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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.

An important drawback of local surgery for lesions in the anal canal is the difficulty of achieving en bloc full-thickness resections. The aim of this study is to evaluate TEM/TEO in lesions of this type from the point of view of morbidity, mortality and the quality of the pathology specimen. This is an observational study with prospective data collection from June 2004 to July 2018. Two groups are defined: group A (rectal tumors with proximal margin between 0 and ≤4 cm from anal verge) and group B (distal margin > 4 cm from anal verge). A technical description is provided; resections and postoperative complications in both groups are compared. During the study period, 757 patients underwent TEM/TEO. Finally, 692 patients were included, 192 patients in group A and 500 patients in group B. An en bloc surgical specimen was obtained in 176/192 patients (91.7%), although the defect was completely sutured in 132 (68.8%). In the comparative analysis, group A did not present significantly greater fragmentation of the resected piece [16/192 (8.3%) vs. 36/500 (7.2%), p = 0.630], although group A was associated with greater involvement of the surgical margin [28/192 (14.6%), 32/500 (6.4%), p = 0.001] and clinically relevant morbidity [16/192 (8.3%), 20/500 (4%), p = 0.034]. There was no mortality. The use of TEM/TEO to remove lesions originating in the anal canal is feasible. But we have to take into account that there is an increase in complications, technical difficulties and affected margins resection.

Since the introduction of screening for colorectal cancer, the use of transanal endoscopic surgery (TEM) has become increasingly popular. However, the technical difficulty of this surgery varies widely. The few studies of learning curve in TEM have produced very disparate results. The aim of this study is to distinguish between straightforward and complex procedures, in order to refer more difficult cases to centers with greater experience. Observational study with prospective data collection and retrospective analysis was carried out between June 2004 and January 2019. All TEMs performed on rectal tumors were included. The complexity of the procedure was defined according to the weighted mean surgical time for each surgeon. A predictive model of complexity was established, with a score higher than 5 indicating a complex lesion. During the study period, 773 TEMs were performed, 708 of which met the study’s inclusion criteria. One hundred and three tumors were defined as complex. Predictors of complexity were as follows: male sex (OR: 1.78, 95% CI 1.1–2.9, score: 1), tumor size > 5 cm (OR: 5.1, 95% CI 3.2–8.2, score: 4), TEM for recurrence (OR: 6.3, 95% CI 2.3–16.7, score: 5), and distance from the upper margin of the tumor to the anal verge > 15 cm (OR: 1.6, 95% CI 0.96–2.7, score: 1). Rather than establishing the learning curve merely in terms of the number of TEM procedures performed, it is important to consider the surgical difficulty of the interventions. To this end, it is essential to differentiate simple TEMs from the complex ones.

Objective This study determines the quality of life and the anorectal function of these patients. Method Observational study of two cohorts comparing patients undergoing rectal tumor surgery using TaETM or conventional ETM after a minimum of six months of intestinal transit reconstruction. EORTC-30, EORTC-29 quality of life questionnaires and the anorectal function assessment questionnaire (LARS score) are applied. General variables are also collected. Results 31 patients between 2011 and 2014: 15 ETM group and 16 TaETM. We do not find statistically significant differences in quality of life questionnaires or in anorectal function. Statistically significant general variables: longer surgical time in the TaETM group. Nosocomial infection and minor suture failure in the TaETM group. Conclusion The performance of TaETM achieves the same results in terms of quality of life and anorectal function as conventional ETM.

Preoperative clinical staging is critical to select those patients whose disease is localized and may benefit from surgery with curative intent. Ideally, such staging should predict tumor invasion, lymphatic involvement and distant metastases. With the cTNM, we are able to select patients who could benefit from endoscopic resection, radical surgery or less radical treatment in patients with distant metastasis. The initial diagnosis of adenocarcinomas of the esophagogastric junction requires endoscopy with biopsies. For clinical staging, thoracoabdominal-pelvic CT scan, endoscopic ultrasound and PET or PET/CT are used. Other useful explorations are: barium swallow, endoscopic mucosal resection or endoscopic submucosal dissection (for assessment in initial stages) and staging laparoscopy. Once the resectability of the tumor has been established, the operability of the tumor should be assessed according to the patient's condition.

