Josep M. Badia

Treatment of 27 postoperative enterocutaneous fistulas with the long half-life somatostatin analogue SMS 201-995

Twenty-seven patients with postoperative enterocutaneous fistulas were treated with parenteral nutrition and SMS 201-995 (100 micrograms/8 hours, subcutaneously), a long half-life somatostatin analogue. At the time SMS 201-995 was started, 11 patients had low output fistulas (less than 1000 ml/48 hours), 11 patients had high output fistulas (above 1000 ml/48 hours), and 5 patients had fistulas sitting in large abdominal wall defects. Within 24 hours of treatment, a mean reduction of 55% of the fistula output was observed. Fistula site or output before treatment had no influence on the magnitude of output reduction. Spontaneous closure was achieved in 77% of the patients after a mean of 5.8 +/- 2.7 days of treatment with this drug. Two patients died (7.4%). Pain at the injection site was referred by 15% of the patients but no other side effects were observed. Glucose intolerance was not observed. SMS 201-995 has been shown to be very useful in the conservative treatment of enterocutaneous fistulas because of its ability to rapidly reduce fistula output and accelerate spontaneous closure.

Laparoscopic cholecystectomy in situs inversus totalis: The importance of being left-handed

Since laparoscopic cholecystectomy has become the standard procedure for the treatment of gallstone disease, several cases have been reported in patients with situs inversus. These cases require more technically demanding procedures due to the symmetrical disposition of the anatomy. Thus, handedness could influence the performance of these operations. The two of us (L.M.O.) and (J.M.B.), a right-handed and a left-handed surgeon, respectively, placed the instruments in reverse mode from that used in orthotopic patients. The right-handed surgeon felt more impairment when dissecting with his left hand and decided to cross the instruments within the abdomen. The left-handed surgeon was able to alternate the performance of the dissection maneuvers between the right and left hands. Surgical procedures are apparently designed for right-handed surgeons and can be approached by the left-handed in alternative ways. In fact, the accommodation of laparoscopic cholecystectomy to left-handedness has been described in the literature. The rare opportunity to operate in a symmetrical way allows the right-handed surgeon to understand the absence of comfort and ergonomy often experienced by left-handed colleagues.

Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries

BACKGROUND Surgical site infections (SSIs) are associated with increased morbidity and mortality. Furthermore, SSIs constitute a financial burden and negatively impact on patient quality of life (QoL). AIM To assess, and evaluate the evidence for, the cost and health-related QoL (HRQoL) burden of SSIs across various surgical specialties in six European countries. METHODS Electronic databases and conference proceedings were systematically searched to identify studies reporting the cost and HRQoL burden of SSIs. Studies published post 2005 in France, Germany, the Netherlands, Italy, Spain, and the UK were eligible for data extraction. Studies were categorized by surgical specialty, and the primary outcomes were the cost of infection, economic evaluations, and HRQoL. FINDINGS Twenty-six studies met the eligibility criteria and were included for analysis. There was a paucity of evidence in the countries of interest; however, SSIs were consistently associated with elevated costs, relative to uninfected patients. Several studies reported that SSI patients required prolonged hospitalization, reoperation, readmission, and that SSIs increased mortality rates. Only one study reported QoL evidence, the results of which demonstrated that SSIs reduced HRQoL scores (EQ-5D). Hospitalization reportedly constituted a substantial cost burden, with additional costs arising from medical staff, investigation, and treatment costs. CONCLUSION Disparate reporting of SSIs makes direct cost comparisons difficult, but this review indicated that SSIs are extremely costly. Thus, rigorous procedures must be implemented to minimize SSIs. More economic and QoL studies are required to make accurate cost estimates and to understand the true burden of SSIs.

Medidas de prevención de la infección del sitio quirúrgico en cirugía abdominal. Revisión crítica de la evidencia

Surgical site infection (SSI) is associated with prolonged hospital stay, increased morbidity, mortality and sanitary costs, and reduced patients quality of life. Many hospitals have adopted guidelines of scientifically-validated processes for prevention of surgical site and central-line catheter infections and sepsis. Most of these guidelines have resulted in an improvement in postoperative results. A review of the best available evidence on these measures in abdominal surgery is presented. The best measures are: avoidance of hair removal from the surgical field, skin decontamination with alcoholic antiseptic, correct use of antibiotic prophylaxis (administration within 30-60 min before incision, use of 1(st) or 2(nd) generation cephalosporins, single preoperative dosis, dosage adjustments based on body weight and renal function, intraoperative re-dosing if the duration of the procedure exceeds 2 half-lives of the drug or there is excessive blood loss), prevention of hypothermia, control of perioperative glucose levels, avoid blood transfusion and restrict intraoperative liquid infusion.

Gallbladder carcinoma: the role of p53 protein overexpression and Ki-67 antigen expression as prognostic markers.

BACKGROUND The overexpression of p53 protein and the expression of Ki-67 antigen may affect the survival of patients with gallbladder carcinoma. This association has been tested in a series of 41 patients with relatively early carcinoma of the gallbladder. METHODS Forty-one surgical specimens from patients with a postoperative histological diagnosis of gallbladder carcinoma were studied. All patients were operated by simple cholecystectomy only because the tumours were not advanced and/or their general condition was poor. Patients submitted to radical operations were excluded. p53 expression was calculated from nuclear staining according to the intensity and extent of positive cells, as graded on a scale from 1 to 3; a combined score of >3 was considered as overexpression. Ki-67 expression was calculated by the MIB-I index: the percentage of positively stained tumour cell nuclei out of the total tumour cells counted (n = 1000); >20% of stained cells was considered positive. RESULTS Twenty-nine gallbladder carcinomas (71%) overexpressed p53 protein in the cell nuclei. No significant differences were found in relation to cell differentiation on the level of tumour infiltration through the gallbladder wall. Five-year survival of patients with gallbladder carcinoma overexpressing p53 was 17.2%, while survival of patients without p53 overexpression was 30% (not significant). Twenty-four cases (58.5%) were considered positive for the MIB-I index. There were no differences between the grade of cell differentiation and wall infiltration. Five-year survival of the patients with a MIB-I positive index was 9.2% as opposed to 27.7% for those with a negative index (not significant). CONCLUSIONS p53 protein nuclear overexpression and Ki-67 protein expression in gallbladder carcinoma were not related to histological differentiation, level of gallbladder wall invasion or patient survival.

Endometriomas de pared abdominal: aspectos diagnósticos

Introduccion Los endometriomas de pared abdominal suelen presentarse como masas dolorosas localizadas en las cicatrices de intervenciones ginecologicas u obstetricas, aunque se han descrito casos esporadicos de localizacion umbilical e inguinal. El objetivo del presente trabajo es determinar las caracteristicas diagnosticas de una serie de endometriomas de pared abdominal. Pacientes y metodo En el periodo de tiempo comprendido entre los anos 1990 a 1998 se diagnosticaron en nuestro servicio 12 casos de endometriomas de pared abdominal. Se consideran para el estudio la edad de las pacientes, los antecedentes ginecologicos, la localizacion del foco endometriosico, la sintomatologia, el tiempo de evolucion y el diagnostico preoperatorio. Resultados La edad media de las pacientes fue de 31,3 anos (rango 19-45). El endometrioma se localizo preferentemente en cicatrices de cesarea (10 casos) y en 5 casos se acompanaba de dolor relacionado con el ciclo menstrual. El tiempo de evolucion de la sintomatologia fue sumamente variable, oscilando entre 3 dias y 3 anos. El diagnostico preoperatorio correcto se realizo en 5 pacientes, en tanto que en el resto se diagnosticaron 4 granulomas de herida, 2 hernias incarceradas y una onfalitis. Conclusiones La presencia de un nodulo cicatrizal en una mujer fertil con antecedente de intervencion ginecologica u obstetrica obliga a considerar el diagnostico de endometrioma. Una anamnesis convenientemente dirigida es de suma utilidad para realizar el diagnostico diferencial (masa dolorosa en relacion con el ciclo menstrual), y en casos de duda puede recurrirse al estudio citologico de material obtenido por puncion-aspiracion. El tratamiento quirurgico consistente en la reseccion completa de la lesion nos parece la opcion mas adecuada.

Antibióticos e infección biliar

Resumen La principal caracteristica de la infeccion quirurgica es que se puede eliminar mediante una operacion. La infeccion biliar no es una excepcion, ya que la extirpacion de la vesicula biliar infectada y el completo drenaje de la via biliar o el absceso hepatico son las principales armas del cirujano para combatirla. Los antibioticos tienen un papel importante, aunque secundario, en el tratamiento de esta infeccion. Las infecciones de origen biliar son frecuentes y potencialmente graves, suelen ser polimicrobianas, se asocian a un alto porcentaje de bacteriemias y requieren un abordaje multidisciplinar. El uso juicioso de la endoscopia, la radiologia intervencionista y la cirugia para conseguir el control del foco infeccioso o el drenaje de la via biliar es el primer paso del tratamiento. Este debe completarse con la administracion empirica de antibioticos con el espectro antibacteriano adecuado. El uso mas racional de los antibioticos en la infeccion biliar, especialmente en lo que respecta a la duracion optima del tratamiento, la posibilidad de desescalada terapeutica o el tratamiento secuencial con antibioticos orales aun esta sujeto a un amplio debate y debera ser objeto de futuros ensayos clinicos.

Recomendaciones de «no hacer»: propuestas de la Asociación Española de Cirujanos al proyecto de «Compromiso por la calidad de las sociedades científicas» ☆

INTRODUCTION The initiative of the Spanish Ministry of Health «Commitment to quality of scientific societies», 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 do» 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 Surgeonss 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.

O053: What surgical site infection rates in colorectal surgery should be considered for benchmarking standards?

colon procedures were only slightly lower (18.8%) than those due to rectal surgery (22.3%). Both, overall SSI rates and organ/space SSI rates did not change significantly over the study period and were respectively: 2007 (20.8%/5.3%), 2008 (19.2%/6.9%), 2009 (21%/9%), 2010 (21%/8.5%), 2011 (20.7%/9.3%) and 2012 (19%/8.9%). Conclusion SSI rates in elective colorectal procedures at VINCat hospitals remained stable over the study period and were higher than those reported by other national programs. There is a need to clarify what surgical site infection rates in colorectal surgery should be considered for benchmarking standards.

Quality assessment in ambulatory surgery in a community hospital

Abstract Clinical quality assessment is reviewed in 3231 patients operated on in the major ambulatory surgery (MAS) program of a 300-bed community hospital over 18 months. The substitution index was 29.96%. Unplanned admission rate was 2.9%, mainly related to anaesthetic complications. Post-operative morbidity occurred in 60 patients (1.9%); all but one being minor. Patient satisfaction was evaluated through a mail questionnaire. None of the respondents was dissatisfied with the process and 95% of them would choose MAS again. The MAS program provides safe and high quality surgical management and is widely accepted by patients.