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Our main goal is to describe how to start and develop a multicenter, prospective, randomized, controlled trial. The first step is to have an idea that will become the hypothesis and a main objective. A bibliographic search should be done to check for clinical interest and originality. Moreover, the study must be feasible and should be finished within 4 years. In order to start the multicenter study, a protocol should be written (in accordance with the SPIRIT guidelines Standard Protocol items: Recommendations for Interventional Trials), including the design type, sample size and participating hospitals. Randomization is key to the design and, therefore, the CONSORT (Consolidated Standards of Reporting Trials) guidelines must be followed. However, if the study cannot be randomized, the TREND (Transparent Reporting of Evaluations with Non-Randomized Designs) guidelines are recommended. When the protocol is approved by the Ethics Committee for Clinical Investigation of the hospital, we ought to create visibility. It is suggested to register the trial on ClincalTrials.gov and submit its publication to indexed magazines. Financial resources are necessary to execute the study and maintain an online database. This allows the registry to be updated and accessible to all the participants in the study. What is more, randomization can be done immediately. And last, but not least, is motivation. Multicentricity equals to participation of all the chosen medical centers. Updating and motivating them by sending a newsletter every 1-3 months keeps participants engaged in the study.

FAST is essential to decide whether trauma patients need laparotomy, but it has a notable decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture.Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who died. The FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables.Over the 13-year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs 14%, P .05). Patients with positive FAST died more than negative FAST (43% vs 26%); and 4 out of 10 hemodynamically unstable patients who underwent non-therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis.FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduced notably by applying preperitoneal packing.

espanolIntroduccion La exactitud del FAST disminuye notablemente en los pacientes politraumaticos con fractura pelvica. El objetivo es analizar las consecuencias de tomar decisiones terapeuticas basadas en el resultado del FAST en los pacientes politraumaticos con fractura de pelvis. Metodos Estudio descriptivo de pacientes con politraumatismos mayores de 16 anos que han ingresado en el area de criticos o que han fallecido previamente, con fractura pelvica. El resultado del FAST ha sido comparado con un valor realmente positivo o negativo segun el resultado de la laparotomia o de la tomografia computarizada. Resultados En 13 anos, se ha incluido a 263 pacientes politraumaticos con fractura pelvica (ISS medio de 31; mortalidad 19%). El FAST tenia una sensibilidad del 65,2%, una especificidad del 69%, una tasa de falsos negativos del 34,8% y una tasa de falsos positivos del 30,9%. Los pacientes hemodinamicamente inestables tenian el doble de mortalidad que los pacientes estables (27% vs. 14%, p Conclusiones La reducida eficacia del FAST en pacientes con fractura de pelvis nos obliga a cuestionarnos las consecuencias de la toma de decisiones terapeuticas con base en sus resultados. Los pacientes con FAST falsamente positivo tienen una mortalidad mayor, que se puede reducir aplicando un packing preperitoneal. EnglishIntroduction FAST is essential to decide if trauma patients need laparotomy, but has a notably decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture. Methods Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who were fallecimiento. FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables. Results Over the 13–year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs. 14%, p Conclusion FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduce notably applying a preperitoneal packing.

