Joaquín Ortega Serrano

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.

Unusual case of upper gastrointestinal bleeding after laparoscopic gastric bypass: erosion of gastric remnant involving a diaphragmatic vessel

A 46-year-old woman had undergone laparoscopic gastric bypass in January 2008 to treat morbid obesity (weight 112 kg, height 165 cm, body mass index 41 kg/m) and subsequent exploratory laparotomy in February 2009 secondary to internal herniation of the biliopancreatic limb. She was brought to the emergency department in November 2009 because she was hemodynamically unstable (heart rate 110 bpm, blood pressure 90/40 mm Hg) with associated melena and dizziness. Her hemoglobin level was 7.8 g/dL, with a hematocrit of 24%. Initial crystalloid resuscitation was instituted, achieving clinical improvement (heart rate 90 bpm, blood pressure 110/60 mm Hg), after which she underwent gastroscopy, with the finding of a erythematous injury to the “z” line, with fibrin, but without active bleeding, suspicious for a Mallory-Weiss tear. The lesion was sclerosed with adrenaline and she received 2 U of red blood cells. She was discharged asymptomatic 48 hours later. Two days after discharge, she presented again because of another episode of melena and mild hemodynamic symptoms, with a decrease in hemoglobin to 6.6 g/dL and hematocrit to 18%. Resuscitation with another 3 U of blood was performed, and she underwent another gastroscopy, without finding the cause of the bleeding. An angiographic computed tomography (CT) scan was performed and revealed leakage of intravenous contrast in the remnant gastric fundus. Gastric distension as seen with an intraluminal hyperdense material that was most likely a blood clot (19 6.25 cm; Fig. 1). Transarterial embolization was performed with selective catheterization of the celiac trunk and superselec-

Alteraciones nutricionales tras dieta muy baja en calorías previa a cirugía bariátrica

INTRODUCTION There has been an alarming worldwide increase of obese people in recent years. Currently, there is no consensus on whether patients that are scheduled to undergo bariatric surgery should lose weight before the intervention. The objective of this research is to analyse the influence of pre-surgery loss of weight in the nutritional parameters of patients. METHODS Fifty patients that were scheduled to undergo bariatric surgery followed a very low caloric diet during 4 weeks prior to the surgery. The nutritional parameters were analysed at 3 specific moments: before starting the diet, at the moment of surgery (when the diet was concluded) and one month after the surgery. RESULTS Average values for hemoglobin, albumina and lymphocytes were kept within the range of normal values at all moments, even though the decrease of those parameters was statistically significant throughout the study (P<.05). By following the very low caloric diet, less than 9.5% of the sample suffered anaemia. CONCLUSIONS Loss of weight prior to surgery does not have a significant influence in the nutritional parameters of the patient. These results would support the indication of losing weight for patients that are considered candidates for bariatric surgery.

