Resección local transanal endoscópica de tumores rectales

La microcirugía endoscópica transanal (TEM) ha cambiado radicalmente la forma de entender el tratamiento de la patología tumoral del recto. La resección radical del recto ha sido durante años la única alternativa para pacientes con tumores rectales. La cirugía radical del recto tiene buenos resultados oncológicos a largo plazo, pero se acompaña de importantes complicaciones postoperatorias y un riesgo de mortalidad no despreciable. Además en muchas ocasiones se precisa de la realización de un estoma. Con el objetivo de evitar la morbimortalidad postoperatoria de la cirugía radical del recto, así como los problemas funcionales derivados de la misma, algunos pacientes seleccionados con tumores rectales cercanos al ano han sido sometidos a resección local por vía transanal directa o transperineal con resultados desalentadores en cuanto a recidivas y morbilidad a corto y largo plazo. La cirugía mediante TEM comenzó siendo una técnica indicada para pequeños tumores rectales localizados en el recto extraperitoneal y se ha ido extendiendo a tumores cada vez de mayor tamaño, más altos y más avanzados, con resultados dispares según las series. La literatura actual avala la resección local mediante TEM para tumores benignos o tumores malignos localizados del recto (T0 N0 – T1 N0). Sin embargo, las limitaciones técnicas y de disponibilidad en muchos centros hace que muchos pacientes sean sometidos a cirugía radical por esta patología..

Treatment for acute uncomplicated diverticulitis without antibiotherapy: systematic review and meta-analysis of randomized clinical trials

Background: Use of antibiotics in selected cases of acute uncomplicated diverticulitis (AUD) has recently been questioned. Objective: The aim of this study is to examine the safety and efficacy of treatment regimens without antibiotics compared with that of traditional treatments with antibiotics in selected patients with AUD. Data sources: PubMed, Medline, Embase, Web of Science, and the Cochrane Library Methods: A systematic review was performed according to PRISMA and AMSTAR guidelines by searching through Medline, Embase, Web of Science, and the Cochrane Library for randomized clinical trials (RCTs) published before December 2022. The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. Study selection: RCTs on treating AUD without antibiotics published in English before December 2022 were included. Intervention: Treatments without antibiotics were compared with treatments with antibiotics. Main outcome measures: The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. Results: The search yielded 1163 studies. Four RCTs with 1809 patients were included in the review. Among these patients, 50.1% were treated conservatively without antibiotics. The meta-analysis showed no significant differences between nonantibiotic and antibiotic treatment groups with respect to rates of readmission [odds ratio (OR) = 1.39; 95% CI: 0.93-2.06; P = 0.11; I-2 = 0%], change in strategy (OR = 1.03; 95% CI: 0.52-2,02; P = 0.94; I-2 = 44%), emergency surgery (OR = 0.43; 95% CI: 0.12-1.53; P = 0.19; I-2 = 0%), worsening (OR = 0.91; 95% CI: 0.48-1.73; P = 0.78; I-2 = 0%), and persistent diverticulitis (OR = 1.54; 95% CI: 0.63-3.26; P = 0.26; I-2 = 0%). Limitations: Heterogeneity and a limited number of RCTs. Conclusions: Treatment for AUD without antibiotic therapy is safe and effective in selected patients. Further RTCs should confirm the present findings

Usefulness of laboratory data in the management of right iliac fossa pain in adults.

International audiencePURPOSE: This study examined the usefulness of inflammatory markers in the management of patients with right iliac fossa pain. PATIENTS AND METHODS: A single site, prospective observational study was conducted from October 2001 to April 2003. Patients with right iliac fossa pain referred to the surgeon were included. Blood samples were obtained for C-reactive protein, leukocyte, and granulocyte analysis. Clinical, surgical, and histopathologic data were collected. Analysis of inflammatory parameters was performed with logistic regression and areas under the receiver operating characteristic curve were compared. RESULTS: C-reactive protein increased with the severity of appendicitis and predicted accurately perforation (r(2) = 0.613; P < 0.0005), showing the highest accuracy among inflammatory markers (areas under the receiver operating characteristics curve were 0.846, 0.753, and 0.685 for C-reactive protein, leukocyte and granulocytes, respectively; P < 0.001). Accuracy improved when C-reactive protein and leukocytes were combined; positive and negative predictive values were 93.2 percent and 92.3 percent, respectively. CONCLUSIONS: C-reactive protein is a helpful marker in the management of patients with right iliac fossa pain; the predictive value improves when combined with leukocyte count. A patient with normal C-reactive protein and leukocytes has a very low probability of appendicitis and should not undergo surgery