Objective The quality of available evidence regarding new minimally invasive techniques to abolish great saphenous vein reflux is moderate. The present study assessed whether radiofrequency ablation (RFA) was noninferior to high ligation and stripping (HLS) and conservative hemodynamic cure for venous insufficiency (CHIVA) for clinical and ultrasound recurrence at 2 years in patients with primary varicose veins (VVs) due to great saphenous vein (GSV) insufficiency. Methods We performed a randomized, single-center, open-label, controlled, noninferiority trial to compare RFA and 2 surgical techniques for the treatment of primary VVs due to GSV insufficiency. The noninferiority margin was set at 15% for absolute differences. Patients aged >18 years with primary VVs and GSV incompetence, with or without clinical symptoms, C2 to C6 CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) clinical class, and GSV diameter >4 mm were randomized with a 1:1:1 ratio to RFA, HLS, or CHIVA. The rate of clinical recurrence at 24 months was the primary endpoint and was analyzed using a delta noninferiority margin of 15%. Ultrasound recurrence, safety, and quality of life were secondary endpoints. Results From December 2012 to June 2015, 225 limbs had been randomized to RFA, HLS, or CHIVA (n = 74, n = 75, and n = 76). Clinical follow-up and Doppler ultrasound examinations were performed at 1 week and 1, 6, 12, and 24 months postoperatively. No differences in postoperative complications or pain were observed among the three groups. RFA was noninferior to HLS and CHIVA for clinical recurrence at 24 months, with an estimated difference in recurrence of 3% (95% confidence interval [CI], −4.8% to 10.7%; noninferiority P = .002) and −7% (95% CI, −17% to 3%; P Conclusions RFA was shown to be noninferior in terms of clinical recurrence to HLS and CHIVA in the treatment of VVs due to GSV insufficiency.

Background The aim of this study is to assess the feasibility of transanal endoscopic surgery (TES) in obese patients. Methods Observational descriptive study evaluating the feasibility of TES in obese rectal tumors between June 2004 and January 2019. Patients were assigned to two groups: body mass index (BMI) Results From 775 patients, 681 were enrolled in the study, 145 (21.3%) of them obese. No statistically significant differences between groups were found with respect to overall morbidity (27, 18.6%).The obese patients presented trends towards shorter mean surgical time (65 min, IQR 48 min), less perforation in the peritoneal cavity (eight, 5.5%), and 133 (91.7%) presented a lower rate of lesion fragmentation. Conclusion There were no significant differences in postoperative outcomes in obese patients (BMI ≥30 kg/m2). TES in those obese patients does not represent a factor of surgical difficulty.

The aim of this study is to assess postoperative morbidity and mortality in tumors with a proximal margin 15 cm or more from the anal verge operated with transanal endoscopic microsurgery (TEM).This observational study of consecutive rectal tumor patients undergoing TEM was carried out from July 2004 to June 2017. We compared the results of rectal tumors at distances of ≥15 cm (group A) and15 cm (group B) from the anal verge.During the study period 667 patients were included: 118 in group A and 549 in group B. In the comparative analysis there were no significant differences in morbidity (p = 0.23), mortality (p = 0.32) or free margin involvement (p = 0.545). Differences were observed in terms of lesion size (p 0.001), surgical time (p 0.001) and peritoneal cavity perforation, which were all increased in group A.TEM for lesions in the rectosigmoid junction is feasible and is not associated with higher morbidity or mortality.

Objective To assess the role of transanal endoscopic operation (TEO) or transanal endoscopic microsurgery (TEM) in rectourethral fistulas (RUF). RUF may appear after radical prostatectomy. Their treatment represents a challenge; many therapies have been proposed, from conservative to aggressive surgical approaches. Transanal endoscopic surgery (TEO or TEM) is a minimally invasive technique to access the site of the RUF to perform repair. Materials and Methods This is an observational study with prospective data collection, conducted between September 2006 and December 2015. All patients were diagnosed with RUF following management of prostate cancer. Conservative treatment was administered in the form of urinary and fecal diversion with cystotomy and terminal colostomy, to achieve total urinary and fecal exclusion. If the fistula persisted, it was treated by TEO or TEM, with or without biological mesh interposition. If this failed, gracilis muscle was applied as salvage therapy. Results Ten patients were diagnosed with RUF. In 1 patient (1 of 10), the fistula healed with bladder catheterization alone. In another patient (1 of 9), it resolved after total urinary and fecal exclusion. Eight patients underwent repair by TEO or TEM, 4 with biological mesh interposition; all 4 presented recurrence. In the other 4 patients treated via TEO or TEM, 2 had early recurrence, whereas the others had healed at follow-up visits after 4-6 months (2 of 8)—a success rate of 25%. The 6 patients who recurred were treated with gracilis muscle interposition via a transperineal approach. Conclusion The low rate of positive results obtained by TEO or TEM argues against its use as technique of choice in RUF, and against the use of biological meshes.