Síndrome de la pinza aortomesentérica

Mujer de 18 anos de edad, sin antecedentes personales de interes, con vomitos de dos semanas de evolucion, que se hicieron incoercibles en las ultimas 48 horas. Un transito esofago-gastro-duodenal con contraste demostro una dilatacion del estomago y oclusion de tercera porcion duodenal, aparentemente por compresion extrinseca (fig. 1). Una ecografia abdominal confirmo la compresion extrinseca del duodeno entre la aorta y la arteria mesenterica superior (fig. 2). Una gastroscopia no evidencio lesiones en estomago ni primera porcion duodenal. Ante estos hallazgos se establecio el diagnostico de sindrome de Wilkie y se inicio nutricion enteral a traves de una sonda lastrada naso-yeyunal, con lo que, tras 55 dias de tratamiento, la paciente aumento 5 kg y se resolvio el cuadro clinico. c i r e s p . 2 0 1 2 ; 9 0 ( 1 ) : 5 3Mujer de 18 anos de edad, sin antecedentes personales de interes, con vomitos de dos semanas de evolucion, que se hicieron incoercibles en las ultimas 48 horas. Un transito esofago-gastro-duodenal con contraste demostro una dilatacion del estomago y oclusion de tercera porcion duodenal, aparentemente por compresion extrinseca (fig. 1). Una ecografia abdominal confirmo la compresion extrinseca del duodeno entre la aorta y la arteria mesenterica superior (fig. 2). Una gastroscopia no evidencio lesiones en estomago ni primera porcion duodenal. Ante estos hallazgos se establecio el diagnostico de sindrome de Wilkie y se inicio nutricion enteral a traves de una sonda lastrada naso-yeyunal, con lo que, tras 55 dias de tratamiento, la paciente aumento 5 kg y se resolvio el cuadro clinico. c i r e s p . 2 0 1 2 ; 9 0 ( 1 ) : 5 3Mujer de 18 años de edad, sin antecedentes personales de interés, con vómitos de dos semanas de evolución, que se hicieron incoercibles en las últimas 48 horas. Un tránsito esófago-gastro-duodenal con contraste demostró una dilatación del estómago y oclusión de tercera porción duodenal, aparentemente por compresión extrı́nseca (fig. 1). Una ecografı́a abdominal confirmó la compresión extrı́nseca del duodeno entre la aorta y la arteria mesentérica superior (fig. 2). Una gastroscopia no evidenció lesiones en estómago ni primera porción duodenal. Ante estos hallazgos se estableció el diagnóstico de sı́ndrome de Wilkie y se inició nutrición enteral a través de una sonda lastrada naso-yeyunal, con lo que, tras 55 dı́as de tratamiento, la paciente aumentó 5 kg y se resolvió el cuadro clı́nico. c i r e s p . 2 0 1 2 ; 9 0 ( 1 ) : 5 3

Combined Treatment of an Aortoesophageal Fistula After Aortoplasty for Aortic Stenosis

The aortoesophageal fistula secondary to the rupture of an aneurysm is a rare entity that usually has a fatal outcome. We present the case of a young patient with an aortoesophageal fistula secondary to a thoracic aortic aneurysm successfully treated with a combination of endoscopic and surgical techniques.

Tratamiento quirúrgico de los tumores del estroma gastrointenstinal. Análisis de nuestra experiencia

INTRODUCTION Gastrointestinal stromal tumours (GIST) make up 2% of gastrointestinal tumours. Surgery is the only treatment method in localised cases. The laparoscopic approach has increased over the last few years. We present our experience in the treatment of GIST. MATERIAL AND METHODS A total of 40 patients with 45 GIST had been subjected to surgical treatment between 1997 and 2010. Data was retrospectively collected on, demographic characteristics, location and tumour biology, diagnosis, type of surgery and the results of that surgery. RESULTS A total of 24 males and 16 women, with a mean age of 66.7 years, were treated. The location was gastric in 24 cases (60%), small intestine in 13 (32.5%), colon in 2 (5%) and oesophagus in 1 case (2.5%). Laparotomy was performed in 27 cases, 12 by laparoscopy (1 thoracoscopy), and 1 endoscopic sigmoid tumour resection. Four cases (10%), all after laparotomy, had recurred after a median follow-up of 31 months (2-120), and 2 patients of the laparotomy group died due to their cancer. After a univariate analysis, the prognostic factors for a laparoscopic recurrence were: tumour size (P=.0001), mitosis number (P=.001), being a locally advanced tumour (P=.01) and a ruptured tumour (P=.002). Only size remained as a prognostic factor after the multivariate analysis (P=.029; RR 1.363; 95% CI; 1.033-1.799). The presence of a locally advanced tumour was shown to be significant in the univariate analysis, while there were no significant factors after the multivariate analysis. CONCLUSIONS Correct preoperative staging is essential for deciding which surgical approach to employ.INTRODUCTION Gastrointestinal stromal tumours (GIST) make up 2% of gastrointestinal tumours. Surgery is the only treatment method in localised cases. The laparoscopic approach has increased over the last few years. We present our experience in the treatment of GIST. MATERIAL AND METHODS A total of 40 patients with 45 GIST had been subjected to surgical treatment between 1997 and 2010. Data was retrospectively collected on, demographic characteristics, location and tumour biology, diagnosis, type of surgery and the results of that surgery. RESULTS A total of 24 males and 16 women, with a mean age of 66.7 years, were treated. The location was gastric in 24 cases (60%), small intestine in 13 (32.5%), colon in 2 (5%) and oesophagus in 1 case (2.5%). Laparotomy was performed in 27 cases, 12 by laparoscopy (1 thoracoscopy), and 1 endoscopic sigmoid tumour resection. Four cases (10%), all after laparotomy, had recurred after a median follow-up of 31 months (2-120), and 2 patients of the laparotomy group died due to their cancer. After a univariate analysis, the prognostic factors for a laparoscopic recurrence were: tumour size (P=.0001), mitosis number (P=.001), being a locally advanced tumour (P=.01) and a ruptured tumour (P=.002). Only size remained as a prognostic factor after the multivariate analysis (P=.029; RR 1.363; 95% CI; 1.033-1.799). The presence of a locally advanced tumour was shown to be significant in the univariate analysis, while there were no significant factors after the multivariate analysis. CONCLUSIONS Correct preoperative staging is essential for deciding which surgical approach to employ.

