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Resumen Introduccion El objetivo principal de nuestro estudio es valorar la seguridad y la eficacia de la colecistostomia percutanea para el tratamiento de la colecistitis aguda determinando la incidencia de efectos adversos que presentan los pacientes sometidos a este procedimiento. Material y metodo Estudio observacional con inclusion consecutiva de todos los pacientes con diagnostico de colecistitis aguda durante 10 anos. La variable principal estudiada ha sido la morbilidad (efectos adversos) recogida de forma prospectiva. Seguimiento minimo de un ano de los pacientes sometidos a colecistostomia percutanea. Resultados De 1.223 pacientes ingresados por colecistitis aguda, 66 pacientes han precisado colecistostomia percutanea. El 21% de estos han presentado algun efecto adverso, con un total de 22 efectos adversos. Tan solo 5 de estos efectos, presentados por 5 pacientes (7,6%), han podido ser atribuidos al propio drenaje vesicular. La mortalidad asociada a la tecnica es del 1,5%. Tras la colecistostomia un tercio de los pacientes (22 pacientes) han sido sometidos a colecistectomia. Se ha realizado intervencion quirurgica urgente por fracaso del tratamiento percutaneo en 2 pacientes, y diferida en otros 2 pacientes por recidiva del proceso inflamatorio. El resto de los pacientes colecistectomizados han sido intervenidos de forma programada pudiendose llevar a cabo el procedimiento de forma laparoscopica en 16 pacientes (72,7%). Conclusion Consideramos la colecistostomia percutanea como tecnica segura y eficaz por relacionarse con una baja incidencia de morbimortalidad, debiendose considerar como alternativa puente o definitiva en aquellos pacientes no tributarios de colecistectomia urgente tras fracaso del tratamiento conservador con antibiotico.

Objective Mild AD can be treated safely and effectively on an outpatient basis without antibiotics. Summary of background data In recent years, it has shown no benefit of antibiotics in the treatment of uncomplicated AD in hospitalized patients. Also, outpatient treatment of uncomplicated AD has been shown to be safe and effective. Methods A Prospective, multicentre, open-label, noninferiority, randomized controlled trial, in 15 hospitals of patients consulting the emergency department with symptoms compatible with AD.The Participants were patients with mild AD diagnosed by Computed Tomography meeting the inclusion criteria were randomly assigned to control arm (ATB-Group): classical treatment (875/125 mg/8 h amoxicillin/clavulanic acid apart from anti-inflammatory and symptomatic treatment) or experimental arm (Non-ATB-Group): experimental treatment (antiinflammatory and symptomatic treatment). Clinical controls were performed at 2, 7, 30, and 90 days.The primary endpoint was hospital admission. Secondary endpoints included number of emergency department revisits, pain control and emergency surgery in the different arms. Results Four hundred and eighty patients meeting the inclusion criteria were randomly assigned to Non-ATB-Group (n = 242) or ATB-Group (n = 238). Hospitalization rates were: ATB-Group 14/238 (5.8%) and Non-ATB-Group 8/242 (3.3%) [mean difference 2.58%, 95% confidence interval (CI) 6.32 to -1.17], confirming noninferiority margin. Revisits: ATB-Group 16/238 (6.7%) and Non-ATB-Group 17/242 (7%) (mean difference -0.3, 95% CI 4.22 to -4.83). Poor pain control at 2 days follow up: ATB-Group 13/230 (5.7%), Non-ATB-Group 5/221 (2.3%) (mean difference 3.39, 95% CI 6.96 to -0.18). Conclusions Nonantibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment. Trial registration ClinicalTrials.gov (NCT02785549); EU Clinical Trials Register (2016-001596-75).