In acute pancreatitis (AP), first 24 h are crucial as this is the period in which the greatest amount of patients presents an organ failure. This suggests patients with Mild AP (MAP) could be early identified and discharged. This is an observational prospective trial with the aim to demonstrate the safety of early discharge in Mild Acute Pancreatitis (MAP).Observational prospective study in a third level single centre. Consecutive patients with AP from March 2012 to March 2014 were collected.MAP, tolerance to oral intake, control of pain, C Reactive Protein150 mg/dL and blood ureic nitrogen5 mg/dL in two samples.pregnant, lack of family support, active comorbidities, temperature and serum bilirubin elevation. Patients with MAP, who met the inclusion criteria, were discharged within the first 48 h. Readmissions within first week and first 30 days were recorded. Adverse effects related to readmissions were also collected.Three hundred and seventeen episodes were collected of whom 250 patients were diagnosed with MAP. From these, 105 were early discharged. Early discharged patients presented a 30-day readmission rate of 15.2% (16 patients out of 105) corresponding to the readmission rates in Acute Pancreatitis published to date. Any patient presented adverse effects related to readmissions.Early discharge in accurately selected patients with MAP is feasible, safe and efficient and leads to a decrease in median stay with the ensuing savings per process and with no increase in readmissions or inmorbi-mortality.

Resumen Introduccion La asociacion de quimiorradioterapia preoperatoria y cirugia endoscopica transanal en el cancer rectal T2-T3 superficial presenta resultados prometedores en pacientes seleccionados. El objetivo principal es evaluar la recurrencia locorregional y sistemica a largo plazo y los objetivos secundarios son aportar resultados de morbilidad postoperatoria y la correlacion entre la respuesta patologica completa y clinica completa. Metodos Estudio observacional retrospectivo de una serie consecutiva de pacientes diagnosticados de cancer de recto T2-T3 superficial, N0, M0 que se trataron con quimiorradioterapia neoadyuvante y escision transanal del tumor (2008-2016). Se recogieron los datos de forma prospectiva. El tratamiento consistio en quimioterapia preoperatoria (5-fluorouracilo o capecitabina) combinada con radioterapia (50,4 Gy) y cirugia endoscopica transanal tras 8 semanas. Se analizaron las variables preoperatorias, quirurgicas, patologicas y los resultados oncologicos a largo plazo. Resultados De los 24 pacientes incluidos, 2 requirieron rescate a cirugia radical por resultados patologicos desfavorables. Con un seguimiento mediano de 45 meses, se observo recurrencia local en un paciente (4,5%) y 2 pacientes presentaron recurrencias sistemicas (9%). La respuesta clinica tumoral completa se logro en 12 pacientes (50%) y la respuesta patologica tumoral completa en 9 pacientes (37,5%). Las complicaciones postoperatorias se apreciaron en 5 pacientes (20,8%), todas leves excepto una. No hubo mortalidad postoperatoria. Conclusiones En este estadio del cancer rectal, nuestros resultados parecen apoyar esta estrategia, principalmente cuando se logra una respuesta patologica tumoral completa. La respuesta clinica tumoral completa no coincide con la respuesta patologica tumoral. Se deben llevar a cabo estudios prospectivos aleatorizados para estandarizar este tratamiento.

