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INTRODUCTION The doctorate is the third cycle of official university studies, which, through the defense of the doctoral thesis leads to the acquisition of the title of doctor or PhD from the Anglo-Saxon countries. Royal Decree law 99/2011 regulates doctoral programs, with a wide margin on quality requirements. The objective of this study is to find out if there is this variation in the requirements of the doctorate programs of the different departments of surgery of the Spanish public universities and to establish a quality scale. METHODS Cross-sectional observational study from 2/22/2021 to 3/3/2021, through a survey sent electronically to the professors of the departments of surgery. RESULTS Thirty-five departments of surgery were consulted, obtaining a response in 29 of them (82.9%). The observed variation regarding requirements has been basically in the quality of the research project, in fact in 25 (86.2%) there are no regulations on this. When it is presented in the form of a compendium of articles, these are required to be original in 15 (51.7%). Regarding the position as author, the doctoral student must be the preferred author, at least in 2 articles in 14 (48.4%) of the programs. In 14 departments (48.4%) there are no regulations on the position of the articles and quartiles of journals. When scoring the different programs according to their requirements, the variability is high, ranging between 2 and 19 points. Funding for the development of the doctorate is meager. CONCLUSIONS There is a wide variability in the requirement of doctoral programs. Homogeneous levels of demand must be defined to promote and protect higher-level doctorates.

The doctorate is the third cycle of official university studies, which, through the defense of the doctoral thesis leads to the acquisition of the title of doctor or PhD from the Anglo-Saxon countries. Royal Decree law 99/2011 regulates doctoral programs, with a wide margin on quality requirements. The objective of this study is to find out if there is this variation in the requirements of the doctorate programs of the different departments of surgery of the Spanish public universities and to establish a quality scale.Cross-sectional observational study from 2/22/2021 to 3/3/2021, through a survey sent electronically to the professors of the departments of surgery.Thirty-five departments of surgery were consulted, obtaining a response in 29 of them (82.9%). The observed variation regarding requirements has been basically in the quality of the research project, in fact in 25 (86.2%) there are no regulations on this. When it is presented in the form of a compendium of articles, these are required to be original in 15 (51.7%). Regarding the position as author, the doctoral student must be the preferred author, at least in 2 articles in 14 (48.4%) of the programs. In 14 departments (48.4%) there are no regulations on the position of the articles and quartiles of journals. When scoring the different programs according to their requirements, the variability is high, ranging between 2 and 19 points. Funding for the development of the doctorate is meager.There is a wide variability in the requirement of doctoral programs. Homogeneous levels of demand must be defined to promote and protect higher-level doctorates.

Resumen Introduccion La cirugia endoscopica y laparoscopica combinada (CELS) ha surgido como un metodo para el tratamiento de lesiones colonicas benignas complejas que, de otro modo, requeririan una reseccion quirurgica. El objetivo de este estudio es describir las distintas tecnicas CELS y evaluar su seguridad, en un procedimiento escasamente difundido en nuestro entorno. Metodo Estudio observacional, retrospectivo, donde se evaluaron los resultados a corto plazo de pacientes diagnosticados de polipos no resecables endoscopicamente sometidos a CELS entre octubre del 2018 a junio del 2020. Se valoraron los resultados postoperatorios, la estancia hospitalaria y los hallazgos patologicos. Resultados Diecisiete pacientes consecutivos fueron sometidos a CELS durante el periodo de estudio. El tamano medio de la lesion fue de 3,5 cm (rango 2,5 a 6,5 cm), la localizacion mas recurrente fue el ciego (10 de 17). La tecnica CELS mas frecuente aplicada fue la reseccion en cuna laparoscopica asistida por endoscopia (11 de 17). En cuatro pacientes, esta reseccion se combino con otra tecnica CELS. Dos casos se sometieron a una reseccion del segmento laparoscopico asistido por endoscopia. El exito de CELS en nuestra serie fue en 14 de 17 (82,4%). La mediana del tiempo quirurgico y estancia hospitalaria fue de 85 min (rango 50 a 225 min) y de dos dias (rango uno a 15 dias), respectivamente. Solo un paciente presento infeccion del organo-cavitaria que no requirio cirugia adicional. Conclusiones CELS es una tecnica segura multidisciplinar, que requiere la colaboracion entre gastroenterologos y cirujanos. Se puede considerar como una alternativa a la reseccion de colon para polipos benignos complejos.