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

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

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

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

Background Telomere length (TL) is one biomarker of cell aging used to explore the effects of the environment on age-related pathologies. Obesity and high body mass index have been identified as a risk factors for shortened TL. Objective To evaluate TL in different subtypes of obese patients, and to examine changes in TL in relation to weight loss after bariatric surgery. Setting University Hospital in Spain. Methods A cohort of 94 patients submitted to bariatric surgery were followed-up during 24 months (t24m: lost to follow-up = 0%). All patients were evaluated before surgery (t0) and during the postoperative period (t6m, t12m, and t24m) for body mass index and metabolic variables. We assessed TL at each timepoint using quantitative polymerase chain reactions and the telomere sequence to single-copy gene sequence ratio method. Results Patients with class III obesity showed significantly shorter TL at baseline than those patients with class II obesity (P = .027). No differences in TL were found between patients with or without type 2 diabetes or metabolic syndrome. Longitudinal analysis did not show an effect of time, type of surgery, age, or sex on TL. However, a generalized estimating equation model showed that TL was shorter amongst class III obesity patients across the time course (P = .008). Comparison between patients with obesity class II and class III showed differences in TL at t6m (adjusted P = .024), whereby class II patients had longer TL. However, no difference was observed at the other evaluated times. Conclusion Obesity severity may have negative effects on TL independently of type 2 diabetes or metabolic syndrome. Although TL is significantly longer in class II obesity patients relative to class III 6 months after bariatric surgery. This difference is not apparent after 24 months.

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

Purpose Persistent occult hypoperfusion after initial resuscitation is strongly associated with increased morbidity and mortality after severe trauma. The objective of this study was to analyze regional tissue oxygenation, along with other global markers, as potential detectors of occult shock in otherwise hemodynamically stable trauma patients. Methods Trauma patients undergoing active resuscitation were evaluated 8 h after hospital admission with the measurement of several global and local hemodynamic/metabolic parameters. Apparently hemodynamically stable (AHD) patients, defined as having SBP ≥ 90 mmHg, HR 2) was measured non-invasively by near-infrared spectroscopy (NIRS) on the forearm. A vascular occlusion test was performed, allowing a 3-min deoxygenation period and a reoxygenation period following occlusion release. Minimal rSO2 (rSO2min), Delta-down (rSO2–rSO2min), maximal rSO2 following cuff-release (rSO2max), and Delta-up (rSO2max–rSO2min) were computed. The NIRS response to the occlusion test was also measured in a control group of healthy volunteers. Results Sixty-six consecutive trauma patients were included. After 8 h, 17 patients were classified as AHD, of whom five were finally considered to have OS and 12 THD. No hemodynamic, metabolic or coagulopathic differences were observed between the two groups, while NIRS-derived parameters showed statistically significant differences in Delta-down, rSO2min, and Delta-up. Conclusions After 8 h of care, NIRS evaluation with an occlusion test is helpful for identifying occult shock in apparently hemodynamically stable patients. Level of evidence IV, descriptive observational study. Trial registration ClinicalTrials.gov Registration Number: NCT02772653.

INTRODUCTION Spleen is frequently damaged in abdominal trauma. Patients with splenic injury with hemodynamic instability, peritonism signs or other surgical injuries need emergent surgery. Hemodynamically stable patients are treated conservatively. Splenic embolization is indicated in injuries with blush, pseudoaneurysms or arteriovenous fistulas. It is unclear its indication in IV and V-grade splenic injuries without contrast extravasation. Our hypothesis is that IV and V-grade splenic injuries embolization decreases conservative treatment failure. MATERIAL AND METHODS Retrospective observational study, including all patients with blunt splenic injuries, prospectively included in our registry of polytraumatic patients (>16 years) since 2006. RESULTS One hundred and seventy patients have been included since 2006. In 2006-2013, when splenic injuries with active bleeding, pseudoaneurysms or arteriovenous fistulas were embolized, 94 patients were included. 37,2% required surgery and 62,8% conservative treatment. Splenic embolization was performed in 17% of patients who were treated conservatively. Conservative treatment failure was 16,9%: 10 cases out of those who underwent medical treatment (4 required embolization and 6 needed surgery). From 2014 to the present, when IV and V-grade injuries were included in the indications for embolization, 76 patients have been included. 38,2% required surgery and 61,8% were treated conservatively (40,4% were embolized and the rest were treated medically). One case (3,6%) of those treated medically and another (5,3%) of those embolized failed. Overall failure of conservative treatment was 4,3%. CONCLUSION Embolization of IV and V-grade splenic injuries decreases conservative treatment failure from 16,9% to 4,3%.