The aim of this study was to assess the reduction in the incidence of parastomal hernia (PH) after placement of prophylactic synthetic mesh using a modified Sugarbaker technique when a permanent end-colostomy is needed.Prevention of PH formation is crucial given the high prevalence of PH and difficulties in the surgical repair of PH.A randomized, prospective, double-blind, and controlled trial. Rectal cancer patients undergoing laparoscopic abdominoperineal resection with permanent colostomy were randomized (1 : 1) to the mesh and nonmesh arms. In the mesh group, a large-pore lightweight composite mesh was placed in the intraperitoneal/onlay fashion using a modified Sugarbaker technique. PH was detected by computed tomography (CT) after a minimum follow-up of 12 months. Analysis was per-protocol.The mesh group included 24 patients and the control group 28. Preoperative data, surgical time, and postoperative morbidity were similar. The median follow-up was 26 months. After CT examination, 6 of 24 PHs (25%) were observed in the mesh group compared with 18 of 28 (64.3%) in the nonmesh group (odds ratio 0.39, 95% confidence interval 0.18-0.82; P = 0.005). The Kaplan-Meier curves showed significant differences in favor of the mesh group (long-rank = 4.21, P = 0.04). The number needed to treat was 2.5, which confirmed the effectiveness of the intervention.Placement of a prosthetic mesh by the laparoscopic approach following the modified Sugarbaker technique is safe and effective in the prevention of PH, reducing significantly the incidence of PH.

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 Alrededor del 2-15% de los pacientes politraumatizados presentan un neumotorax oculto. La aplicacion del tratamiento conservador (observacion) en la practica clinica diaria aun sigue siendo controvertido. Nuestra hipotesis es que es factible realizar un tratamiento conservador. El objetivo de este estudio es evaluar la eficacia y los efectos adversos del tratamiento conservador del neumotorax oculto en nuestro medio. Metodos Estudio observacional retrospectivo (analisis de base de datos con registro prospectivo) realizado en un hospital universitario de nivel II . Inclusion de 1.087 pacientes politraumatizados mayores de 16 anos ingresados en el area de criticos desde 2006 hasta 2013. Resultados En este periodo, 126 pacientes presentaron neumotorax oculto, en 73 (58%) se decidio observacion. En 9 pacientes (12%) fracaso la observacion (precisaron colocacion de drenaje pleural) por aumento del neumotorax o aparicion de hemotorax. De los pacientes observados, 16 fueron ventilados bajo presion positiva. En este grupo fracaso la observacion en 3 pacientes (19%). Ningun paciente presento neumotorax a tension u otro problema relacionado con la ausencia de drenaje. No hubo diferencias entre grupos (observacion vs. drenaje) respecto a mortalidad, estancia hospitalaria ni estancia en la unidad de criticos. Conclusion El tratamiento de eleccion de los pacientes con neumotorax oculto es la observacion clinica. Este tratamiento tambien es factible en los pacientes ventilados bajo presion positiva.

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

This study determines the quality of life and the anorectal function of these patients.Observational study of two cohorts comparing patients undergoing rectal tumor surgery using TaETM or conventional ETM after a minimum of six months of intestinal transit reconstruction. EORTC-30, EORTC-29 quality of life questionnaires and the anorectal function assessment questionnaire (LARS score) are applied. General variables are also collected.31 patients between 2011 and 2014: 15 ETM group and 16 TaETM. We do not find statistically significant differences in quality of life questionnaires or in anorectal function. Statistically significant general variables: longer surgical time in the TaETM group. Nosocomial infection and minor suture failure in the TaETM group.The performance of TaETM achieves the same results in terms of quality of life and anorectal function as conventional ETM.La técnica de referencia de la cirugía rectal sigue siendo la escisión total del mesorrecto (ETM), en la que se aplica la laparoscopia por sus ventajas. El intento de evitar el 17% de reconversión hace que se apliquen técnicas transanales. La ETM transanal (TaETM) se lleva a cabo por grupos experimentales con buenos resultados oncológicos y de morbimortalidad.Este estudio determina la calidad de vida y la función anorrectal de estos pacientes.Estudio observacional de dos cohortes que compara pacientes intervenidos por tumor rectal mediante TaETM o ETM convencional después de 6 meses mínimo de la reconstrucción del tránsito intestinal. Se aplican los cuestionarios de calidad de vida EORTC-30 y EORTC-29, y el cuestionario de valoración de función anorrectal (LARS score). También se recogen variables generales.Entre 2011 y 2014 fueron intervenidos 31 pacientes: 15 en el grupo de ETM y 16 en el de TaETM. No se encuentran diferencias estadísticamente significativas en cuanto a cuestionarios de calidad de vida ni respecto a la función anorrectal. Variables generales estadísticamente significativas: tiempo quirúrgico mayor en el grupo TaETM, e infección nosocomial y fallo de sutura menores en el grupo TaETM.La realización de TaETM obtiene los mismos resultados en cuanto a calidad de vida y función anorrectal que la ETM convencional.The gold standard of rectal surgery remains total mesorrectal excision (ETM) in which laparoscopy is applied for its advantages. The attempt to avoid 17% conversion rate implies that transanal techniques are applied. Transanal ETM (TaETM) is performed by experimental groups with good oncological and morbimortality results.

Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure with low morbidity. The definition of risk factors for postoperative complications would help to identify the patients likely to require more care and surveillance in an ambulatory or 1-day surgery (A-OdS) program. The main endpoints are overall 30-day morbidity and relevant morbidity. The secondary objectives are to detect risk factors for complications, rehospitalization, and the time of occurrence of the postoperative complications, and to describe the adverse effects following hospitalization that the A-OdS program would avoid. This is an observational study of consecutive patients undergoing TEM between June 2004 and December 2016. Overall and relevant morbidity based on the Clavien–Dindo (Cl–D) classification were recorded, as were demographic, preoperative, surgical, and pathology variables. Univariate and multivariate analyses of the risk factors were carried out. Six hundred and ninety patients underwent surgery, of whom 639 were included in the study. Overall morbidity rate was 151/639 patients (23.6%); the clinically relevant morbidity rate was 36/639 (Cl–D > II) (5.6%) and mortality 2/639 (0.3%). The most frequent complication was rectal bleeding, recorded in 16.9% (108/639 patients) and grade I in 86/108 patients (78. 9%). The period with the greatest risk of complications was the first 2 days. The rehospitalization rate after 48 h was 7%. The risk factors for complications were as follows: tumor size > 6 cm (OR 3.2, 95% CI 1.3–7.8), anti-platelet medication (OR 2.3, 95% CI 1.1–5.1), and surgeon’s experience

Although the incidence of colorectal cancer increases with the patient’s age, the elderly continue to be less likely to be scheduled for surgery. Transanal endoscopic micro-surgery (TEM) is a surgical alternative to total mesorectal excision (TME) in early stage rectal cancer and/or in selected patients that could decrease morbidity and mortality rates in this group of patients. Our main objective is to assess the safety and feasibility of TEM in elderly (75–84 years) and very elderly (≥ 85 years) patients. Observational study was conducted with prospective data collection of all consecutive patients who underwent TEM between April 2004 and January 2017. Patients were assigned to groups according to age. Descriptive and comparative analyses between groups were performed. We analyzed 693 patients, 429 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.

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.

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.

Resumen Objetivo El hallazgo en una biopsia de mama de lesiones proliferativas atipicas, implica la necesidad de cirugia y extirpacion de dicha lesion. El objetivo del estudio fue determinar la tasa de escisiones completas mediante el uso del dispositivo Intact ® -BLES de lesiones categorizadas B3 en biopsia asistida por vacio (BAV). Pacientes y metodos Realizamos un estudio descriptivo observacional de la utilidad de este sistema que consigue, con anestesia local y ambulatoriamente, la obtencion percutanea de una muestra de tejido de 20 × 20 mm, permitiendo la valoracion de los margenes de reseccion, llevado a cabo entre febrero de 2012 y septiembre de 2014. Resultados Se analizaron 25 procedimientos. La biopsia inicial demostraba principalmente la presencia de atipia epitelial plana (56%) e hiperplasia ductal atipica (32%). El tamano medio de la pieza extirpada fue de 20 × 10 × 8 mm, en un especimen unico, permitiendo la valoracion de margenes en todas ellas (100%). En el estudio anatomopatologico definitivo no se encontro lesion residual en el 68% de los casos, asi como 2 casos (8%) de carcinoma intraductal (CDIS), infradiagnosticados con la biopsia inicial. El estudio de margenes demostro estar libres en el 85% de los casos. No ha habido ningun efecto adverso importante, solo un caso de hematoma y un caso de dolor superior al normal. Conclusiones El sistema de escision percutanea (Intact ® -BLES) permite mediante un procedimiento con anestesia local, de forma ambulatoria y sin complicaciones importantes evitar la cirugia en un 88% de los casos de lesiones premalignas en la biopsia inicial. Asi mismo, permite demostrar la presencia de CDIS en un 8% de los casos (infradiagnosticados).

