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Resumen Antecedentes y objetivo El cancer tiroideo puede manifestarse clinicamente por la presencia de un nodulo cervical, o constituir un hallazgo casual en el estudio histologico de la glandula extirpada con diagnostico, a priori, benigno. El objetivo del presente estudio fue estudiar las diferencias clinicas, de manejo quirurgico y curso evolutivo entre los tumores tiroideos incidentales y los tumores detectados clinicamente. Material y metodos Estudio retrospectivo de pacientes intervenidos por enfermedad tiroidea, ya fuese benigna o maligna, en el periodo comprendido entre enero de 2000 y marzo de 2014. De 1.415 pacientes que se sometieron a algun tipo de cirugia tiroidea se identificaron un total de 264 neoplasias, de las cuales 170 fueron incidentales. Se realizo comparacion entre carcinomas incidentales versus no incidentales. Ademas, entre los incidentales se compararon los casos cuya indicacion quirurgica fue enfermedad de Graves frente a bocio multinodular. Resultados Los carcinomas incidentales presentaron estadios mas precoces y requirieron cirugia menos agresiva. No se observaron diferencias en las complicaciones quirurgicas entre ambos grupos, aunque tanto la mortalidad como las tasas de recidiva fueron notablemente mayores en el grupo de no incidentales (4,4% vs 0% y 13,2% vs 4,8% respectivamente). Los carcinomas desarrollados sobre enfermedad de Graves no mostraron diferencias respecto al resto de los tumores incidentales, respecto a complicaciones, mortalidad o recidiva tras la cirugia. Conclusiones El cancer tiroideo en estadios iniciales presenta mayor supervivencia y mejor respuesta al tratamiento quirurgico.

Background and objective Thyroid cancer may be clinically evident as a tumor mass in the neck or as a histopathological incidental finding after thyroid surgery for an apparent benign condition. Our objective was to assess the differences in clinical signs, surgical management, and course between incidental and clinically diagnosed thyroid tumors. Methods A retrospective study was conducted on patients operated on for benign or malignant thyroid disease from January 2000 to March 2014. Among the 1415 patients who underwent any thyroid surgery, 264 neoplasms were found, of which 170 were incidental. A comparison was made of incidental versus non-incidental carcinomas. Among incidental carcinomas, cases whose indication for surgery was Graves’ disease were compared to those with multinodular goiter. Results Incidental carcinomas were in earlier stages and required less aggressive surgery. There were no differences in surgical complications between incidental and clinical tumors, but mortality and relapses were markedly higher in non-incidental cancers (4.4% vs 0% and 13.2% vs 4.8% respectively). Carcinomas developing on Graves’ disease showed no differences from all other incidental tumors in terms of complications, mortality, or relapse after surgery. Conclusions Early stage thyroid cancer has better survival and prognosis after surgical treatment.

Resumen Objetivos La hemorragia digestiva alta (HDA) es una potencial complicacion tras la cirugia bariatrica, con una incidencia entre el 2 y el 4%. El objetivo de este estudio es presentar nuestra incidencia de HDA tras cirugia bariatrica, su forma de presentacion y su manejo mediante un algoritmo terapeutico. Pacientes y metodo Estudio observacional prospectivo de una serie de 300 cirugias bariatricas por laparoscopia de manera consecutiva, desde enero del 2004 hasta diciembre del 2012. Se recogen datos demograficos, forma de presentacion, diagnostico y tratamiento de la HDA. En 280 pacientes se practico bypass gastrico segun la tecnica de Wittgrove modificada, con anastomosis circular en 265 y anastomosis longitudinal en 15. En 20 pacientes se practico gastrectomia vertical. Resultados Aparecieron 27 casos (9%) de HDA tratados con: cirugia en un caso por inestabilidad hemodinamica; con gastroscopia diagnostica-terapeutica en 13 casos (en 2 casos, 2 veces); en 10 de ellos, aparecio de forma precoz (1-6 dias) cuyo origen fue la linea de sutura de la anastomosis gastroyeyunal (GY) y en 3 de forma tardia, a los 15-20 dias, siendo su origen una ulcera en la boca anastomotica. En el resto (13 pacientes), el manejo fue de forma conservadora. Conclusiones Aunque el manejo conservador de la HDA resuelve la mayoria de los casos, la clinica y la forma de presentacion deben alertarnos, por lo que, en casos graves de sangrado, se requerira de una endoscopia urgente. Es importante un equipo multidisciplinar y una comunicacion estrecha entre cirujanos y endoscopistas para el manejo de esta seria complicacion.