Introduction The association of preoperative chemoradiotherapy and transanal endoscopic surgery in T2 and superficial T3 rectal cancers presents promising results in selected patients. The main objective is to evaluate the long-term loco-regional and systemic recurrence and, as secondary objectives, to provide results of postoperative morbidity and the correlation between complete clinical and pathological response. Methods This is a retrospective observational study including a consecutive series of patients with T2-T3 superficial rectal cancer, N0, M0 who refused radical surgery (2008–2016). The treatment consisted of preoperative chemotherapy (5-fluorouracil or capecitabine) combined with radiotherapy (50, 4 Gy) and transanal endoscopic surgery after 8 weeks. Preoperative, surgical, pathological and long-term oncologic results were analyzed. Results Twenty-four patients were included in the study. Two of them required rescue radical surgery for unfavorable pathological results. A local recurrence (4.5%) was observed and 2 patients presented systemic recurrence (9%), with a median follow-up of 45 months. A complete clinical tumor response was achieved in 12 patients (50%), and complete pathological tumor response in 9 patients (37.5%). Postoperative complications were observed in 5 patients (20.8%), and they were mild except one. There was no postoperative mortality. Conclusions In this stage of rectal cancer, our results seem to support this strategy, mainly when a complete pathological response is achieved. The complete clinical tumor response does not coincide with the pathological tumor response. Randomized prospective studies should be performed to standardize this treatment.

Introduction An occult pneumothorax is found in 2%–15% trauma patients. Observation (without tube thoracostomy) in these patients presents still some controversies in the clinical practice. The objective of the study is to evaluate the efficacy and the adverse effects when observation is performed. Methods A retrospective observational study was undertaken in our centre (university hospital level II ). Data were obtained from a database with prospective registration. A total of 1087 trauma patients admitted in the Intensive Care Unit from 2006 to 2013 were included. Results In this period, 126 patients with occult pneumothorax were identified, 73 patients (58%) underwent immediate tube thoracostomy and 53 patients (42%) were observed. Nine patients (12%) failed observation and required tube thoracostomy for pneumothorax progression or haemothorax. No patient developed a tension pneumothorax or experienced another adverse event related to the absence of tube thoracostomy. Of the observed patients 16 were under positive pressure ventilation, in this group 3 patients (19%) failed observation. There were no differences in mortality, hospital length of stay or intensive care length of stay between the observed and non-observed group. Conclusion Observation is a safe treatment in occult pneumothorax, even in pressure positive ventilated patients.

Resumen Introduccion El politraumatismo sigue siendo una de las principales causas de muerte entre los 10 y los 40 anos, causando graves incapacidades en los pacientes que sobreviven. El objetivo de nuestro estudio es realizar un analisis de calidad de la atencion del paciente politraumatizado mediante un estudio epidemiologico. Metodo Registro prospectivo de todos los pacientes politraumaticos atendidos en nuestro hospital, mayores de 16 anos, que ingresan en el area de criticos o mueren antes del ingreso. Resultados Desde marzo del 2006 hasta agosto del 2014, registramos 1.200 politraumatizados. La mayoria fueron hombres (75%), con una mediana de edad de 45 anos. El ISS medio fue de 20,9 ± 15,8 y el mecanismo de accion mas frecuente fue cerrado (94% casos). La mortalidad global fue del 9,8% (117 casos), siendo la muerte neurologica la principal causa de fallecimiento (45,3%), seguida de la muerte por shock hipovolemico (29,1%). En 17 casos (14,5% fallecimiento) la mortalidad fue considerada como evitable o potencialmente evitable un total de 327 pacientes (27,3%) precisaron de tratamiento quirurgico urgente y 106 pacientes (8,8%) precisaron de un tratamiento mediante radiologia intervencionista de caracter urgente. El 18,5% de los pacientes (222) presentaron alguna lesion inadvertida, con un total de 318 lesiones inadvertidas. Conclusion La atencion ofrecida en nuestro centro es correcta. La necesidad de una recogida de datos prospectiva de la atencion global a los pacientes politraumatizados es necesaria e imprescindible para poder evaluar la calidad ofrecida y mejorar los resultados.

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 two periods (before and after the application of a protocol that includes ET), between 2009 and 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.

Resumen Introduccion La isquemia mesenterica aguda (IMA) presenta una elevada mortalidad. El diagnostico y el tratamiento precoces son claves. En nuestro centro aplicamos un protocolo terapeutico que incluye la radiologia vascular intervencionista (RVI) en pacientes con IMA sin irritacion peritoneal. El objetivo de este estudio fue evaluar el uso de la RVI conjuntamente con la cirugia convencional en el manejo de la IMA de intestino delgado potencialmente reversible diagnosticada mediante tomografia computarizada vascular (angio-TC). Metodos Estudio observacional, retrospectivo y descriptivo, donde se valora el manejo diagnostico y terapeutico de la IMA en 2 periodos (antes y despues de la aplicacion de un protocolo que incluye la RVI) entre 2009 y 2013. El diagnostico de eleccion es mediante angio-TC, ante la sospecha clinico-analitica. Resultados Nuestra serie incluye a 73 pacientes diagnosticados de IMA mediante angio-TC (45: 2009-2011; 28: 2012-2013). La leucocitosis es frecuente (82%), siendo menos frecuente la lactacidemia (47% vs. 53%). Hay 49 pacientes con IMA y exploracion abdominal normal. En el 51% se realizo cirugia de reseccion intestinal (supervivencia 44%); 18%: revascularizacion mediante RVI (supervivencia 67%); 31%: tratamiento paliativo (supervivencia 0%). El 33% de los pacientes sometidos a RVI como primera linea precisaron de cirugia de rescate (reseccion intestinal). La mortalidad global es del 67% (2009-2011) vs. 62% (2012-2013). Conclusiones Desde la aplicacion del protocolo ha aumentado la indicacion de RVI para tratar a pacientes sin irritacion peritoneal, objetivando una disminucion de la mortalidad global. En nuestra experiencia, la aplicacion de RVI en casos de IMA sin irritacion peritoneal al diagnostico puede incrementar la supervivencia.

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 dehiscence's risk in patients who underwent midline laparotomy incisions.Observational longitudinal retrospective study.Patients who underwent midline laparotomy incisions in the General and Digestive Surgery Department of the Sabadell's Hospital-Parc Taulí's Health and University Corporation-Barcelona, between January 1, 2010 and June 30, 2010. Dependent variable: Abdominal wound dehiscence.Global risk score, preoperative risk score (postoperative variables were excluded), global and preoperative probabilities of developing abdominal wound dehiscence.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).The risk model developed by van Ramshorst et al. to predict the abdominal wound dehiscence's risk in the preoperative phase has a limited usefulness. Additional refinements in the preoperative risk score are needed to improve its accuracy.

Background Trauma injuries are the main cause of death in the world. The aim of this study is to determine how trauma patients are treated in Spain at an organizational level. Material and methods A questionnaire was prepared consisting of 14 questions regarding aspects of the trauma care organization and trauma education. It was posted on the web site of the Spanish College of Surgeons and all members were encouraged to participate. Results One hundred and ninety questionnaires from 110 different hospitals were received. More than two-thirds (67.3%) of the centers had protocols for treating trauma patients, with 81% of them based on ATLS guidelines. Almost three-quarters (72.6%) of the doctors had completed the ATLS course, and 38.9% the DSTC course. There was a specific education program in trauma in 24.5% of the centers, and 35.5% had a Trauma Committee. There was a rehabilitation program in 24.5% of the centers. Conclusion Very few of the participating centers would fulfill the requirements of the American College of Surgeons accreditation for trauma centers. Trauma care in Spain has improved a lot in the recent years, but there is still a lot to do to reach the level of that in the United States of America.