Resumen Introduccion Las constantes vitales detectan la presencia de hemorragia al perder grandes cantidades de sangre, lo que comporta una gran morbimortalidad. El Shock Index (SI) es un parametro que detecta el sangrado con puntos de corte de 0,9. El objetivo de este estudio es valorar si un punto de corte de ≥ 0,8 es mas sensible para detectar sangrado oculto, permitiendo iniciar maniobras terapeuticas mas precoces. Metodos Estudio analitico de validacion del SI que incluye pacientes politraumatizados graves mayores de 16 anos. Se registran constantes vitales y escalas predictivas de sangrado: SI, Assessment of Blood Consumption score y Pulse Rate Over Pressure score. Se analiza la relacion del SI con 5 marcadores predictivos de sangrado: necesidad de transfusion masiva, embolizacion angiografica, control del sangrado quirurgico, muerte por shock hipovolemico y «sangrado activo» (presencia de al menos uno de los 4 marcadores anteriores en un paciente). Resultados Recogida prospectiva de datos de 1.402 pacientes politraumatizados durante 10 anos. El Injury Severity Score medio fue de 20,9 (DE 15,8). Hubo una mortalidad del 10%. El SI medio fue de 0,73 (DE 0,29). En total presentaron «sangrado activo» el 18,7% de la serie. El SI medio en los pacientes con «sangrado activo» fue de 0,87, mientras que las constantes vitales estaban dentro de la normalidad. El area bajo la curva ROC del SI para el «sangrado activo» fue de 0,749. Conclusiones El SI con un punto de corte ≥ 0,8 es mas sensible que aquel con el punto de corte ≥ 0,9 y permite iniciar maniobras de reanimacion mas precoces en los pacientes con sangrado oculto.

Introduction Vital signs indicate the presence of bleeding only after large amounts of blood have been lost, with high morbidity and mortality. The Shock Index (SI) is a hemorrhage indicator with a cut-off point for the risk of bleeding at 0.9. The aim of this study is to assess whether a cut-off of ≥0.8 is more sensitive for detecting occult bleeding, providing for early initiation of therapeutic maneuvers. Methods SI analytical validation study of severe trauma patients older than 16 years of age. Vital signs were recorded, and scales for predicting bleeding included: SI, Assessment of Blood Consumption score, and Pulse Rate Over Pressure score. The relationship between the SI and 5 markers for bleeding was analyzed: need for massive transfusion, angiographic embolization, surgical bleeding control, death due to hypovolemic shock, and the overall predictor “active bleeding” (defined as the presence of at least one of the 4 markers above). Results Data from 1402 trauma patients were collected prospectively over a period of 10 years. The mean Injury Severity Score was 20.9 (SD 15.8). The mortality rate was 10%. The mean SI was 0.73 (SD 0.29). “Active bleeding” was present in 18.7% of patients. The SI area under the ROC curve for “active bleeding” was 0.749. Conclusions An SI cut-off point ≥0.8 is more sensitive than ≥0.9 and allows for earlier initiation of resuscitation maneuvers in patients with occult active bleeding.

The main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure.Observational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy.Of 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%).We consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment.