La imagen del mesSíndrome de la pinza aortomesentéricaSuperior mesenteric artery syndrome

Mujer de 18 anos de edad, sin antecedentes personales de interes, con vomitos de dos semanas de evolucion, que se hicieron incoercibles en las ultimas 48 horas. Un transito esofago-gastro-duodenal con contraste demostro una dilatacion del estomago y oclusion de tercera porcion duodenal, aparentemente por compresion extrinseca (fig. 1). Una ecografia abdominal confirmo la compresion extrinseca del duodeno entre la aorta y la arteria mesenterica superior (fig. 2). Una gastroscopia no evidencio lesiones en estomago ni primera porcion duodenal. Ante estos hallazgos se establecio el diagnostico de sindrome de Wilkie y se inicio nutricion enteral a traves de una sonda lastrada naso-yeyunal, con lo que, tras 55 dias de tratamiento, la paciente aumento 5 kg y se resolvio el cuadro clinico. c i r e s p . 2 0 1 2 ; 9 0 ( 1 ) : 5 3Mujer de 18 anos de edad, sin antecedentes personales de interes, con vomitos de dos semanas de evolucion, que se hicieron incoercibles en las ultimas 48 horas. Un transito esofago-gastro-duodenal con contraste demostro una dilatacion del estomago y oclusion de tercera porcion duodenal, aparentemente por compresion extrinseca (fig. 1). Una ecografia abdominal confirmo la compresion extrinseca del duodeno entre la aorta y la arteria mesenterica superior (fig. 2). Una gastroscopia no evidencio lesiones en estomago ni primera porcion duodenal. Ante estos hallazgos se establecio el diagnostico de sindrome de Wilkie y se inicio nutricion enteral a traves de una sonda lastrada naso-yeyunal, con lo que, tras 55 dias de tratamiento, la paciente aumento 5 kg y se resolvio el cuadro clinico. c i r e s p . 2 0 1 2 ; 9 0 ( 1 ) : 5 3Mujer de 18 años de edad, sin antecedentes personales de interés, con vómitos de dos semanas de evolución, que se hicieron incoercibles en las últimas 48 horas. Un tránsito esófago-gastro-duodenal con contraste demostró una dilatación del estómago y oclusión de tercera porción duodenal, aparentemente por compresión extrı́nseca (fig. 1). Una ecografı́a abdominal confirmó la compresión extrı́nseca del duodeno entre la aorta y la arteria mesentérica superior (fig. 2). Una gastroscopia no evidenció lesiones en estómago ni primera porción duodenal. Ante estos hallazgos se estableció el diagnóstico de sı́ndrome de Wilkie y se inició nutrición enteral a través de una sonda lastrada naso-yeyunal, con lo que, tras 55 dı́as de tratamiento, la paciente aumentó 5 kg y se resolvió el cuadro clı́nico. c i r e s p . 2 0 1 2 ; 9 0 ( 1 ) : 5 3