Evolución de la calidad de vida tras cirugía radical o conservadora en cáncer de mama

Introducción: De todos los factores que pueden influir en la calidad de vida relacionada con la salud (CVRS), el tratamiento quirúrgico puede ser uno de los más importantes. Las características sociodemográficas o aspectos clínicos relacionados con el cáncer de mama o sus tratamientos también pueden modificar la CVRS. Objetivos: Analizar las relaciones entre el tipo de intervención (cirugía conservadora (CC) o radical) y la CVRS al año. Describir las características de las pacientes y la evolución de su CVRS al mes, a los 6 meses y al año de la intervención. Se analizan las asociaciones entre las características sociodemográficas o clínicas de las pacientes y las puntuaciones de CVRS al año de la intervención. Adicionalmente se analiza la capacidad predictiva de los instrumentos de medida de CVRS. Material y métodos: Estudio multicéntrico, observacional, prospectivo, en el que una cohorte de pacientes intervenidas de cáncer de mama fue seguida durante un año. Se midió su CVRS al mes, a los 6 meses y al año de la intervención mediante una escala general de CVRS (EuroQol-5D), una escala específica de CVRS en cáncer (EORTC QLQC30) y una escala específica de CVRS en cáncer de mama (EORTC QLQ-BR23). Resultados: Se incluyeron 551 pacientes, de las que participaron 446. La edad media fue 59,09 años (Rango: 20-91). La CVRS fue mejorando a lo largo del año de seguimiento. Respecto al EuroQol, las puntuaciones de la Escala Visual Analógica (EVA) mejoraron (p<0,0001); sin embargo, la tarifa no mostró cambios significativos (p=0,1323). En cambio, la puntuación global del EORTC QLQ-C30 mejoró (p<0,0001), así como todas las dimensiones funcionales y de síntomas y la mayoría de ítems independientes del EORTC QLQ-C30. Las dimensiones del EORTC QLQ-BR23 mostraron mejoría, salvo el funcionamiento sexual y la preocupación por el futuro, que presentaron un discreto empeoramiento. La CC ofreció mejores actividades diarias, mejor funcionamiento físico, emocional y social, menos fatiga, dolor, insomnio o impacto económico al año de la intervención. Adicionalmente, proporcionó mejor imagen corporal, menos molestias en el brazo y menos efectos secundarios del tratamiento sistémico, pero a expensas de mayores preocupaciones por el futuro y más síntomas locales en la mama que la cirugía radical. Entre los factores sociodemográficos y de acceso, la edad comprendida entre los 60 y 69 años y la menor de 50 años, así como ser soltera o ama de casa se asociaron con una mejor CVRS. En relación con los factores clínicos y de tratamiento, las pacientes con estadios I y II, con tipo histológico carcinoma ductal infiltrante (CDI) papilar, así como las intervenidas de forma conservadora o aquellas que no requirieron linfadenectomía axilar presentaron mejor CVRS. En el análisis multivariable, una edad mayor de 70 años, estar casada, separada o viuda, el estadio III o no recibir QT fueron factores independientes predictivos de peor CVRS al año. Sin embargo, ser ama de casa, la CC, el CDI papilar, provenir de la consulta o no recibir RT fueron factores independientes predictivos de una mejor CVRS al año. Adicionalmente, la CVRS medida al mes mediante los tres cuestionarios fue predictiva de la CVRS al año. Conclusiones: La CVRS de las pacientes fue buena y mejoró con el seguimiento. Existen diferencias en la CVRS según la modalidad de intervención, puesto que la CC ofreció beneficios en múltiples ítems frente a la radical, aunque mostró mayores preocupaciones por el futuro y más síntomas locales. Determinados factores sociodemográficos y clínicos pueden influir en la CVRS, y algunos de ellos independientemente. Los instrumentos de medida de CVRS utilizados precozmente pueden predecir la CVRS al año de la intervención.Introduction: Multiple factors could affect Health Related Quality of Life (HRQoL) of breast cancer patients. Objectives: Assess associations between HRQoL and type of intervention (Breast Conserving Surgery (BCS) or mastectomy). Describe HRQoL evolution over one year after surgery. Analyze associations between sociodemographic or clinical factors and HRQoL scores. And finally, analyze the predictive ability of HRQoL measurement instruments. Methods: Observational, multicenter and prospective study of a cohort of patients with breast cancer that was followed one year after surgery. HRQoL was assessed at one month, six months and one year after surgical intervention using three questionnaires: EuroQol-5D, EORTC QLQ-C30 and its breast cancer specific module BR-23. Results: Of 551 patients included in the study, 446 participated. Mean age was 59.09 years (range: 20-91). Visual Analogue Scale (VAS) from EuroQol improved; however, EuroQol Score showed no significant change. In contrast, Global Health Status of EORTC QLQ-C30 improved, as well as all its scales and most of its independent items. Dimensions of EORTC QLQ-BR23 experienced improvement, except for sexual functioning and future perspective, that experienced a slight worsening. BCS provided better rol, physical, social and emotional functioning, better body image and less fatigue, pain, insomnia, financial difficulties, arm symptoms and systemic therapy side-effects, but increased concerns about the future and more breast symptoms than mastectomy one year after surgery. Age between 60-69 years and under 50 years, being single or housewife, stage I-II, invasive papillary carcinoma, BCS or lack of axillary dissection were associated with better HRQoL. Howerver, age over 70 years, being married, separated or widowed, stage III or not receive adyuvant chemotherapy were independent predictors of worse HRQoL. In contrast, being housewife, BCS, invasive papillary carcinoma, come from outpatient clinic or not receive radiotherapy were independent predictive factors of better HRQoL after one year. Moreover, HRQoL measured at one month was predictive of HRQoL at one year. Conclusions: HRQoL was good and improved during the follow-up. Differences in HRQoL according to the type of intervention were found in favour of BCS. Demographic and clinical factors can influence HRQoL and some of them independently. HRQoL measurement instruments can predict early HRQoL