Background Adhesions are the most important cause of intestinal obstruction. Approximately 25% of surgical admissions for acute abdominal conditions are due to intestinal obstruction. Better diagnostic and treatment methods of intestinal obstruction could potentially reduce mortality rate to 5%–10%. Gastrografin ® could contribute to this achieve this. Aim To present a protocol to treat adhesion intestinal obstruction with Gastrografin ® that is safe, and allows shorter hospital stays and shorter time between admission and surgery. Material and methods All patients with adhesion intestinal obstruction without symptoms of strangulation were treated with Gastrografin ® , intravenous fluids and nasogastric tube. Those in whom contrast reach the colon in 8, 12 or 24 h were considered to have partial obstruction, and were fed orally. If Gastrografin ® failed in the following 24 h, a laparotomy was performed. Results Out of a total of 211 episodes (164 patients), 170 episodes received contrast and in 142 cases Gastrografin ® reached the colon (104 episodes at 8 h, 11 at 12 h, and 27 at 24 h). A laparotomy was required in 28 patients because of failed treatment, and in another 5 for other causes. Conclusions A management protocol for adhesion intestinal obstruction with Gastrografin ® is safe, reduces morbidity and mortality, and leads to a shorter hospital stay.

Resumen Introduccion la exeresis local del adenocarcinoma de recto T2N0M0 (ADC-T2), mediante microcirugia endoscopica transanal (TEM), se beneficia en conseguir una menor morbilidad con mejor calidad de vida. Sin embargo, la recidiva local de la exeresis local es superior al 20%, inaceptable en estos momentos. Pacientes y metodo estudio observacional de seguimiento prospectivo. Los pacientes ADC-T2 son consensuados en el comite de tumores a las actuaciones terapeuticas: escision total del mesorrecto (ETM), TEM simple, TEM con quimiorradioterapia (Qt-Rt) postoperatoria, Qt-Rt preoperatoria con posterior TEM y rescate a cirugia radical (ETM) en menos de 4 semanas. Resultados se ha intervenido a 146 pacientes mediante TEM; 75 adenocarcinomas, 59 adenomas, 6 lesiones cicatriciales, 5 carcinoides y 1 GIST. De los adenocarcinomas, 22 fueron ADC-T2. Seguimiento: mediana, 16 (intervalo, 3-32) meses. La recidiva local total ha sido del 18% (4/22). Segun la estrategia terapeutica la recidiva local fue: TEM como unico procedimiento en el 20% (2/10). Se realizo en 3 pacientes rescate a cirugia radical tras TEM, sin recidiva local ni sistemica. TEM con Qt-Rt posterior a la cirugia se realizo en 6, con una recidiva local del 33% (2/6). Se practico Qt-Rt y posteriormente TEM en 3 pacientes, sin recidiva local ni sistemica. Conclusiones el tratamiento del ADC-T2 mediante TEM simple no es razonable. La asociacion de Qt-Rt tras TEM, no consigue mejorar los resultados a la ETM. Es factible rescatar a los pacientes sin que altere la supervivencia total. La Qt-Rt preoperatoria y TEM parece ser la linea cuando se consiga una respuesta histologica y clinica, aunque es necesaria la respuesta por parte de ensayos clinicos.

Introduction The local exeresis adenocarcinoma of the rectum T2 N0 M0 (ADC-T2), using transanal endoscopic microsurgery (TEM), has the benefit of achieving lower morbidity with a better quality of life. However, local occurrence of the local exeresis is greater than 20%, which is unacceptable these days. Patients and methods Prospective, observational follow up study. The tumours committee agreed that those ADC-T2 patients could have the following treatments: total mesorectal excision (TME), simple TEM, TEM with postoperative chemo-and radiotherapy (Ct-Rt), preoperative Ct-Rt with subsequent TEM, and radical surgical rescue (TME) within at least 4 weeks. Results Of the 146 patients operated on using TEM, 75 had adenocarcinomas, 59 adenomas, 6 scarring wounds, 5 carcinoids, and 1 GIST. Of the adenocarcinomas 22 were ADC-T2. Follow up: median of 16 months (range, 3–32 months). The overall local recurrence was 18% (4/22). According to the treatment strategy the local occurrence was: TEM as the only procedure, 20% (2/10). Radical surgical rescue was performed on 3 patients after TEM, with no local or systemic recurrences. TEM with Qt-Rt after surgery was performed on 6 patients, with a local recurrence of 33% (2/6). Ct-Rt and subsequent TEM in 3 patients, with no local or systemic recurrences. Conclusions Treatment of ADC-T2 using simple TEM is not effective. The combination of Ct-Rt after TEM, does not improve the results of TME. It is possible to rescue those patients without changing the overall survival. Preoperative Ct-Rt and TEM appears to be the approach that obtains a clinical and histological response, although a response is needed by clinical trials.