Resumen Introduccion La Ley de Ordenacion de las Profesiones Sanitarias (LOPS) indica que los profesionales sanitarios realizaran a lo largo de su vida profesional una formacion continuada y acreditaran regularmente su competencia profesional. El objetivo del estudio ha sido realizar una encuesta nacional para conocer la opinion de los cirujanos espanoles y asi poder preparar un proyecto de recertificacion por la Asociacion Espanola de Cirujanos (AEC). Metodos Estudio observacional transversal efectuado en junio-julio de 2020 mediante una encuesta remitida a los miembros de la AEC. Resultados La encuesta tuvo un total de 1.230 visitas y una tasa global de finalizacion de 784 respuestas (67,3%). El 69,6% desconocian las previsiones de la LOPS, el 83,4% no conocian iniciativas similares en otras especialidades y el 95,5% coincidian en demandar una informacion adecuada. El 71,4% la creian necesaria, pero solo el 57% opinaban que deberia ser obligatoria. El 82,9% estarian de acuerdo que deberia ser regulada mediante un procedimiento oficial objetivo y previsible. Conclusiones El concepto de reacreditacion no es bien conocido en nuestra especialidad, y en vista de los resultados obtenidos parece necesaria una informacion adecuada y fiable. Por ello seria pertinente proponer por la AEC un proyecto especifico de evaluacion de actividades y competencias.

Resumen En la practica clinica asistencial la existencia de determinadas «unidades quirurgicas especializadas», que se distinguen por su estructura, dotacion de recursos humanos, organizacion, docencia e investigacion ya son una realidad en la mayoria de los hospitales en Espana. Igualmente, estan ya en marcha programas de formacion especializada tipo fellowship, financiados de forma no estatal, en algunas de las areas reconocidas de unidades quirurgicas especializadas dentro de la cirugia general y aparato digestivo, algunas de ellas avaladas por la AEC. No obstante, hasta el momento no existia un modelo para dotarlo de reconocimiento y acreditacion. La AEC ha disenado una normativa para la acreditacion de unidades quirurgicas especializadas en cirugia general y aparato digestivo, que servira de base tambien para definir la formacion en estas areas. El proceso de acreditacion, y con ello de mejora de la calidad, engloba aspectos de calidad estructural, calidad de proceso y calidad de resultados.

Resumen El objetivo de este articulo es ilustrar como poner en marcha y desarrollar un estudio multicentrico prospectivo, controlado y aleatorizado. Por ello, lo primero que se necesita es crear una idea que genere una hipotesis y un objetivo principal. La busqueda bibliografica nos permite ver su relevancia clinica y las evidencias publicadas. Ademas, hay que plantearse si el estudio es viable economicamente y si puede ser completado en un periodo menor a 4 anos. Una vez ideado el estudio multicentrico, para ejecutarlo se debe redactar un protocolo (segun la guia Standard Protocol items: Recommendations for Interventional Trials [SPIRIT 2013]). En el se recogeran el tipo de diseno, el tamano muestral y los centros que participaran. La aleatorizacion es clave en el diseno. Si puede ser aleatorizado, se recomienda utilizar la guia Consolidated Standards of Reporting Trials (CONSORT), si no, la Transparent Reporting of Evaluations with Non-Randomized Designs (TREND). Cuando el protocolo es aprobado por el Comite Etico de Investigacion Clinica del hospital, hay que darle visibilidad. Es por eso que se recomienda su registro en ClincalTrials.gov y su publicacion en revistas indexadas. Para el inicio del estudio, se requiere buscar fuentes de financiacion. Estas permiten tener una base de datos on line, que permiten aleatorizar al momento y mantener el registro al dia desde cualquier centro. Por ultimo, hay que destacar que es imprescindible la motivacion. La multicentricidad solo se entiende si todos los centros participan. Asi que informar de resultados y dar animos cada 1-3 meses (en forma de newsletter) es una manera de conseguir un buen funcionamiento del estudio.

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.