Antimicrobial Stewardship Programs Are Required in a Department of Surgery: "How" Is the Question A Quasi-Experimental Study: Results after Three Years

Objective: Our aim was to describe our antimicrobial stewardship program and the methodology based on the results in a surgical department. Methods: Our study was a quasi-experimental study conducted from January 1, 2009, through September 30, 2017. The site was the General and Digestive Surgery Department in a public primary referral center, the University Hospital of Getafe (Madrid, Spain). We implemented the antimicrobial stewardship program following a prospective audit and feedback model, with a surgeon incorporated into the manaagement group. We studied the deaths and 30-day re-admission rates, length of stay, prevalence of gram-negative bacilli, meropenem resistance, and days of treatment with meropenem. Results: After three years of the program, we recorded a significant decrease in Pseudomonas aeruginosa prevalence, a significant increase in Klebsiella pneumoniae prevalence, a decrease in meropenem resistance, and a reduction in meropenem days of treatment. Conclusions: Antimicrobial stewardship programs have a desirable effect on patients. In our experience, the program team should be led by a staff from the particular department. When human resources are limited, the sustainability, efficiency, and effectiveness of interventions are feasible only with adequate computer support. Finally, but no less important, the necessary feedback between the prescribers and the team must be based on an ad hoc method such as that provided by statistical control charts, a median chart in our study.MINECO ID project (TIN 2013-45491-R)2.150 JCR (2020) Q3, 125/211 Surgery0.773 SJR (2020) Q2, 135/293 Infectious DiseasesNo data IDR 2020UE

Programa de optimización de antibióticos en un servicio de Cirugía General y Digestiva: efecto sobre prescripción de meropenem en sus dos primeros de implantación

La resistencia antimicrobiana es una de las alertas sanitarias actuales. Su emergencia se relaciona con el aumento de consumo de antibióticos, especialmente significativo en carbapenémicos alcanzado casi un 40% de aumento, y en su uso no óptimo, llegando al 30-50% en el ámbito hospitalario. Las estrategias para la lucha contra la resistencia se dirigen al desarrollo de nuevos antibióticos, a medidas de control-prevención de infección y la optimización de su uso, donde encontramos los Programas de Optimización de Antibióticos (PROA). Actualmente se apela a la implicación de los cirujanos en este compromiso, siendo escasas las experiencias PROA centradas en Cirugía General y Digestiva. Esta es la primera experiencia nacional al respecto. En nuestro hospital se creó un grupo PROA (estrategia de auditoría prospectiva y feedback), incluyendo a un cirujano general y digestivo. El grupo revisa los tratamientos antimicrobianos y realiza recomendaciones sobre selección, dosis, duración o desescalado, que el especialista en cirugía transmite verbalmente al responsable, que la acepta o no. Se revisaron todos los pacientes ingresados consecutivamente en el servicio de Cirugía General y Digestiva de nuestro centro desde 01/2009 hasta 09/2016, en dos periodos: Pre-PROA: de 01/01/2009 a 30/09/2014, retrospectiva. Post-PROA: de 01/10/2014 a 30/09/2016, prospectiva. Los datos se recogieron mediante una base de datos informatizada (WASPSS: Wise Antimicrobial Stewardship Program), que integra base de datos informatizadas previamente, con capacidad de lectura retrospectiva y sostenible automáticamente. Se recogió la evolución temporal de la prescripción de carbapenémicos, medida en días de tratamiento (DOT × 1.000 ocupaciones/cama/día), en ambos periodos a estudio, en el servicio de Cirugía General y Digestiva. En la figura se muestra la evolución temporal de DOT de meropenem en el servicio de Cirugía General y Digestiva en periodo pre-PROA vs post-PROA. Se objetiva un descenso de nivel y tendencia en la prescripción de meropenem tras la implantación de PROA en nuestro servicio de Cirugía General y Digestiva. Conocer la situación de partida de la unidad/centro donde se va a implantar un PROA es fundamental para su éxito. En nuestro caso documentar el creciente uso de carbapenémicos nos permitió enfocar la estrategia hacia este objetivo. Según la literatura, los PROA han demostrado disminuir y mejorar el uso de antibióticos, así como disminuir los efectos adversos. En nuestro caso, la implantación de PROA produjo un descenso de la prescripción de meropenem en el servicio de Cirugía, objetivado desde el primer momento de su implantación. La representación mediante serie temporal descarta las modificaciones se deban a un cambio gradual en el servicio. El cambio de la prescripción no se debió al cambio en la prevalencia de microorganismos. El papel del cirujano en el equipo PROA es factor relevante en los resultados obtenidos sobre la monitorización 0009-739X – See front matter © 2017 Elsevier España, S.L. Todos los derechos reservados antibiótica. Es necesario el compromiso de los especialistas en Cirugía para hacer hincapié en el uso racional de los antimicrobianos y para promover la mejora continua de la práctica clínica quirúrgica.Sin financiación0.841 JCR (2017) Q4, 170/200 SurgeryUE

