Pere Rebasa Cladera

Valoración de las alteraciones de la función anorrectal en el postoperatorio inmediato y tardío tras la microcirugía transanal endoscópica

Resumen Introduccion y objetivo La microcirugia transanal endoscopica (TEM) es una tecnica innovadora que permite la escision local de lesiones rectales, benignas y malignas en fase inicial con mayores ventajas tecnicas y menor morbimortalidad que mediante las tecnicas habituales. Precisa de un utillaje especifico; destaca un rectoscopio de 4 cm de diametro que provoca una dilatacion anal mantenida. El objetivo de nuestro estudio es comprobar los efectos de la TEM en la funcionalidad anorrectal. Material y metodos Se incluyo a todos los pacientes intervenidos por via TEM a los que se les realizo una manometria y un cuestionario de continencia anal preoperatoria y a las 3 semanas y 4 meses postoperatorios. Se valoraron las variaciones en la presion basal (PB) y en la presion de contraccion voluntaria (PCV); tambien las variaciones en el cuestionario de continencia anal. Resultados Se intervino a 68 pacientes entre junio de 2004 y agosto de 2006. Al analizar la PB y la PCV preoperatorias (38,89; 126,28) se observo una disminucion estadisticamente significativa de ambas presiones a las 3 semanas (26,61; 104,75) que retorna a valores basales a los 4 meses (33,81; 118,9). No hubo variaciones en la prueba de continencia anal ni relacion entre la variacion de las presiones y el tiempo quirurgico. Conclusion La TEM produce una alteracion manometrica estadisticamente significativa que se normaliza a los 4 meses y que no se traduce en ninguna alteracion clinica en el postoperatorio inmediato ni en el tardio y, por tanto, es una tecnica segura que no produce alteraciones en la funcionalidad anorrectal.

¿Cómo evaluamos la actividad de los médicos internos residentes? El libro informático del residente

Resumen Introduccion La evolucion de nuestra especialidad en los ultimos anos obliga a realizar actualizaciones no solo en contenidos, sino en una evaluacion de los conocimientos aprendidos. El objetivo de este articulo es presentar nuestra experiencia en un modelo de evaluacion integral. Se basa en una valoracion de los conocimientos teoricos y las habilidades quirurgicas. Material y metodo El programa de formacion para los MIR que hemos aplicado esta fundamentado en 4 apartados: asistencial, formacion continuada, investigacion (doctorado) y control de la actividad realizada (libro informatico del residente). Permite una evaluacion de los conocimientos teoricos y las habilidades aprendidas al final de cada rotacion. Mediante la creacion del libro informatico del residente que presentamos, se practica cada 6 meses una cuantificacion de la actividad de forma continua y comparada. Resultados En julio de 2004, iniciamos la puesta en marcha de este sistema de evaluacion de la actividad de los residentes. Se entrego a cada uno de ellos su propia base de datos para que iniciara su desarrollo mediante la introduccion de todas las actividades realizadas. Se presentan los resultados de la actividad global y particular de cada residente. Conclusiones El metodo que utilizamos permite seguir la evolucion integral del residente y realizar, al final de cada ano y de la residencia, una valoracion totalmente objetiva. La generalizacion de este metodo o uno similar facilitara la realizacion de comparaciones con otros centros y bajo premisas similares. Por otra parte, podria unificar criterios y determinar desviaciones de formacion.

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.

OriginalRegistro prospectivo en politraumatismos graves. Análisis de 1.200 pacientesProspective registry of severe polytrauma. Analysis of 1200 patients

INTRODUCTION Polytrauma continues to be one of the main causes of death in the population between 10-40 years of age, and causes severe discapability in surviving patients. The aim of this study is to perform an analysis of the quality of care of the polytrauma patient using an epidemiological study. METHOD Prospective registry of all polytrauma patients treated at our hospital over 16 years of age, admitted to the critical care area or dead before admission. RESULTS From March 2006 to August 2014, we registered 1200 polytrauma patients. The majority were men (75%) with a median age of 45. The mean ISS was 20,9±15,8 and the most common mechanism of injury was blunt trauma (94% cases), The global mortality rate was 9.8% (117 cases), and neurological death was the most frequent cause (45.3%), followed by hypovolemic shock (29,1%). In 17 cases (14,5% of deaths) mortality was considered evitable or potentially evitable, A total of 327 patients (27.3%) needed emergency surgery and 106 patients (8,8%) needed emergency treatment using interventional radiology. 18,5% of patients (222) presented an inadverted injury, with a total of 318 inadverted injuries. CONCLUSION Trauma care at our centre is adequate. A prospective registry of the global care of polytrauma patients is necessary to evaluate the quality of care and improve results.Introduction Polytrauma continues to be one of the main causes of death in the population between 10-40 years of age, and causes severe discapability in surviving patients. The aim of this study is to perform an analysis of the quality of care of the polytrauma patient using an epidemiological study.

Registro prospectivo en politraumatismos graves. Análisis de 1.200 pacientes

INTRODUCTION Polytrauma continues to be one of the main causes of death in the population between 10-40 years of age, and causes severe discapability in surviving patients. The aim of this study is to perform an analysis of the quality of care of the polytrauma patient using an epidemiological study. METHOD Prospective registry of all polytrauma patients treated at our hospital over 16 years of age, admitted to the critical care area or dead before admission. RESULTS From March 2006 to August 2014, we registered 1200 polytrauma patients. The majority were men (75%) with a median age of 45. The mean ISS was 20,9±15,8 and the most common mechanism of injury was blunt trauma (94% cases), The global mortality rate was 9.8% (117 cases), and neurological death was the most frequent cause (45.3%), followed by hypovolemic shock (29,1%). In 17 cases (14,5% of deaths) mortality was considered evitable or potentially evitable, A total of 327 patients (27.3%) needed emergency surgery and 106 patients (8,8%) needed emergency treatment using interventional radiology. 18,5% of patients (222) presented an inadverted injury, with a total of 318 inadverted injuries. CONCLUSION Trauma care at our centre is adequate. A prospective registry of the global care of polytrauma patients is necessary to evaluate the quality of care and improve results.Introduction Polytrauma continues to be one of the main causes of death in the population between 10-40 years of age, and causes severe discapability in surviving patients. The aim of this study is to perform an analysis of the quality of care of the polytrauma patient using an epidemiological study.