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Del Cerro Rodríguez D, González-Pola Yuncal S, Altamirano S, García Saavedra S, Gómez Tellado M. [A case of abdominal internal hernia through the foramen of Winslow in a pediatric emergency department]. An Sist Sanit Navar 2024; 47:e1068. [PMID: 38488072 PMCID: PMC10933693 DOI: 10.23938/assn.1068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/12/2023] [Accepted: 02/16/2024] [Indexed: 03/18/2024]
Abstract
Abdominal internal hernia is a rare cause of intestinal obstruction in pediatric emergency departments, being the herniation through the foramen of Winslow an exceptional entity (less than 0.5% of the herniae). We report the case of a 15-year-old adolescent male without previous surgical interventions who presented with abdominal pain and vomiting; computed tomography scans showed intestinal obstruction due to an internal hernia through the foramen of Winslow. To reduce the herniated ileum, the patient required surgical intervention with diagnostic laparoscopy, which, due to bad visualization, was changed to supraumbilical midline laparotomy. There was no need to resect the affected ileum as it appeared healthy. We did not perform a preventive technique to reduce the risk of recurrence. Postoperative pelvic collection was conservatively managed with antibiotics. The patient undergoes regular follow-up in the pediatric surgery department.
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Peña Mejía LA, Ruiz Niño GV, Arteta Cueto AA. Relation between histopathological findings, clinical severity, and the need of surgery in patients with Crohn's disease. Gastroenterol Hepatol 2023:S0210-5705(23)00473-9. [PMID: 38007153 DOI: 10.1016/j.gastrohep.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/07/2023] [Accepted: 11/20/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION Defining histological variables that make it possible to establish the activity of Crohn's disease (CD) and predict the patients who may present a higher risk of clinical complications and surgical interventions could lead to timely adjustments in medical therapy and elective surgeries that represent a lower risk of complications. The purpose of the study is to determine the relation between the histopathological findings using the Naini and Cortina score, the clinical severity, and the indication for surgery in a group of patients with CD. MATERIALS AND METHODS Descriptive, retrospective, cross-sectional study of 44 patients diagnosed with CD, treated at the San Vicente Fundación University Hospital in Medellín between 2010 and 2022. RESULTS Of the 44 patients, 36 ileum samples and 34 colon samples were obtained. Of the patients with inflammatory behavior, 87.5% did not have surgical intervention (p=0.022), a value that remained significant in the ileum subgroup (p=0.0058). 91.3% of the patients with ileal involvement did not develop perianal disease (p=0.01). Granulomas only occurred in 2 patients with a colon sample (5.8%). In the histological score of N&C both in the ileum and in the colon, no statistically significant differences were obtained in relation to the surgical outcome (p = 0.34 and 0.054), respectively. CONCLUSION The histological index of N&C was not a predictor in Crohn's disease (CD) related to the surgical outcome.
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Affiliation(s)
| | | | - Ariel Antonio Arteta Cueto
- Especialista en Patología, profesor asociado Departamento de Patología, Facultad de Medicina, Grupo de Investigaciones en Patología Universidad de Antioquia (GRIP-UdeA) Universidad de Antioquia, Colombia.
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R. Alonso-Beato, M.-O. Lago-Rodríguez, M. López-Rubio, A. Gómez-Tórtola, I. García-Fernández-Bravo, C.-M. Oblitas, F. Galeano-Valle, P. Demelo-Rodríguez. Risk of thrombosis recurrence among patients with COVID-19- and surgery-associated venous thromboembolism. Rev Clin Esp 2023. [PMID: 36990384 PMCID: PMC10043968 DOI: 10.1016/j.rceng.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Introduction Recent surgery is a well-known major transient risk factor for venous thromboembolism (VTE) due to the low risk of VTE recurrence after anticoagulation is discontinued. On the other hand, the risk of VTE recurrence among patients with COVID-19-associated VTE is unknown. This study aimed to compare the risk of VTE recurrence between patients with COVID-19- and surgery-associated VTE. Methods A prospective observational single-center study was performed including consecutive patients diagnosed with VTE in a tertiary hospital from January 2020 to May 2022 and followed up for at least 90 days. Baseline characteristics, clinical presentation, and outcomes were assessed. The incidence of VTE recurrence, bleeding, and death was compared between both groups. Results A total of 344 patients were included in the study: 111 patients with surgery-associated VTE and 233 patients with COVID-19-associated VTE. Patients with COVID-19-associated VTE were more frequently men (65.7% vs 48.6%, p = 0.003). VTE recurrence was 3% among COVID-19 patients and 5.4% among surgical patients, with no significant differences (p = 0.364). The incidence rate of recurrent VTE was 1.25 per 1000 person-months in COVID-19 patients and 2.29 person-months in surgical patients, without significant differences (p = 0.29). In the multivariate analysis, COVID-19 was associated with higher mortality (HR 2.34; 95% CI 1.19–4.58), but not with a higher risk of recurrence (HR 0.52; 95% CI 0.17–1.61). No differences were found in recurrence in the multivariate competing risk analysis (SHR 0.82; 95% CI 0.40–2.05). Conclusions In patients with COVID-19 and surgery-associated VTE, the risk of recurrence was low, with no differences between both groups.