Gastrointestinal bleeding (GB) is a potential complication after bariatric surgery and its frequency is around 2-4% according to the literature. The aim of this study is to present our experience with GB after bariatric surgery, its presentation and possible treatment options by means of an algorithm.From January 2004 to December 2012, we performed 300 consecutive laparoscopic bariatric surgeries. A total of 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of a gastrojejunal anastomosis using a circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. Demographics, clinical presentation, diagnostic evaluation and treatment were reviewed. A total of 20 patients underwent a sleeve gastrectomy.Twenty-seven cases (9%) developed GB. Diagnosis and therapeutic endoscopy was required in 13 patients. The onset of bleeding occurred between the 1(st)-6(th) postop days in 10 patients, and the origin was at the gastrojejunostomy staple-lines, and 3 patients had bleeding from an anastomotic ulcer 15-20 days after surgery. All other patients were managed non-operatively.Conservative management of gastrointestinal bleeding is effective in most cases, but endoscopy with therapeutic intent should be considered in patients with severe or recurrent bleeding. Multidisciplinary postoperative follow- up is very important for early detention and treatment of this complication.

Resumen Introduccion La estenosis de la anastomosis gastroyeyunal (GY) representa la complicacion mas frecuente en la cirugia de derivacion gastrica por laparoscopia, llegando en algunas series a alcanzar el 15%. Presentamos nuestra incidencia de estenosis de la anastomosis GY en el bypass gastrico laparoscopico, su forma de presentacion y su manejo a largo plazo. Material y metodo Desde enero del 2004 hasta diciembre del 2012 se han realizado 280 bypass gastricos por la laparoscopia, segun la tecnica de Wittgrove modificada. La anastomosis GY circular se practico con material de autosutura tipo CEAA n.° 21 en 265 casos, en los restantes se realizo con una anastomosis longitudinal con grapadora lineal de 45 mm. A todos los pacientes con intolerancia persistente a la alimentacion se les realizo transito baritado o gastroscopia. Cuando se evidencio estenosis GY (diametro Resultados En 20 casos (7,1%) se desarrollo una estenosis GY, en 4 de ellos el diagnostico inicial fue con transito baritado. Todos los casos fueron confirmados por gastroscopia. De ellos, 5 pacientes tenian antecedentes de hemorragia digestiva alta que precisaron esclerosis endoscopica de la linea de sutura de la anastomosis GY. Todos los casos se han resuelto mediante dilatacion endoscopica, precisando en un caso 2 sesiones de dilatacion, en otro caso 3 sesiones y el resto, una. No se han detectado reestenosis. Uno de los pacientes sufrio una perforacion de ulcera postanastomotica. Conclusiones La estenosis de la anastomosis GY es una complicacion frecuente tras el bypass gastrico en Y de Roux. Favorecida por anastomosis de pequeno calibre. La endoscopia es la piedra angular para el diagnostico y tratamiento, pues resuelve la mayoria de casos, siendo rara la revision quirurgica.

Objective Gastrojejunal stricture (GYS), is not only a common complication after laparoscopic gastric bypass, but its frequency is also about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass. Patients and method From January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis, which was performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance barium transit and/or gastroscopy were performed. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation. Results Twenty cases (7.1%) developed a gastrojejunal stricture; in 4 of these cases the initial diagnosis was made by barium transit and all cases were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up re-stricture has not been detected. Conclusion Stricture at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.