Background Acute pancreatitis is one of the main causes of intra-abdominal hypertension, which may lead to multiple physiologic alterations. The aim of this study was to determine the relationship between acute pancreatitis and intra-abdominal hypertension, and to evaluate the utility of intra-abdominal pressure (IAP) as a marker of severity in acute pancreatitis. Methods From July 2002 to July 2004, 45 patients admitted for acute pancreatitis were included in this prospective, observational study. The diagnostic criteria for acute pancreatitis were compatible clinical manifestations and a 3-fold increase in serum amylase levels. Severe pancreatitis was defined as Apache II score ≥8. IAP was determined every 12 hours, and the maximum and the mean values were used for analysis and correlated with prognostic factors of acute pancreatitis. Results A statistical relationship was observed between maximum IAP and the typical prognostic factors of acute pancreatitis. Maximum IAP had a significant relationship with the computed tomography severity index and the number of complementary tests required. The maximum IAP was significantly greater in patients who died and in patients requiring vasoactive drugs, total parenteral nutrition, or operative treatment related to complications. The maximum IAP was also greater in patients who developed systemic inflammatory response syndrome, multiorgan failure, increase in number and/or volume of intra-abdominal collections, those who required aspiration of the necrosis for suspected infection, those who demonstrated the presence of microorganisms, and those with positive blood cultures. Conclusion The maximum IAP is a useful, inexpensive, and easy method to measure prognostic marker of the evolution and complications of acute pancreatitis.

Transanal endoscopic microsurgery (TEM) uses specific equipment that allows resection of large rectal adenomas and incipient malignancies in the rectal ampulla. TEM aims to provide an alternative to conventional abdominal surgery (low anterior resection or abdominoperineal amputations), which carries not inconsiderable morbidity and mortality. Application of the technique of endoanal excision is limited by the height and extension of the lesions. In this review, the authors present their own experience with this technique and that described in the literature. The protocol for selecting candidates for TEM, their preoperative preparation, equipment, characteristics of the surgical technique, postoperative complications, and follow-up are described. The collaboration of a multidisciplinary team is essential when developing this technique. TEM-associated morbidity is low and mortality is practically nil. TEM is the technique of choice in large rectal adenomas and malignant rectal tumors in stages pT1 localized in the rectal ampulla. The frequency of recurrence is similar to that in abdominal surgery. The technique does not cause complications of urinary or sexual dysfunction and fecal incontinence is minimal. In more advances stages of rectal cancer, the results of better patient selection and future studies on the possible application of neoadjuvant therapy associated with TEM are required.

s / Pancreatology 15 (2015) S1eS141 S56 Patients & methods: We retrospectively identified patients with necrotizing pancreatitis from in-hospital databases (2004-2014) in four tertiary referral centers and included patients who underwent primary PCD for (suspected) infected necrosis. Results: In total 369/1427patients (26%)werediagnosedwithnecrotizing pancreatitis, of whom 117 patients (32%) underwent primary PCD for suspected infected necrosis. Infected necrosis was ultimately proven in 82 patients (70%). In theproactivePCD center42patients (36%)were treated versus 75 patients (64%) in the other centers, with a median of 3 PCD procedures (interquartile range (IQR) 2-4) and a 16Fr drain size (IQR 14-20) versus 2 PCD procedures (IQR 1-2) and a 14Fr drain (IQR 12-14) P