Laparoscopic surgery for rectal TME achieves better patient recovery, lower morbidity, and shorter hospital stay than open surgery. However, in laparoscopic rectal surgery, the overall conversion rate is nearly 20 %. Transanal TME combined with laparoscopy, known as Hybrid NOTES, is a less invasive procedure that provides adequate solutions to some of the limitations of rectal laparoscopy. Transanal TME via TEO with technical variants (intracorporeal resection and anastomosis, TEO review of the anastomosis) attempts to standardize and simplify the procedure. Prospective observational study was used describe and assess the technique in terms of conversion to open surgery, overall morbidity, surgical site infection and hospital stay. The sample comprised consecutive patients diagnosed with rectal tumor less than 10 cm from the anal verge who were candidates for low anterior resection using TME (except T4). Demographic, surgical, postoperative, and pathological variables were analyzed, as well as morbidity rates. From September 2012 to August 2014, 32 patients were included. The conversion rate was 0 %. Overall morbidity was 31.3 %, SSI rate was 9.4 %, and mean hospital stay was 8 days. Oncological radical criteria were achieved with pathological parameters of 94 % of complete TME and a median circumferential margin of 13 mm. The introduction of technical variants of TEO for transanal resection can facilitate a procedure that requires extensive experience in transanal and laparoscopic surgery. Studies of sphincter function, quality of life, and long-term oncological outcome are now necessary.

Aim To determine the percentage of residual lesion observed in the pathology study of transanal endoscopic surgery (TEM) specimens after endoscopic polypectomy of malignant rectal polyps with questionable margins, and the need for further surgery. Secondary aims: to determine the morbidity and mortality associated with this procedure and to identify the percentage of recurrence after excision by TEM. Methods Observational study with prospective data collection of all patients undergoing TEM after endoscopic polypectomy for malignant rectal polyps or non-invasive high-grade neoplasia, from January 2004 to December 2016. An en bloc full-thickness wall excision of the scar was performed. Variables recorded: histology of TEM specimen, 30-day morbidity and mortality according to the Clavien-Dindo classification, need for salvage surgery and recurrence. Results Fifty out of 690 patients undergoing TEM during the study period (36 adenocarcinomas, five non-invasive high-grade neoplasias and 9 neuroendocrine tumors) were included. Post-surgery histology showed residual lesion in 21 (42%) patients: 7 neuroendocrine tumors, 10 adenomas and 4 adenocarcinomas (two pT1, one pT2 and one pT3). The pT2 and pT3 patients (4%) underwent salvage surgery. No recurrence was observed, and mean follow-up was 29.1Â ± 21.6 months. The 30-day morbidity rate was 14%, but 4/7 with Clavien-Dindo grade I. Conclusions After endoscopic polypectomy of malignant rectal polyps with questionable margins, the presence of residual lesion in the pathology study of transanal resection specimens is high. TEM with full-thickness resection of these lesions is an appropriate treatment, allowing disease control and achieving minimal morbidity.

Acute diverticulitis (AD) is a highly prevalent disease in Spain. Its chronic-recurrent appearance and high rate of relapse mean that it has a major epidemiological and economic impact on our health system. In spite of this, it has not been studied in any great depth. Reassessing its etiopathology, recent studies have observed that it is an inflammatory disease—not, as classic theories had postulated, an infectious one. In the light of these findings, the suitability of antibiotics for its treatment has been reconsidered. At present, however, the evidence for incorporating these findings into clinical practice guidelines remains insufficient. This study was designed to analyse the safety and efficacy of a non-antibiotic treatment for mild AD. Patients with mild AD (grade 0 in the modified Neff classification) who meet the inclusion criteria will be randomly assigned to one of two outpatient treatment strategies: (a) classical treatment (antibiotics, anti-inflammatories and low-fibre diet) or (b) experimental treatment (anti-inflammatories and low-fibre diet). Clinical controls will be performed at 2, 7, 30, and 90 days. We will determine whether there are any differences in the clinical outcome between groups. The main objective is to demonstrate that antibiotics neither accelerate the resolution of the disease nor decrease the number of complications and/or recurrences in these patients, suggesting that their use may be unnecessary. The results of this trial will help to optimize and homogenize the treatment of this highly prevalent disease. However, more studies are required before firm changes can be introduced in international clinical practice guidelines. Trial registration: The trial has been registered at the ClinicalTrials.gov database (ID: NCT02785549) and the EU Clinical Trials Register database (EudraCT number: 2016-001596-75).