Levosimendan increases portal blood flow and attenuates intestinal intramucosal acidosis in experimental septic shock

It has been proposed that vasodilatory therapy may increase microcirculatory blood flow and improve tissue oxygenation in septic shock. The authors aimed to evaluate the effects of levosimendan in systemic and splanchnic hemodynamics in a porcine model of septic shock in a randomized animal controlled study. This study was performed in an animal research facility in a university hospital. Anesthetized pigs were monitored with a pulmonary artery catheter and an ultrasonic blood flow probe in the portal vein for measurement of systemic and portal blood flows and with a tonometer placed in the small intestine for measurement of the intramucosal-arterial PCO2 gap. Three groups of pigs were studied: nonseptic (n = 7), septic (n = 7), and septic treated with levosimendan (n = 7). Levosimendan was administered i.v. at t = -10 min (200 microg/kg in i.v. bolus followed by 200 microg/kg per h). Sepsis was induced at t = 0 min by the administration of live Escherichia coli. Vascular reactivity was tested by the hemodynamic response to noradrenaline. Levosimendan markedly attenuated the sepsis-induced increase in pulmonary vascular resistance, decrease in portal/systemic blood flow, oliguria, impairment in oxygenation, hyperkalemia, and the widened intramucosal-arterial PCO2 gap. Systemic blood pressure and vascular resistance did not differ as compared with the septic untreated group. Responses to noradrenaline significantly improved in animals treated with levosimendan. Treatment with levosimendan in this animal model of sepsis attenuated pulmonary vasoconstriction and improved portal blood flow, intestinal mucosal oxygenation, pulmonary function, and vascular reactivity.Sin financiación3.203 JCR (2010) Q1, 16/68 Peripheral vascular diasease, 20/188 Surgery; Q2, 25/66 Hematology, 7/23 Critical care medicineUE

Predictors of complications and mortality following left colectomy with primary stapled anastomosis for cancer: results of a multicentric study with 1111 patients

Aim: Reports detailing the morbidity–mortality after left colectomy are sparse and do not allow definitive conclusions to be drawn. We aimed to identify risk factors for anastomotic leakage, perioperative mortality and complications following left colectomy for colonic malignancies. Method: We undertook a STROBE-compliant analysis of left colectomies included in a national prospective online database. Forty-two variables were analysed as potential independent risk factors for anastomotic leakage, postoperative morbidity and mortality. Variables were selected using the ‘least absolute shrinkage and selection operator’ (LASSO) method. Results: We analysed 1111 patients. Eight per cent of patients had a leakage and in 80% of them reoperation or surgical drainage was needed. A quarter of patients (24.9%) experienced at least one minor complication. Perioperative mortality was 2%, leakage being responsible for 47.6% of deaths. Obesity (OR 2.8, 95% CI 1.00–7.05, P = 0.04) and total parenteral nutrition (TPN) (OR 3.7, 95% CI 1.58–8.51, P = 0.002) were associated with increased risk of leakage, whereas female patients had a lower risk (OR 0.36, 95% CI 0.18–0.67, P = 0.002). Corticosteroids (P = 0.03) and oral anticoagulants (P = 0.01) doubled the risk of complications, which was lower with hyperlipidaemia (OR 0.3, P = 0.02). Patients on TPN had more complications (OR 4.02, 95% CI 2.03–8.07, P = 0.04) and higher mortality (OR 8.7, 95% CI 1.8–40.9, P = 0.006). Liver disease and advanced age impaired survival, corticosteroids being the strongest predictor of mortality (OR 21.5, P = 0.001). Conclusion: Requirement for TPN was associated with more leaks, complications and mortality. Leakage was presumably responsible for almost half of deaths. Hyperlipidaemia and female gender were associated with lower rates of complications. These findings warrant a better understanding of metabolic status on perioperative outcome after left colectomy