Diseño y cálculo de un reductor de velocidad con relación de transmisión 7.1 y par máximo a la salida de 4500 Nm

[ES] El objetivo del presente trabajo final de grado es el de diseñar y calcular un reductor de velocidad de dos etapas, que va a ser utilizado a nivel industrial, e incorporado en cualquier tipo de maquinaria. Primeramente, se van a analizar las posibles transmisiones existentes en el mercado, descartando las que no se adecúen a la consecución del objetivo del trabajo. Una vez elegida la mejor solución posible y teniendo presente el diseño del reductor, se va a proceder a seleccionar los componentes necesarios que garanticen el correcto funcionamiento del mismo, para un determinado número de horas de funcionamiento. Posteriormente, se van a realizar los diferentes cálculos necesarios partiendo de los datos iniciales, dimensionando los árboles, engranajes y rodamientos para posteriormente realizar una simulación de funcionamiento. Cabe destacar, que se van a tener en cuenta ambos sentidos de giro en las hipótesis de funcionamiento, ya que los engranajes utilizados transmiten esfuerzos axiales de dirección variable, según su sentido de giro. Por otro lado, se va a estudiar tanto la deflexión lateral como el comportamiento a fatiga en las secciones más críticas de cada árbol, así como los esfuerzos transmitidos por los engranajes helicoidales. Finalmente, se va a confeccionar un presupuesto detallado de cada uno de los componentes del reductor, reflejando de este modo el coste de producción final. Por último, se van a realizar tanto planos acotados de conjunto como de despiece, para definir completamente la geometría y dimensiones de los elementos que componen el reductor de velocidad.[EN] The aim of this final degree work is to design and calculate a two stage speed reducer, which can be used at industrial level, and incorporated in any type of machinery. First, the possible transmissions on the market are going to be analysed, discarding those that do not suit the achievement of the objective of the work. Once the best possible solution has been chosen, bearing in mind the design of the reducer, the necessary components are going to be selected to guarantee the correct operation of the same, for a certain number of hours of operation. Afterwards, the different calculations are going to be carried out starting from the initial data, sizing the trees, gears and bearings and then perform a simulation of operation. It should be noted, that both directions of rotation are going to be taken into account in the operating hypothesis, since the gears used transmit axial forces of variable direction, according to their direction of rotation. On the other hand, we are going to study both lateral deflection and fatigue behaviour in the most critical sections of each tree, as well as the efforts transmitted by helical gears. Finally, a detailed budget is going to be made for each of the components of the reducer, thus reflecting the final production cost. Finally, we are going to carry out both dimensioned drawings of assembly and cutting, to define completely the geometry and dimensions of the elements that compose the speed reducer.[CA] L'objectiu del present treball final de grau és el de dissenyar i calcular un reductor de velocitat de dos etapes, que va a ser utilitzat a nivell industrial, i incorporat en qualsevol tipus de maquinària. Primerament, es van a analitzar les possibles transmissions existents en el mercat, descartant les que no s'adeqüen a la consecució de l'objectiu del treball. Una vegada triada la millor solució possible i tenint present el disseny del reductor, es va a procedir a seleccionar els components necessaris que garantisquen el correcte funcionament d'aquest, per a un determinat nombre d'hores de funcionament. Posteriorment, es van a realitzar els diferents càlculs necessaris partint de les dades inicials, dimensionant els arbres, engranatges i rodaments per a posteriorment realitzar una simulació de funcionament. Cal destacar, que es van a tindre en compte tots dos sentits de gir en les hipòtesis de funcionament, ja que els engranatges utilitzats transmeten esforços axials de direcció variable, segons el seu sentit de gir. D'altra banda, es van a estudiar tant la deflexió lateral com el comportament a fatiga en les seccions més crítiques de cada arbre, així com els esforços transmesos pels engranatges helicoïdals. Finalment, es va a confeccionar un pressupost detallat de cadascun dels components del reductor, reflectint d'aquesta manera el cost de producció final. Finalment, es van a realitzar tant plans fitats de conjunt com d'especejament, per a definir completament la geometria i dimensions dels elements que componen el reductor de velocitat.Moro Valdezate, E. (2018). Diseño y cálculo de un reductor de velocidad con relación de transmisión 7.1 y par máximo a la salida de 4500 Nm. http://hdl.handle.net/10251/115918TFG