Colorectal adenomatous polyps are considered premalignant lesions, although a high percentage are already malignant at the time of their removal. Full-thickness excision in patients with adenoma detected in preoperative biopsy enables much more accurate pathology examination and has shown that local surgery is appropriate for T1 adenocarcinoma.To determine whether full-thickness excision during transanal endoscopic surgery is the treatment of choice for rectal adenoma, and to identify possible predictors of invasive adenocarcinoma associated with this type of lesion.Prospective, observational study.The study was conducted at a university teaching hospital.All patients scheduled for transanal endoscopic surgery after detection of adenoma in a preoperative biopsy between June 2004 and February 2013 entered the study.The principal variable was the presence of invasive adenocarcinoma in the pathology study. Other study variables were the epidemiological variables sex and age; the clinical variables tumor size, number of quadrants affected, distance from the anal verge, and tumor location; and the morphological variables tumor aspect, degree of dysplasia, preoperative biopsy (tubulo-villous), endorectal ultrasound, and pelvic MRI stage. Variables found to be related to the risk of malignancy in rectal adenomas were evaluated using univariate and multivariate analysis.Of 471 patients who underwent surgery, 277 had a preoperative diagnosis of adenoma. Final pathology studies showed 52 (18.8%) invasive adenocarcinomas, among which 27 were pT1 (52%), 16 pT2 (30.7%), and 9 pT3 (17.3%). Factors predictive of invasive adenocarcinoma were sessile morphology (OR 3.2, 95%CI 1.4-7.1), high-grade dysplasia (OR 2.3, 95%CI 1.2-4.8), and endorectal ultrasound stage uT2-T3 (OR 3.8, 95%CI 1.6-9).The limitations are derived from the observational design.In this sample, half of the adenocarcinomas from adenomas were T1 adenocarcinomas. Because a high proportion of rectal adenomas are, in fact, invasive adenocarcinomas, full-thickness excision is appropriate.

Aquest treball preten valorar la utilitat del model de risc d'evisceracio desenvolupat per Van Ramshorst et al. entre els pacients sotmesos a cirurgia abdominal per laparotomia mitja en el Servei de Cirurgia General i de l'Aparell Digestiu de l'Hospital de Sabadell – Corporacio Sanitaria i Universitaria Parc Tauli – Barcelona. El model de risc inclou dades postoperatories que fan perdre capacitat pronostica clinica, per aquest motiu es proposa una modificacio d'aquest model (Van Ramshorst modificat), tenint en compte nomes les variables preoperatories. Podem concloure que mentre el model de risc d'evisceracio de Van Ramshorst et al. es util en la nostra mostra de pacients, la modificacio proposada necessitaria retocs per a millorar la seva capacitat pronostica.

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.

Resumen Introduccion Aunque el tratamiento del traumatismo esplenico ha cambiado en las ultimas decadas, no existen datos de la actitud que los cirujanos espanoles adoptamos frente a este tipo de lesion tan frecuente. El proposito de este estudio es determinar el perfil del traumatismo esplenico en los adultos con traumatismo abdominal severo y el tratamiento que se realiza en nuestro medio. Metodo Estudio de datos de registros de trauma de 6 hospitales espanoles: Hospital Gregorio Maranon, Hospital de Getafe, Hospital Doce de Octubre, Hospital Virgen de la Vega, Hospital de Torrevieja y Corporacio Sanitaria Parc Tauli. Resultados Se analizo a 566 pacientes con lesiones esplenicas (448 hombres y 118 mujeres). El tipo de traumatismo fue fundamentalmente cerrado (94%) y el mecanismo lesional mas frecuente fue el accidente de trafico El ISS medio de la serie fue de 25,2. El tratamiento fue inicialmente quirurgico en el 56,6%, siendo en el 43,4% restante, conservador. De estos, el 6,5% de los pacientes requirio finalmente cirugia y en el 8,8% se realizo angioembolizacion esplenica. De los pacientes intervenidos al inicio, en el 85,3% de los casos se realizo esplenectomia, y cirugia conservadora de bazo en el 14,7%, de los que el 4,6% fracasaron y requirieron nueva intervencion quirurgica con esplenectomia. Conclusion El tratamiento en Espana para el traumatismo esplenico continua siendo en su mayoria quirurgico (fundamentalmente esplenectomia). La angioembolizacion y el tratamiento conservador continuan teniendo escasa presencia.

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.

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.

Transanal endoscopic microsurgery (TEM) was originally designed for the removal of rectal tumors, principally incipient adenomas, and adenocarcinomas up to 20 cm from the anal verge. However, with the evolution of the technique and the increase in surgeons' experience, new indications have emerged and TEM may now be used in place of other surgical procedures which are associated with higher morbidity. The aim of our study was to evaluate our group's use of TEM or transanal endoscopic operations (TEO) for conditions other than rectal tumors.An observational study of TEM (using Wolf equipment) or TEO (using Storz equipment) for indications other than excision of rectal tumors was conducted from June 2004 to July 2012.Four hundred twenty-four procedures were performed using TEM/TEO: removal of adenocarcinomas in 148 (34.9 %) patients, adenomas in 236 (55.7 %), post-polypectomy excision in 12 (2.8 %), removal of neuroendocrine tumors in 8 (1.9 %), and atypical indications in 20 (4.7 %). Atypical indications were pelvic abscess (3), benign rectal stenoses (2), rectourethral fistula after prostatectomy (3), gastrointestinal stromal tumor (3), endorectal condylomata acuminata (1), rectal prolapse (2), extraction of impacted fecaloma in the rectosigmoid junction (1), repair of traumatic and iatrogenic perforation of the rectum (2), and presacral tumor (3).The use of TEM/TEO in atypical indications may benefit patients by avoiding surgical procedures associated with greater morbidity.

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.

espanolIntroduccion: la diverticulitis aguda (DA) es cada vez mas frecuente en los servicios de Urgencias. Es necesario un manejo seguro y eficaz con criterios de clasificacion que permitan un tratamiento dirigido. Objetivo: verificar que la clasificacion radiologica de Neff modificada (mNeff) asociada a criterios clinicos (sindrome de respuesta inflamatoria [SIRS] y comorbilidad) permite un manejo seguro de la DA. Material y metodos: estudio descriptivo prospectivo en una poblacion de pacientes diagnosticados de DA mediante tomografia computarizada (TC). El protocolo consiste en la aplicacion de la clasificacion de mNeff y criterios clinicos de SIRS y comorbilidad que permiten tratamiento ambulatorio, ingreso, drenaje o cirugia. Resultados: el estudio comprende el periodo de febrero de 2010 a febrero de 2016, con un total de 590 episodios de DA en 271 mujeres y 319 hombres, con una edad mediana de 60 anos (rango: 25-92 anos). Grados de mNeff: grado 0 (408 pacientes, 70,6%): 376/408 (92%) tributarios a tratamiento domiciliario; alta 254/376 (67,5%); reconsultaron 33 pacientes y 22 reingresaron; exito: 91%. Grado Ia (52, 8,9%): 31/52 (59,6%) tributarios a tratamiento ambulatorio; alta 11/31 (35,5%); reconsultaron ocho e ingresaron cinco. Grado Ib (49, 8,5%): cinco cirugias y dos drenajes. Grado II (30, 5,2%): diez cirugias y cuatro drenajes. Grado III (5, 0,9%): una cirugia y un drenaje. Grado IV (34, 5,9%): diez pacientes con buena evolucion con tratamiento conservador; 24/34 (70,6%) fueron intervenidos; colocamos 3/34 (8,8%) drenajes percutaneos. Conclusion: la clasificacion de mNeff es una clasificacion segura y aplicable basada en los hallazgos radiologicos de la TC. Junto con datos clinicos y de comorbilidad, permite un mejor manejo del cuadro de DA. EnglishIntroduction: Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management. Objective: To determine whether the combined use of the modified Neff radiological classification (mNeff) and clinical criteria (systemic inflammatory response syndrome [SIRS] and comorbidity) can ensure safe management of AD. Material and methods: Prospective descriptive study in a population of patients diagnosed with AD by computerized tomography (CT). The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery. Results: The study was carried out from February 2010 to February 2016. A total of 590 episodes of AD were considered: 271 women and 319 men, with a median age of 60 years (range: 25-92 years). mNeff grades were as follows: grade 0 (408 patients 70.6%); 376/408 (92%) were considered for home treatment; of these 376 patients, 254 (67.5%) were discharged and controlled by the Home Hospitalization Unit; 33 returned to the Emergency Room for consultation and 22 were re-admitted; the success rate was 91%. Grade Ia (52, 8.9%): 31/52 (59.6%) were considered for outpatient treatment; of these 31 patients, 11 (35.5%) were discharged; eight patients returned to the Emergency Room for consultation and five were re-admitted. Grade Ib (49, 8.5%): five surgery and two drainage. Grade II (30, 5.2%): ten surgery and four drainage. Grade III (5, 0.9%): one surgery and one drainage. Grade IV (34, 5.9%): ten patients showed good evolution with conservative treatment. Of the 34 grade IV patients, 24 (70.6%) underwent surgery, and three (8.8%) received percutaneous drainage. Conclusions: The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD.

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.

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.

The prevalence of terminal parastomal hernia (PH) after colostomy placement may be as high as 50%. The effect of the PH may range from discomfort to life-threatening complications. Surgical procedures for repairing PH are difficult to perform and present a high-failure rate.To reduce the incidence of PH by implanting a lightweight mesh in the sublay position.Randomized, controlled, prospective study. Patients were scheduled for permanent end colostomy surgery to treat cancer of the lower third of the rectum, performed by the same colorectal surgery team. An Ultrapro lightweight mesh was inserted in the sublay position in the study group. Using simple randomization, the sample size required was estimated to be 27 per group. Patients were followed-up clinically and radiologically with abdominal computed tomography by an independent clinician and a radiologist who were all blind to the aims of the study, 1 month and every 6 months after surgery.: The groups were homogeneous in terms of their clinical and demographic characteristics. Surgical time and postoperative morbidity were similar in the 2 groups. Mortality was 0. No mesh intolerance was reported. In the clinical follow-up (median: 29 months, range: 13-49), 11/27 (40.7%) hernias were recorded in the control group compared with 4/27 (14.8%) in the study group (P = 0.03). Abdominal computed tomography identified 14/27 (44.4%) hernias in the control group compared with 6/27 (22.2%) in the study group (P = 0.08).Parastomal placement of a mesh reduces the appearance of PH. The technique is safe, well-tolerated, and does not increase morbidity rates.

Introduction Parastomal hernia (PH) is a common complication of end colostomy, found in over 50% of patients. Abdominal computerized tomography (CT) may help diagnosis. The prevalence of PH may be higher than previously reported. We present a new CT classification for use in clinical practice. Method A cross-sectional, descriptive observational study was carried out, assessing the clinical and radiological prevalence of PH in 75 patients with an end colostomy operated on since 1997. Clinical examinations were performed by a single surgeon. Abdominal CTs were assessed by a single radiologist. Results PH was observed clinically in 33 (44%) of 75 patients and 27 (82%) were symptomatic. Using the classification 0 (Normal), I (Hernial sac containing stoma loop), II (Sac containing omentum), III (Sac containing a loop other than stoma), radiological PH was observed in 35 (47%) patients. Clinical/radiological concordance (Kappa index = 0.4) increased proportionally with sac size. All type-III PHs (n = 9) were symptomatic. The combined prevalence of PH detected by one or other method was 60.8%. Conclusion Clinical and radiological prevalence of PH is high. As there is no gold standard for PH detection, we recommend a combination of the two methods. A new classification for use in clinical practice is proposed.

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 formacion en el manejo del paciente politraumatizado toma cada vez mas importancia en nuestro pais y en todo el mundo en general, pero hay un gran desconocimiento en cuanto a quien atiende en nuestro medio a estos pacientes y como se forman los residentes de cirugia para su evaluacion, diagnostico y tratamiento. Objetivos Conocer por los residentes de cirugia el estado actual de su formacion y aprendizaje en la atencion al paciente politraumatizado en nuestro pais, y saber su opinion a cerca de como mejorarla. Al mismo tiempo, analizar si la atencion al paciente politraumatizado en nuestros hospitales ha variado en los ultimos anos, asi como los factores que pueden influir en el aprendizaje del manejo de estos pacientes. Material y metodo Encuesta enviada por carta en sobre prefranqueado a 78 hospitales con acreditacion docente para la formacion de residentes, durante el periodo de marzo a octubre de 2005. Resultados Cuando se comparo la atencion tradicional al politraumatizado con la de los ultimos 5 anos, no se encontraron diferencias estadisticamente significativas (p = 0,77). El hecho de que el hospital fuese centro de referencia para la atencion del politraumatismo no afecto, de manera significativa, a que el residente se sintiese bien formado (p = 0,7) ni bien informado (p = 0,33). Conclusiones Los residentes de cirugia no se sienten bien formados ni bien informados acerca del manejo del politraumatizado a pesar de trabajar en hospitales que tratan a este tipo de pacientes y que cada vez mas los cirujanos se implican en el traumatismo. Tambien se objetiva un reducido numero de lineas de investigacion en politraumatismos, a pesar de la vinculacion universitaria de los centros.

espanolIntroduccion: la pancreatitis aguda es una enfermedad con tendencia a recurrir, sobre todo si persiste la causa que la desencadena. Nuestro objetivo es determinar la tasa de recurrencia de la pancreatitis aguda biliar tras un primer episodio y su intervalo de aparicion, asi como identificar los factores de riesgo de recidiva. Material y metodo: hemos incluido todos los pacientes ingresados por un primer episodio de pancreatitis aguda de origen litiasico durante cuatro anos. Las variables principales estudiadas fueron reingreso por recurrencia e intervalo de tiempo de aparicion del nuevo episodio. Resultados: hemos incluido 296 pacientes que han ingresado en un total de 386 ocasiones. La incidencia de la pancreatitis aguda biliar en nuestro medio es de 17,5/100.000 habitantes/ano. El 19,6% de las pancreatitis han sido graves (22,6% de pancreatitis agudas graves en el primer episodio vs. 3,6% en las pancreatitis recurrentes) con una mortalidad global del 4,4%. La tasa global de recurrencia ha sido del 15,5%, con un intervalo de tiempo de 82 dias de mediana. El 14,2% de los pacientes han presentado recurrencia despues de un episodio de pancreatitis sin que se les hubiera realizado colecistectomia o colangio-pancreatografia retrograda endoscopica. Las pancreatitis agudas graves recurren un 7,2% mientras que las leves lo hacen el 16,3%, siendo este el unico factor de riesgo de recurrencia hallado. Conclusiones: los pacientes ingresados por pancreatitis deberian ser colecistectomizados a la mayor brevedad posible o ser priorizados en la lista de espera. En su defecto, una alternativa a la cirugia podria ser la colangio-pancreatografia retrograda endoscopica con esfinterotomia en casos seleccionados. EnglishIntroduction: Acute pancreatitis is often a relapsing condition, particularly when its triggering factor persists. Our goal is to determine the recurrence rate of acute biliary pancreatitis after an initial episode, and the time to relapse, as well as to identify the risk factors for recurrence. Material and method: We included all patients admitted for a first acute gallstone pancreatitis event during four years. Primary endpoints included readmission for recurrence and time to relapse. Results: We included 296 patients admitted on a total of 386 occasions. The incidence of acute biliary pancreatitis in our setting is 17.5/100,000 population/year. In all, 19.6% of pancreatitis were severe (22.6% of severe acute pancreatitis for first episodes versus 3.6% for recurring pancreatitis), with an overall mortality of 4.4%. Overall recurrence rate was 15.5%, with a median time to relapse of 82 days. In total, 14.2% of patients relapsed after an acute pancreatitis event without cholecystectomy or endoscopic retrograde cholangio-pancreatography. Severe acute pancreatitis recur in 7.2% of patients, whereas mild cases do so in 16.3%, this being the only risk factor for recurrence thus far identified. Conclusions: Patients admitted for pancreatitis should undergo cholecystectomy as soon as possible or be guaranteed priority on the waiting list. Otherwise, endoscopic retrograde cholangio-pancreatography with sphincterotomy may be an alternative to surgery for selected patients.

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.

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.

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.