Resumen Introduccion Se ha disenado un protocolo de prehabilitacion trimodal con el objetivo de valorar si contribuye a disminuir la morbilidad postoperatoria, valorar el efecto de la prehabilitacion en la estancia hospitalaria global y analizar la evolucion de la capacidad funcional antes y despues de cirugia. Metodos Estudio observacional unicentrico con pacientes con cancer colorrectal intervenidos quirurgicamente con intencion curativa despues de un protocolo de prehabilitacion trimodal. Se recoge morbilidad postoperatoria segun el Comprehensive Complication Index y estancia hospitalaria, y se compara con una matriz historica. Tambien se recoge capacidad funcional antes y despues de la aplicacion del protocolo de prehabilitacion. Resultados En comparacion con la poblacion historica se consigue disminuir el Comprehensive Complication Index global de forma estadisticamente significativa de 13,2 a 11,5. Desglosando por tipo de morbilidad, todas disminuyen en porcentaje sin conseguir significacion (infeccion espacio quirurgico del 11,7 al 8,4%; infeccion nosocomial del 15,8 al 10%, y morbilidad medica del 8,6 al 4,2%). La estancia hospitalaria global pasa de 6 a 4 dias y el porcentaje de pacientes que se preparan en casa disminuye de forma estadisticamente significativa en ambos casos. Conclusiones La prehabilitacion trimodal puede contribuir a disminuir la morbilidad postoperatoria y la estancia hospitalaria global de los pacientes intervenidos de neoplasia colorrectal.

Introduction A trimodal prehabilitation protocol was designed with the aim to evaluate whether it contributes to reducing postoperative morbidity, to evaluate the effect of prehabilitation on overall hospital stay, and to analyze the evolution of functional capacity before and after surgery. Methods A single-center observational study of patients with colorectal cancer who underwent surgery with curative intent after a trimodal prehabilitation protocol. We collected data for postoperative morbidity according to the Comprehensive Complication Index and hospital stay, which were compared with a historical matrix. Functional capacity data were also collected before and after the application of the prehabilitation protocol. Results Compared to the historical population, the overall Comprehensive Complication Index was reduced from 13.2 to 11.5, which was statistically significant. Analyzed by morbidity type, all decreased in percentage, although without achieving significance (surgical site infection from 11.7% to 8.4%, nosocomial infection 15.8 to 10% and medical morbidity 8.6% to 4.2%). The overall hospital stay went from 6 to 4 days, and the decrease in the percentage of patients who prepared at home was statistically significant in both cases. Conclusions Trimodal prehabilitation can contribute to lowering the postoperative morbidity and overall hospital stay of patients undergoing colorectal cancer surgery.

Introduction Physicians, especially surgeons, are significatively affected by burnout. Duty-hour violation, as well as discrimination, abuse and sexual harassment may contribute to burnout. A study about this topic has been published in residents from United States, demonstrating a high incidence of burnout. Our objective is to know which is the situation in Spain and to compare it with United States. Methods Cross-sectional observational study carried out in January-February 2020, based on the responses to a validated survey administered to General Surgery residents in Spain. Results There are 931 General Surgery Residents. 739 have entered in the survey and 452 (61.2%) eventually responded to it. In any occasion during the training period, 55.1% reported discrimination based on their gender, 8.8% reported racial discrimination, 73.9% reported verbal/psychological abuse, 7.1% reported physical abuse and 16.4% reported sexual harassment. Attending surgeons are the most frequent source of sexual harassment and physical and verbal abuse, whereas patients are the most frequent cause of gender discrimination. Burnout symptoms were reported by 47.6% of residents and 4.6% reported suicidal thoughts. 98% of residents reported duty-hour violations and 47% of them do not have the day off after to be on call. Both of these issues are burnout predictive factors. Conclusions Mistreatment (discrimination, abuse and harassment) occurs among General Surgery residents during their training period in our country. Every kind of mistreatment is more frequent in Spain than in the United States, with the exception of racial discrimination. It is associated with exceeding weekly duty-hour. It is necessary to know these problems and to avoid them in order to improve work environment of General Surgery training period.

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.

Resumen Introduccion La fragilidad se asocia con una mayor morbimortalidad postoperatoria. El manejo multidisciplinar individualizado de estos pacientes puede mejorar la calidad asistencial. Los objetivos de este trabajo son conocer el porcentaje de pacientes fragiles con cancer colorrectal en nuestra poblacion y describir la morbimortalidad asociada a la cirugia y la evolucion del tratamiento paliativo. Metodos Estudio observacional prospectivo de pacientes con cancer colorrectal quirurgico (1 de febrero del 2018-30 de abril del 2019). Cribado de paciente fragil y clasificacion segun grados de fragilidad. Decision terapeutica (cirugia o tratamiento paliativo) segun grado de fragilidad y voluntades explicitas del paciente. Analisis de comorbilidad postoperatoria (segun Clavien-Dindo y Comprehensive Complication Index), mortalidad y seguimiento oncologico. Resultados Fueron visitados 193 pacientes con cancer colorrectal quirurgico, con una edad media de 74 anos (44-92). Cribado: 46 pacientes fragiles (24%), con una edad media de 80 anos (57-92). Se optimizo e intervino a 22 pacientes (48%), con una edad media de 78 anos (57-89). Efectos adversos relevantes del 27,7% (4 efectos adversos grado iv a, uno iv b y otro v, segun Clavien-Dindo). Comprehensive Complication Index de 17,5. Tratamiento paliativo en 24 pacientes (52%), con una edad media de 82 anos (59-92). Seguimiento medio de 7,8 meses, 2 muertes por progresion de la enfermedad (8,3%), 5 reconsultas por complicaciones del cancer colorrectal (20,1%). Conclusiones El manejo multidisciplinar e individualizado del paciente fragil con cancer colorrectal es clave para mejorar la calidad asistencial en el tratamiento de este grupo de pacientes.

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.

To determine current outcomes and predictors of treatment failure among patients with surgical site infection (SSI) after colorectal surgery.A multicentre observational prospective cohort study of adults undergoing elective colorectal surgery in 10 Spanish hospitals (2011-2014). Treatment failure was defined as persistence of signs/symptoms of SSI or death at 30 days post-surgery.Of 3701 patients, 669 (18.1%) developed SSI; 336 (9.1%) were organ-space infections. Among patients with organ-space SSI, 81.2% required source control: 60.4% reoperation and 20.8% percutaneous/transrectal drainage. Overall treatment failure rate was 21.7%: 9% in incisional SSIs and 34.2% in organ-space SSIs (p 0.001). Median length of stay was 15 days (IQR 9-22) for incisional SSIs and 24 days (IQR 17-35) for organ-space SSIs (p 0.001). One hundred and twenty-seven patients (19%) required readmission and 35 patients died (5.2%). Risk factors for treatment failure among patients with organ-space SSI were age ≥65 years (OR 1.83, 95% CI: 1.07-1.83), laparoscopy (OR 1.7, 95% CI: 1.06-2.77), and reoperation (OR 2.8, 95% CI: 1.7-4.6).Rates of SSI and treatment failure in organ-space SSI after elective colorectal surgery are notably high. Careful attention should be paid to older patients with previous laparoscopy requiring reoperation for organ-space SSI, so that treatment failure can be identified early.

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.

Resumen Introduccion El libro informatico del residente quirurgico (LIRQ) tiene por objetivos: simplificar el registro de la actividad formativa de los residentes quirurgicos y permitir obtener informes fiables y detallados sobre la misma, para su evaluacion. Metodos El LIRQ es una base de datos unica y compartida. Los residentes registran de manera prospectiva sus actividades, en 3 bloques: quirurgico, cientifico y docente. Permite acceder a informes de la actividad registrada, actualizados al momento. Resultados Periodo de estudio, usando el LIRQ: Entre junio de 2011 y mayo de 2013. Se registraron un total de 4.255 cirugias y 11.907 procedimientos quirurgicos. Por otro lado, cada residente registro 250 cirugias por ano y 700 procedimientos quirurgicos por ano. La actividad quirurgica como cirujano principal que se desarrolla el primer ano de residencia es, principalmente, en cirugia urgente (68,01%) y por via laparotomica (97,73%), mientras que durante el quinto ano de residencia se desarrolla un 51,27% en cirugia programada y se utiliza la via laparoscopica en un 23,10% de los casos. Durante este periodo, los residentes participaron en un total de 11 publicaciones cientificas, 75 presentaciones en congresos y 69 actividades de formacion continuada. Conclusiones El LIRQ es una herramienta util que simplifica el registro y analisis de los datos sobre la actividad quirurgica y cientifica de los residentes. Constituye un paso adelante en la evaluacion de la formacion de los residentes quirurgicos, sin embargo, es solo un paso intermedio en el camino del desarrollo de un registro espanol de mayor envergadura.