Sphincter damage during fistulotomy for perianal fistulae and its relationship with faecal incontinence

Background The length of sphincter which can be divided during fistulotomy for perianal fistula is unclear. The aim was to quantify sphincter damage during fistulotomy and determine the relationship between such damage with symptoms and severity of faecal incontinence and long-term quality of life (QOL). Methods A prospective cohort study was performed over a 2-year period. Patients with intersphincteric and mid to low transsphincteric perianal fistulas without risk factors for faecal incontinence were scheduled for fistulotomy. All patients underwent 3D endoanal ultrasound (3D-EAUS) pre-operatively and 8 weeks postoperatively. Measurements were taken of pre- and postoperative anal sphincter involvement and division. Anal continence was assessed using the Jorge-Wexner scale and QOL scores pre, 6 and 12 months postoperatively. Results Forty-nine patients were selected. A strong correlation between pre- and postoperative measurements was found p < 0.001. A median length of 41% of the external anal sphincter and 32% of the internal anal sphincter was divided during fistulotomy. Significant differences in mild symptoms of anal continence were found with increasing length of external anal sphincter division. But there was no significant deterioration in continence, soiling, or quality of life scores at the 1-year follow-up. Division of over two-thirds of the external anal sphincter was associated with the highest incontinence rates. Conclusions 3D-EAUS is a valuable tool for quantifying the extent of sphincter involvement pre- and postoperatively. Post-fistulotomy faecal incontinence is mild and increases with increasing length of sphincter division but does not affect long-term quality of life

Prognostic implications of surgical specimen quality on the oncological outcomes of open and laparoscopic surgery in mid and low rectal cancer

Purpose: Determine differences in pathologic outcomes between laparoscopic (LAP) and open surgery (OPEN) for mid and low rectal cancer and its influence in long-term oncological outcomes. Methods: Retrospective case matched study at a tertiary institution. Adults with rectal cancer below 12 cm from the anal verge operated between January 2005 and September 2018 were included. Primary outcomes were quality of specimen, overall survival (OS), disease-free survival (DFS), and local recurrence (LR). Results: The study included 311 patients, LAP = 108 (34.7%), OPEN = 203 (65,3%). A successful resection was accomplished in 81% of the LAP group and in 84.5% of the OPEN (p = 0.505). No differences in free distal margin (LAP = 100%, OPEN = 97.5%; p = 0.156) or circumferential resection margin (LAP = 95.2%, OPEN = 93.2%; p = 0.603) were observed. However, mesorectum quality was incomplete in 16.2% for LAP and in 8.1% for OPEN (p = 0.048). OS was 91.1% for LAP and 81.1% for OPEN (p = 0.360). DFS was 81.4% for LAP and 77.5% for OPEN (p = 0.923). Overall, LR was 2.3% without differences between groups. Conclusions: Laparoscopic approach could affect the quality of surgical specimen due to technical aspects. However, if principles of surgical oncology are respected, minor pathologic differences in the quality of the mesorectum may not influence on the long-term oncologic outcomes

Short-term outcomes of colorectal cancer surgery in older patients : a novel nomogram predicting postoperative morbi-mortality

Purpose To analyze short-term outcomes of curative-intent cancer surgery in all adult patients diagnosed with colorectal cancer undergoing surgery from January 2010 to December 2019 and determine risk factors for postoperative complications and mortality. Methods Retrospective study conducted at a single tertiary university institution. Patients were stratified by age into two groups: < 75 years and ≥ 75 years. Primary outcome was the influence of age on 30-day complications and mortality. Inde- pendent risk factors for postoperative adverse events or mortality were analyzed, and two novel nomograms were constructed. Results Of the 1486 patients included, 580 were older (≥ 75 years). Older subjects presented more comorbidities and tumors were located mainly in right colon (45.7%). After matching, no between-group differences in surgical postoperative com- plications were observed. The 30-day mortality rate was 5.3% for the older and 0.8% for the non-older group (p < 0.001). In multivariable analysis, the independent risk factors for postoperative complications were peripheral vascular disease, chronic pulmonary disease, severe liver disease, postoperative transfusion, and surgical approach. Independent risk factors for 30-day mortality were age ≥ 80 years, cerebrovascular disease, severe liver disease, and postoperative transfusion. The model was internally and externally validated, showing high accuracy. Conclusion Patientsaged≥75yearshadsimilarpostoperativecomplicationsbuthigher30-daymortalitythantheiryounger counterparts. Patients with peripheral vascular disease, chronic pulmonary disease, or severe liver disease should be informed of higher postoperative complications. But patients aged ≥ 80 suffering cerebrovascular disease, severe liver disease, or need- ing postoperative transfusion should be warned of significantly increased risk of postoperative mortality

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity &gt; 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic