metodo Desde enero de 1998 hemos intervenido a 82 pacientes con hernia inguinal bilateral en regimen de CMA (sin ingreso). En 57 pacientes se realizo una hernioplastia bilateral laparoscopica totalmente extraperitoneal (TEP) y en 25, una hernioplastia abierta de Lichtenstein o de Gilbert. Los datos se han recogido de forma prospectiva. Se valoran parametros clinicos, anestesicos y quirurgicos, ingresos, grado de satisfaccion y recidiva. Resultados Cuarenta y ocho pacientes recibieron anestesia general y 34, raquidea. Dos pacientes del grupo de TEP precisaron reconversion a hernioplastia abierta. En 11 pacientes (13,4%) fracaso la CMA, ingresando 5 intervenidos por TEP (8,8%) y 6 por cirugia abierta (24%). El indice de sustitucion actual es del 52,9% en cirugia abierta y del 90,1% en la TEP. En el seguimiento se ha detectado una recidiva bilateral precoz en un paciente con TEP. El grado de satisfaccion fue referido como excelente o satisfactorio en el 94,7% de los casos con TEP y el 88% de los de cirugia abierta. Conclusion El tratamiento de la hernia inguinal bilateral –TEP y cirugia abierta– puede realizarse de manera segura, eficaz, eficiente y con excelente aceptacion del paciente, dentro de un programa de CMA.