Perforation in the peritoneal cavity during transanal endoscopic microsurgery represents a major challenge. It is usually treated by primary suture, though some authors propose laparoscopic repair with or without ostomy. It is unclear whether perforation increases the risk of tumor dissemination. The purpose of the study is to assess the safety of primary suture of peritoneal perforation and the long-term risk of dissemination, also, to determine risk factors for perforation and to propose a predictive model for lesions with risk of perforation. This is an observational study with prospective data collection at Parc Tauli University Hospital, Sabadell, of patients undergoing transanal surgery with perforation into the peritoneal cavity from June 2004 to September 2017. The main variable is postoperative morbidity and mortality. The long-term follow-up of local recurrence and peritoneal tumor dissemination is described, and a quantitative predictive model for peritoneal cavity perforation is proposed. Forty-five patients out of 686 (6.6%) presented perforation into the peritoneal cavity. Ten patients (22.2%) in the perforation group had morbidity, a rate similar to the non-perforated group. There was no peritoneal dissemination in patients with adenoma or with carcinoma treated with curative intent. In the quantitative predictive model, risk factors for perforation were proximal edge of tumor > 14 cm from anal verge (6 points), size ≥ 6 cm (2), age ≥ 85 years (4), anterior quadrant (3) , and sex (2). Total scores of ≥ 6 points predicted perforation. Primary suture after peritoneal cavity perforation during transanal surgery is safe and does not increase the risk of recurrence or peritoneal dissemination. Our predictive model provides guidance regarding the risk of perforation and the need to suture the defect after transanal surgery resection.

Background: Subcutaneous (s.c.) glucose sensors have become a key component in type 1 diabetes management. However, their usability is limited by the impact of foreign body response (FBR) ...

Endorectal ultrasound (ERUS) is considered the technique of choice for selecting patients for transanal endoscopic surgery (TEM). The aim of this study was to evaluate the accuracy of ERUS in patients with rectal tumors who later underwent TEM, and to analyze the factors that influence this accuracy. Observational study including prospective data collection of patients with rectal tumors undergoing TEM with curative intent between June 2004 and May 2016. Preoperative staging by EUS (uT) was correlated with the pathology results after TEM (pT). The accuracy of the EUS was evaluated and a series of variables (tumor morphology, height, lesion size, quadrant, definitive pathology, the surgeon assessing the ERUS, and waiting time from the date of the ERUS until surgery) were analyzed as possible predictors of diagnostic accuracy. Six hundred and fifty-one patients underwent TEM, of whom 495 met the inclusion criteria. The overall accuracy of EUS was 78%, sensitivity 83.78%, specificity 20%, PPV 91.3%, and NPV 11%. Forty patients (8.08%) were understaged and 50 (10.9%) were overstaged. In the multivariate analysis, the surgeon’s experience emerged as the most important predictor of accuracy (p

Introduction The aim is comparing the quality of care at a typical American trauma center (USC) vs an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths. Methods Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy. Results The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P = .06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P=.001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was ‘knowledge-based’ (44%). In contrast, at the SRC center the most common errors were ‘rule-based’ (58%) (P Conclusions The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and ‘ruled-based’ errors have been found in the Spanish center.

Resumen Introduccion El objetivo del estudio es comparar la calidad asistencial de un trauma center americano (USC) vs. un centro equivalente de referencia europeo (SRC) en Espana, a traves del analisis de la mortalidad evitable. Metodos Estudio comparativo que evalua pacientes politraumatizados mayores de 16 anos que han sido exitus durante su hospitalizacion. Se han identificado las muertes evitables o potencialmente evitables, analizando los errores en el manejo, clasificandolos segun la taxonomia de la Joint Comission . Resultados La incidencia de mortalidad evitable y potencialmente evitable fue del 7,7% en el USC, y del 13,8% en el SRC. Segun la taxonomia de la Joint Comission , el principal tipo de error fue clinico en ambos centros, debido a errores de intervencion (tratamiento). Los errores ocurren en urgencias y fueron causados por medicos. En el USC, el 73% de los errores fue de tipo terapeutico comparado con el 59% en el SRC (p = 0,06). El SRC tuvo un 41% de errores diagnosticos vs. solo el 18% en el USC (p = 0,001). En ambos centros, el principal tipo de error fue humano, siendo tipo knowledge-based el mas frecuente en el USC (44%) vs. rule-based en el SRC (58%) (p Conclusiones El uso de un lenguaje comun para analizar los errores de manejo es una clave esencial para establecer puntos de referencia estandares y universales. Comparando la calidad asistencial de un trauma center americano con la de un centro de referencia espanol, hemos detectado unos errores evitables extraordinariamente parecidos. Se han hallado mas errores diagnosticos y de tipo ruled-based en el centro espanol.