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Butrón-Bris B, Lladó I, Gallo E, Navarro R, Rodríguez-Jiménez P, Delgado-Jiménez Y. Wide excision in hidradenitis suppurativa. Does it modify the course of disease? Actas Dermosifiliogr 2023:S0001-7310(23)00081-9. [PMID: 36764388 DOI: 10.1016/j.ad.2022.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 02/11/2023] Open
Abstract
There is a lack of studies assessing whether wide excision surgery in hidradenitis suppurativa affected areas is useful for the global control of the hidradenitis suppurativa. We aimed to find whether surgery results were a better global control on the disease activity in both, the area where the surgery is performed and distant areas. We evaluated the disease course of 17 patients with hidradenitis suppurativa who underwent wide excision of complex fistula tracts between October 2018 and January 2022 at the Hospital Universitario de la Princesa, Madrid. We found that wide excision of complex fistulas produces an overall positive effect on the inflammatory activity in hidradenitis suppurativa that may be important to achieve an adequate control of the disease.
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Ramia-Angel JM, Jaén-Torrejimeno I, Serrablo-Requejo A, Rodriguez-Laiz GP, López-Guerra D, Abadía-Forcen T, Alenda C, Serradilla-Martín M, Blanco-Fernandez G. Adenosquamous cancer of the pancreas: A multicenter retrospective study. Gastroenterol Hepatol 2021; 45:543-551. [PMID: 34952130 DOI: 10.1016/j.gastrohep.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Adenosquamous cancer of the pancreas (ASCP) is an aggressive, infrequent subtype of pancreatic cancer that combines a glandular and squamous component and is associated with poor survival. METHODS Multicenter retrospective observational study carried out at three Spanish hospitals. The study period was: January 2010- August 2020. A descriptive analysis of the data was performed, as well as an analysis of global and disease-free survival using the Kaplan-Meier statistic. RESULTS Of a total of 668 pancreatic cancers treated surgically, twelve were ASCP (1.8%). Patient mean age was 69.2±7.4 years. Male/female ratio was 1:1. The main symptom was jaundice (seven patients). Correct preoperative diagnosis was obtained in only two patients. Nine pancreatoduodenectomies and three distal pancreatectosplenectomies were performed. 25% had major complications. Mean tumor size was 48.6±19.4 mm. Nine patients received adjuvant chemotherapy. Median survival time was 5.9 months, and median disease-free survival was 4.6 months. 90% of patients presented recurrence. Ten of the twelve patients in the study (83.3%) died, with disease progression being the cause in eight. Of the two surviving patients, one is disease-free and the other has liver metastases. CONCLUSION ASCP is a very rare pancreatic tumor with aggressive behavior. It is rarely diagnosed preoperatively. The best treatment, if feasible, is surgery followed by the standard chemotherapy regimens for pancreatic adenocarcinoma.