Resumen Introduccion Las adherencias son la causa mas importante de oclusion intestinal, suponen un 25% de las consultas por dolor abdominal. Con un correcto manejo de este cuadro, la mortalidad asociada puede ser menor de un 5-10%. El Gastrografin ® puede ayudar a ello. Objetivo La aplicacion de un protocolo de manejo de la oclusion intestinal adherencial con Gastrografin ® es segura y permite disminuir la estancia hospitalaria y el tiempo de indicacion de cirugia por fallo del tratamiento conservador. Material y metodo Estudio prospectivo observacional, siguiendo un protocolo preestablecido. Una vez diagnosticado el cuadro, descartadas otras causas de oclusion y la presencia de sufrimiento intestinal, se administra Gastrografin ® y se inicia tratamiento conservador. Si el Gastrografin ® pasa al colon en el control de las 8, 12 o 24 h posteriores a su administracion, se considera la oclusion como parcial, se inicia dieta oral y se evalua el alta. Si no pasa el contraste a las 24 h, se indica cirugia. Resultados Desde enero de 2009 hasta diciembre de 2011, se trataron 211 episodios (164 pacientes). En 170 episodios se administro contraste con llegada del mismo al colon en 142 episodios (104 episodios a las 8 h, 11 a las 12 h y 27 a las 24 h) Se intervien a 28 pacientes por fallo del tratamiento conservador y a 5 por otras causas. Conclusiones La aplicacion de un protocolo en el que se incluye el uso de Gastrografin ® en la oclusion intestinal adherencial es seguro y permite tomar decisiones terapeuticas con mayor celeridad y con una menor estancia hospitalaria.

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 La elevada incidencia de la hernia paraestomal y la controversia en su reparacion hacen que su prevencion sea un area de intensa investigacion. El objetivo del presente articulo es describir la tecnica de Sugarbaker modificada con una nueva malla para la prevencion de una hernia paraestomal, utilizando un abordaje laparoscopico.

Resumen Introduccion No hay datos cuantificados de la actividad real conseguida durante los 5 anos de formacion en Espana de la especialidad de Cirugia General y del Aparato Digestivo (CGAD). Igualmente, hay escasos datos en los programas de otros paises y especialidades quirurgicas. El objetivo es estimar la actividad media quirurgica global, por areas de capacitacion especifica y grado de complejidad, del programa espanol de la especialidad. Participantes y metodo Estudio multicentrico prospectivo observacional sobre la actividad de los residentes de CGAD en Espana a traves del libro informatico del residente de la Asociacion Espanola de Cirujanos (LIR-AEC). Cada residente registra su propia actividad supervisado por su tutor.El periodo de muestra fue de 6 meses. A partir de los resultados se estimaron las medianas de actividad anual y del periodo de la residencia. Resultados Actividad quirurgica: se ha estimado que durante la residencia asisten a 1.325 intervenciones, realizan como cirujano principal 654 (49%). Actividad asistencial: la media de guardias es de 5,2 ± 1,8 al mes. La actividad en consultas externas es de 548 primeras visitas y casi el doble de segundas visitas. Actividad cientifica: el numero total de cursos y congresos es de 34. La media estimada de comunicaciones a congresos es de 14 y de publicaciones de 3. Conclusiones El LIR-AEC es una herramienta adecuada para verificar la actividad del programa espanol de CGAD. Estos resultados permitiran una evaluacion comparativa con la formacion de los programas de otros paises y especialidades quirurgicas.

Rectal prolapse repair techniques using laparoscopic abdominal surgery are the treatments of choice. However, in patients with increased morbidity, perineal surgical techniques are indicated. Transanal endoscopic surgery is presented as a possible alternative option in groups with increased experience in it.

Resumen Introduccion La introduccion del libro informatico del residente, de la Asociacion Espanola de Cirujanos (LIR-AEC), nos ha permitido realizar evaluaciones particulares y generales de cada residente. El objetivo ha sido conocer la media de actividades asistenciales, cientificas y quirurgicas segun el programa de la especialidad. Material y metodo Registro de la actividad de los residentes en el LIR-AEC. Se ha cuantificado la actividad general por ano y por rotacion. Se ha analizado la relacion de intervenciones asistidas y realizadas y segun grados de complejidad. La media de actividades cientificas y asistenciales y la de guardias al mes. Resultados Desde 2004, 8 residentes han registrado su actividad en el LIR-AEC. Asisten a una media de 1.514 intervenciones, de las cuales realizan como cirujano 922 (62%). Asisten a 185 intervenciones laparoscopicas, de las que realizan 72 (39%). Como cirujanos, 864 (94%) de los 922 procedimientos son de los niveles 1, 2 y 3 (el 64, el 75 y el 53%, respectivamente). Realizan una media de 5,75 guardias por mes. Acuden de media durante la residencia a un total de 21 cursos y congresos. Participan en un total de 24 comunicaciones y posters, asi como en 6 publicaciones de media en la residencia. Conclusiones El LIR-AEC permite una evaluacion continua de la actividad del residente. Hemos podido conocer la media de actividades que realiza cada residente durante una rotacion y un ano determinados, esto permite conocer con exactitud si se cumplen los minimos definidos.