Background Body contouring surgery is in high demand following the increase in bariatric surgery. But these types of procedures are associated with high complication rates that cause long hospital stays and have a negative effect on patient satisfaction. The purpose of this study is to identify predictors of complications in order to optimize outcomes in these patients and find a relationship between complication rate and satisfaction. Materials and methods Out of a group of 175 post-bariatric patients, 72 patients underwent body contouring surgery following massive weight loss from 2003 to 2008. They were reviewed retrospectively for demographic data, pre- and postoperative weight status, co-morbidities and complications and reoperation rate. Patient satisfaction was evaluated. Results (a) Complications: The overall complication rate was 45.8%. The most frequent were seromas (23.6%); infection (13.9%), bleeding (11.1%), hematoma (6.9%) (needing transfusions [6.9%]), skin necrosis (6.9%) and umbilical necrosis (4.2%). A total of 8 patients required reoperation (11.1%). (b) Satisfaction rating: (1) very satisfied: 51.4%, (2) satisfied: 31.9%, (3) dissatisfied: 8.3%, (4) very dissatisfied: 8.3%. (c) The presence of complications was significantly associated with patients’ satisfaction, reoperation rate and longer hospital stays ( P 001). Conclusions Post operative complications were frequent. No predictors could be found to prevent these complications and optimize patient selection and appropriate timing of surgery. Patients with complications had a significantly higher reoperation rate, longer hospital stay and more dissatisfaction. The patients’ satisfaction was negatively influenced by complication occurrence and not by the esthetic results.

Resumen Introduccion Las abdominoplastias se han convertido en un proceso quirurgico frecuente en pacientes con perdida masiva de peso tras cirugia bariatrica. Este tipo de procedimientos no estan exentos de complicaciones que afectan a la calidad de vida y satisfaccion del paciente. El objetivo de este estudio es encontrar los factores de riesgo para desarrollar dichas complicaciones y evaluar la satisfaccion de nuestros pacientes. Material y metodos A un total de 72 pacientes, de los 175 intervenidos de cirugia bariatrica, se les realizo una abdominoplastia entre 2003 y 2008. Fueron revisados, retrospectivamente: datos demograficos, estado pre- y poscirugia, comorbilidades, tasa de complicaciones y reintervencion. El nivel de satisfaccion fue medido mediante una encuesta expresada en una escala tipo Likert. Se realizo un analisis comparativo de las distintas variables entre pacientes con y sin complicaciones. Resultados a) Complicaciones: tasa global del 45,5%. La mas frecuente fue el seroma (23,6%); infeccion (13,9%), sangrado (11,1%), hematoma (6,9%) (requiriendo transfusion [6,9%]), necrosis de piel (6,9%) y necrosis umbilical (4,2%). Se reintervino a 8 pacientes (11,1%). b) Satisfaccion: 1) muy satisfecho: 51,4%; 2) satisfecho: 31,9%; 3) insatisfecho: 8,3%; 4) muy insatisfecho: 8,3%. c) Se encuentra una relacion estadisticamente significativa entre complicaciones, reintervencion, estancia media y satisfaccion (p Conclusion Las complicaciones son relativamente frecuentes en este tipo de pacientes, alargando la estancia media y posteriores controles ambulatorios. No hemos identificado factores de riesgo que ayuden a prevenir este tipo de complicaciones. El grado de insatisfaccion esta en relacion con las complicaciones postoperatorias del procedimiento quirurgico y no con el resultado estetico.

Background context Surgery for disc herniation is one of the most common traumas and neurosurgical procedures. Although discectomy has low morbidity, serious intra-abdominal complications can affect retroperitoneal structures, such as the large vessels, small intestine, and ureters. Case report A 36-year-old woman in uncontrollable pain presented with left sciatic neuralgia in the L5 region. Magnetic resonance imaging revealed an extruded left paracentral hernia at L5–S1. With the patient in the decubitus prone position, trauma surgeons specializing in spine surgery performed an L5–S1 flavectomy and a simple discectomy. Intraoperative complications were not observed. About 4 hours after surgery, the patient reported sharp abdominal pain and had persistent hypotension. Emergency abdominal computed tomography showed hemoperitoneum in the pouch of Douglas and left parietocolic space. Laparoscopic exploration confirmed hemoperitoneum without visible cause, a seton perforation of the small intestine, and a few adhesions in the right iliac fossa that were consequences of previous appendectomy. A laparotomy was then performed. A lesion was discovered in the mesentery of the rectosigmoid junction coinciding with the S5–L1 space. A segmental bowel resection and mechanical side-to-side anastomosis, with drainage, were done. The patient recovered satisfactorily despite a surgical wound infection. Discussion Although bowel perforation after discectomy rarely occurs, spine surgeons must try to prevent them by being more cautious during surgery. General surgeons must be highly suspicious of the presence of an intra-abdominal complication when there are signs and symptoms of a postoperative acute abdomen.

Resumen Introduccion Las vias clinicas son planes asistenciales integrales y sistematizados para determinados procesos. En marzo de 2002 se implanto en nuestro servicio la via clinica de la colecistectomia laparoscopica. El objetivo de este trabajo es presentar la evaluacion de la via clinica de dicho proceso tras 1 ano de implantacion. Metodologia Se ha estudiado a todos los pacientes incluidos en la via clinica desde su implantacion. Los criterios de evaluacion incluyen el grado de cumplimiento, los indicadores de efectividad en la atencion clinica, el impacto economico y los indicadores de satisfaccion basados en una encuesta. Los resultados se comparan con la serie de pacientes intervenidos durante el ano previo a la implantacion de la via clinica. En nuestro hospital se realiza gestion analitica y hemos analizado el gasto medio por proceso antes y despues de la implantacion de la via clinica. Resultados Se ha evaluado una serie de 160 pacientes consecutivos intervenidos durante 1 ano previo a la elaboracion de la via clinica que cumplieran los criterios de inclusion aceptados, con una estancia media de 3,27 dias. El gasto medio por proceso antes de la implantacion de la via fue de 2.149 ± 768 euros. Tras la implantacion de la via clinica y despues de 1 ano se ha incluido a 140 pacientes, con un porcentaje de inclusion del 100%. La estancia media de los pacientes incluidos en la via clinica fue de 2,2 dias. El grado de cumplimiento de las estancias ha sido del 66,7%. Las causas mas frecuentes de incumplimiento han sido las dependientes del personal, seguidas de las dependientes del paciente (intolerancia oral, dolor, etc.). El gasto medio en la serie de pacientes incluidos en la via clinica ha sido de 1.845 ± 618 euros. Conclusiones La colecistectomia laparoscopica es un proceso idoneo para iniciar la sistematizacion de las vias clinicas. Los resultados evidencian que se ha conseguido disminuir de forma significativa la estancia hospitalaria y el gasto medio por proceso sin aumentar la morbilidad y con un alto grado de satisfaccion de los pacientes.

Resumen Introduccion. Las vias clinicas son herramientas que facilitan la atencion sistematica y multidisciplinaria del paciente. Son especialmente utiles en procesos frecuentes y con un curso clinico predecible, en los que encontramos una elevada variabilidad en su asistencia. El objetivo de este trabajo es presentar los resultados de la evaluacion de la via clinica de la tiroidectomia tras 5 meses de implantacion. Pacientes y metodo Entre octubre de 2001 y marzo de 2002 fueron intervenidos 44 pacientes por enfermedad tiroidea (35 tiroidectomias totales y nueve hemitiroidectomias). Los resultados se comparan con una serie obtenida de un muestreo aleatorio estratificado de 56 pacientes operados previamente a la implantacion de la via clinica. La via contempla una estancia media de 2 dias en la hemitiroidectomia, y de 3, en la tiroidectomia total. Se incorpora a la via clinica un protocolo de tratamiento de reposicion de calcio asociado con la tiroidectomia total. Se establecen como indicadores: la estancia hospitalaria, los efectos adversos y los resultados de la encuesta de satisfaccion a los pacientes. Resultados La estancia media de los pacientes con hemitiroidectomia fue de 3,3 dias antes de la implantacion de la via clinica y de 2,4 tras esta, y la de los pacientes con tiroidectomia total fue de 4,3 dias antes de la via clinica y de 3,4 dias despues de esta, con diferencias estadisticamente significativas en ambos procesos. No hubo diferencias en cuanto aefectos adversos antes o despues de la implantacion de la via clinica. Al 93,2% de los pacientes le parecioadecuado el tiempo de ingreso en el hospital. Conclusiones La implantacion de la via clinica de la tiroidectomia ha conseguido disminuir la variabilidad clinica y, con ello, acortar la estancia hospitalaria, todo ello sin aumentar las complicaciones y con un alto grado de satisfaccion de los pacientes.

Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass, but its frequency is about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass.From January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis is performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation.Twenty cases (7.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and all case were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up has not been detected re-stricture.Structure at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.

Resumen La hernia de Morgagni es una rara variedad de hernia diafragmatica, con frecuencia descubierta en la edad adulta, cuyo tratamiento es mayoritariamente quirurgico. Presentamos el caso de un paciente de 65 anos con una hernia de Morgagni gigante, con un defectodiafragmatico de 12 × 7 cm, tratado por laparoscopia mediante la colocacion de una malla bilaminar intraabdominal. Ademas se revisa el tratamiento actual de esta patologia, en el que la laparoscopia comienza a ocupar un lugar predominante.

Perianal hidradenitis suppurativa is a chronic recurrent inflammatory, suppurating, and fistulizing disease of apocrine glands, adjacent anal canal skin, and soft tissues. The standard treatment used for extensive cases is a staged surgical procedure allowing the wound to heal by secondary intention or the delayed use of skin grafts.A long-standing case, disabling for the patient, with extensive involvement of the buttock region, treated in one stage, which for reconstruction required the use of sliding plasties and free skin grafts, is reported.The outcome was satisfactory. Primary closure after wide excision using plastic-surgery techniques may help us resolve complex situations and obtain good results and a rapid recovery.The method of closure with a combination of skin flaps and skin graft in one stage can be considered a valid surgical option for a group of patients with extensive perianal hidradenitis.

Intestinal invagination in adults is an uncommon but potentially serious condition that is usually diagnosed during surgery by the presence of a mechanical obstructive syndrome. We report a series of adults with intestinal invagination and discuss preoperative diagnosis and surgical procedures.We analyzed the files of all the seven patients aged over 18 years with a postoperative diagnosis of intestinal invagination and treated at our center between 1996 and 2000.Preoperative causal diagnosis was established in six cases by ultrasonography and computed tomography. All the patients received surgery, three as emergency and four programmed. The lesions causing the invagination were: three benign (Meckel's diverticulum, inflammatory pseudotumor, fibroid polyp) and one malignant (degenerative villous adenoma polyp) located in the terminal ileum, two malignant lesions in the cecum (both adenocarcinomas over a polyp), and in the remaining case a double lymphoma of the jejunum and ileum. The intussusceptions were ileoileal in three cases and ileocolic in four. We performed intestinal resection in six cases and one excision of Meckel's diverticulum.Preoperative diagnosis of intussusception was possible in most cases. Sonography and computed tomography proved the most effective and useful preoperative diagnostic methods. In adults colonic invagination is almost always malignant while small bowel is almost always benign. Invagination in adults must be clarified by surgery, and intestinal resection is the procedure of choice.

The aim of this study is to present the evaluation and monitoring of a clinical pathway for thyroidectomy 1 year after its implementation and after 4 years’ follow up. We compare the results of an evaluation and monitoring indicators series before and after the establishment of the clinical pathway for thyroidectomy in the Surgery Department of Morales Meseguer Hospital, a general university hospital in Murcia, Spain. Implementation of the clinical pathway led to a reduction in length of hospital stay for all the surgery patients (4.8 ± 2.1 and 3.6 ± 1.9 days before and after pathway implementation, respectively; P < 0.001). Implementation of the clinical pathway led to a reduction in cost in all the operated patients (3357 ± 966 and 2695 ± 970 US$ before and after implementing the clinical pathway, respectively; P < 0.001). Evolution of the mean hospital cost according to year of study shows a reduction from 2000 (3400 ± 1056 US$) to 2004 (2404 ± 666 US$) with a slight increase during 2005 (2721 ± 1335 US$) (P < 0.001). Implementation of the clinical pathway for thyroidectomy has successfully reduced clinical variation and therefore the length of hospital stay and mean cost of the process. In subsequent years, no such major improvements have been made with regard to hospital stay, although they are still clearly better than those before pathway implementation.