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

Resumen Introduccion En la actualidad no se dispone de un conjunto adecuado de indicadores para benchmarking en las unidades de cirugia general del Sistema Nacional de Salud. Este trabajo presenta la seleccion, el desarrollo y los resultados del estudio piloto de un primer grupo de indicadores para esta finalidad. Metodos Se realizo una seleccion y priorizacion de indicadores mediante un Delphi modificado con un grupo de expertos de la Asociacion Espanola de Cirujanos. Los indicadores priorizados fueron sometidos a un estudio cualitativo de factibilidad y, para aquellos medidos por historia clinica, cuali-cuantitativo de fiabilidad en un hospital publico. Se obtuvieron resultados de concordancia simple y estadistico kappa, ajustado y no ajustado por prevalencias y sesgos, para 3 evaluadores con un muestreo aleatorio sistematico de 30 casos por indicador. Resultados De los 13 indicadores propuestos, 12 resultaron factibles (5 de historia clinica y 7 de bases de datos). De los 5 de historia, 3 resultaron fiables (concordancia interobservador > 95% o indice kappa > 0,6 para compuestos y subindicadores, o bien kappa ajustado por prevalencias y sesgos > 0,6 en presencia de prevalencias extremas) y 2 necesitaron ser redefinidos a partir de los resultados obtenidos. Conclusiones Los 5 indicadores de historia clinica podran utilizarse para comparar unidades quirurgicas, mientras que los 7 indicadores factibles de bases de datos necesitaran mayor validacion y ajuste de riesgo para permitir comparaciones entre servicios. Los resultados del centro evaluado muestran areas de mejora en algunos procesos de la atencion.

Background In a previous study, we found that Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) overpredicts morbidity risk in emergency gastrointestinal surgery. Our aim was to find a POSSUM equation adjustment. Methods A prospective observational study was performed on 2,361 patients presenting with a community-acquired gastrointestinal surgical emergency. The first 1,000 surgeries constituted the development cohort, the second 1,000 events were the first validation intramural cohort, and the remaining 361 cases belonged to a second validation extramural cohort. Results (1) A modified POSSUM equation was obtained. (2) Logistic regression was used to yield a statistically significant equation that included age, hemoglobin, white cell count, sodium and operative severity. (3) A chi-square automatic interaction detector decision tree analysis yielded a statistically significant equation with 4 variables, namely cardiac failure, sodium, operative severity, and peritoneal soiling. Conclusions A modified POSSUM equation and a simplified scoring system (aLicante sUrgical Community Emergencies New Tool for the enUmeration of Morbidities [LUCENTUM]) are described. Both tools significantly improve prediction of surgical morbidity in community-acquired gastrointestinal surgical emergencies.

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.

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.

Background A variety of systems have been applied to identify and address errors in the management of multiple trauma patients. This lack of standardisation represents a serious problem. Objectives Detect preventable and potentially preventable deaths, and classify all the errors with universal language. Methods We studied all trauma patients over 16 admitted to the critical care unit or who died before. In multidisciplinary sessions we decided which deaths were preventable, potentially preventable and non preventable. Guided by ATLS protocols, we detected errors in their management that were classified using the taxonomy of Joint Commission. Results We registered 1236 trauma patients (ISS 20.77). Of the 115 trauma deaths, 19 were preventable or potentially preventable deaths. We recorded 130 errors in all deaths, 46 of them in preventable or potentially preventable deaths. Using our own classification, the main errors were delay in starting correct treatment or performance of CT in hemodynamically unstable patients. Using the taxonomy of Joint Commission, the main type error was clinical, during the intervention: the delay in initiating correct treatment. Mistakes were made in the emergency department by medical specialists. The incidence of therapeutic and diagnostic errors was similar. The main cause of error was human failure, specifically ‘rule-based’ errors Conclusions Measuring and recording the results is the first step on the way to improving the quality of care for trauma patients. A common language like the taxonomy of Joint Commission will help standardise patient safety data, thus improving the recording of incidents and their analysis and treatment.

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.

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