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.

Resumen Introduccion La preparacion mecanica de colon (PMC) en la cirugia colorrectal es un dogma que se ha cuestionado en los ultimos anos. El objetivo de este estudio es demostrar que la morbilidad en cirugia programada colorrectal es igual o menor sin la PMC. Material y metodo Pacientes sometidos a cirugia programada de colon izquierdo y recto con anastomosis primaria fueron aleatorizados en dos grupos. Al grupo PMC se le practico la preparacion y al grupo sin PMC, solo enemas de limpieza. Se recogieron variables demograficas, oncologicas, nutricionales y quirurgicas, modelos de prediccion de riesgo y morbimortalidad. Resultados Se incluyo a 193 pacientes, 69 con PMC y 71 sin ella; 89 pacientes con anastomosis colocolica (PMC, 38; sin PMC, 51) y 50 con anastomosis colorrectal (PMC, 31; sin PMC, 19). En el analisis general, se apreciaron diferencias estadisticamente significativas a favor de no preparar en cuanto a la morbilidad (el 43,5% en el PMC y el 27% en los sin PMC) e infeccion nosocomial (el 27,5 y el 11,4%). En la infeccion de herida, sin diferencias estadisticamente significativas, se obtuvo el 11,6% en el PMC, frente al 5,7% en el sin PMC. Las unicas muertes fueron 2/69 (2,9%) pacientes en el grupo PMC. Segun localizacion de anastomosis, en las colocolicas las diferencias fueron mas acusadas y estadisticamente significativas en las variables morbilidad, dehiscencia de anastomosis e infeccion nosocomial. en las anastomosis colorrectales no fue tan evidente el efecto de no preparar. Conclusiones Nuestros resultados indican que no existe un beneficio de la PMC en la cirugia ante anastomosis colocolicas. No preparar no tiene relacion con mas morbilidad en infeccion de herida ni dehiscencia anastomotica. En anastomosis colorrectales, las diferencias no tan evidentes hacen necesarias series mas amplias.

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.

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.

Introduction The identification of molecular markers that can facilitate disease detection, staging and outcome prediction is an important aim in cancer research. Accumulating evidence has suggested that miRNAs play an active role controlling development, differentiation and cancer progression. The de-regulation of miRNA expression has been found in several types of solid tumours and several recent studies have demonstrated that miRNAs are stably detectable in plasma/serum. The aim of the present study was to investigate the miRNA expression patterns in stage III colorectal cancer tumours and evaluate changes in circulating miRNA levels associated with colorectal cancer. Methods Genome-wide microarray analysis of miRNA expression was performed on 12 paired tumour and non-tumour tissues from stage III colorectal cancer patients. A selection of differentially overexpressed miRNAs were then validated by quantitative real time polymerase chain reaction and further determined in serum of a set of independent colorectal cancer patients and healthy individuals. Results Using 1.5-fold expression difference as a cut-off level, 43 miRNAs were identified as differentially expressed in tumour versus normal tissue. Eleven over-expressed miRNAs (miR-135b, miR-141, miR-18a, miR-20a, miR-21, miR-224, miR-29a, miR-31, miR-34a, miR-92a, miR-96) were confirmed by qRT-PCR as significantly overexpressed in tumour samples versus normal ones. We were able to detect 9 of these 11 miRNAs in serum samples from colorectal cancer patients and healthy individuals. Serum levels of miR-18a, miR-21, miR-34a and miR-96 were significantly higher in colorectal cancer patients than in controls (p Conclusion Our results highlight a substantial number of miRNAs which are differentially expressed in stage III colorectal cancer patients. Moreover, they suggest that circulating miR-18a, miR-21, miR-34a and miR-96 may be used as potential biomarkers in the screening and monitoring of colorectal cancer patients.