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Affiliation(s)
- Jose Manuel Ramia-Angel
- Servicio de Cirugía General. Hospital General Universitario, Alicante, España; ISABIAL: Instituto de Investigación Sanitaria y Biomédica, Alicante, España
| | | | - Alejandro Serrablo-Requejo
- Servicio de Cirugía General. Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón, Zaragoza, España
| | - Gonzalo P Rodriguez-Laiz
- Servicio de Cirugía General. Hospital General Universitario, Alicante, España; ISABIAL: Instituto de Investigación Sanitaria y Biomédica, Alicante, España
| | - Diego López-Guerra
- Servicio de Cirugía General. Complejo Hospitalario de Badajoz, Badajoz, España
| | - Teresa Abadía-Forcen
- Servicio de Cirugía General. Hospital Universitario Miguel Servet, Zaragoza, España
| | - Cristina Alenda
- Servicio de Cirugía General. Hospital General Universitario, Alicante, España; Servicio de Anatomía Patológica. Hospital General Universitario, Alicante, España
| | - Mario Serradilla-Martín
- Servicio de Cirugía General. Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón, Zaragoza, España.
| | - Gerardo Blanco-Fernandez
- Servicio de Cirugía General. Complejo Hospitalario de Badajoz, Badajoz, España; Universidad de Extremadura, Badajoz, España
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Mwinga S, Kulohoma C, Mwaniki P, Idowu R, Masasabi J, English M. Quality of surgical care in hospitals providing internship training in Kenya: a cross sectional survey. Trop Med Int Health 2015; 20:240-9. [PMID: 25348925 PMCID: PMC4309502 DOI: 10.1111/tmi.12422] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate services in hospitals providing internship training to graduate doctors in Kenya. METHODS A survey of 22 internship training hospitals was conducted. Availability of key resources spanning infrastructure, personnel, equipment and drugs was assessed by observation. Outcomes and process of care for pre-specified priority conditions (head injury, chest injury, fractures, burns and acute abdomen) were evaluated by auditing case records. RESULTS Each hospital had at least one consultant surgeon. Scheduled surgical outpatient clinics, major ward rounds and elective (half day) theatre lists were provided once per week in 91%, 55% and 9%, respectively. In all other hospitals, these were conducted twice weekly. Basic drugs were not always available (e.g. gentamicin, morphine and pethidine in 50%, injectable antistaphylococcal penicillins in 5% hospitals). Fewer than half of hospitals had all resources needed to provide oxygen. One hundred and forty-five of 956 cases evaluated underwent operations under general or spinal anaesthesia. We found operation notes for 99% and anaesthetic records for 72%. Pre-operatively measured vital signs were recorded in 80% of cases, and evidence of consent to operation was found in 78%. Blood loss was documented in only one case and sponge and instrument counts in 7%. CONCLUSIONS Evaluation of surgical services would be improved by development and dissemination of clear standards of care. This survey suggests that internship hospitals may be poorly equipped and documented care suggests inadequacies in quality and training.
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Affiliation(s)
- Stephen Mwinga
- KEMRI‐Wellcome Trust Research ProgrammeNairobiKenya
- Ministry of HealthGovernment of KenyaNairobiKenya
| | | | - Paul Mwaniki
- KEMRI‐Wellcome Trust Research ProgrammeNairobiKenya
| | - Rachel Idowu
- Vanderbilt Institute for Global HealthVanderbilt School of MedicineNashvilleTNUSA
| | | | - Mike English
- KEMRI‐Wellcome Trust Research ProgrammeNairobiKenya
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
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Navas D, Ríos A, Febrero B, Rodríguez JM, Lloret F, Parrilla P. [Severe lower gastrointestinal bleeding due to GIST tumor. Radiological embolization and surgery]. CIR CIR 2014; 82:686-689. [PMID: 25393869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Gastrointestinal stromal tumors (GIST) were identified only recently. These tumors usually have no symptoms, although they are localized, operable and curable. Although rare, if they are not diagnosed and treated early, they become very aggressive. The most common manifestation is gastrointestinal bleeding from mucosal erosion. Their presentation as severe lower gastrointestinal bleeding is exceptional. CLINICAL CASE We report a patient with severe lower gastrointestinal bleeding stabilized by interventional radiology that subsequently required surgery for definitive care. CONCLUSIONS Therapeutic use of radiological embolization is increasingly widespread in bleeding at various levels, achieving hemodynamic stabilization of patients. However, it must be kept in mind that, in cases of unknown etiology of lower gastrointestinal bleeding, possible causes must be investigated.
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Affiliation(s)
- Diana Navas
- Servicio de Cirugía General y del Aparato Digestivo, CIBEREHD (Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas). IMIB (Instituto Murciano de Investigaciones Sanitarias), Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Antonio Ríos
- Servicio de Cirugía General y del Aparato Digestivo, CIBEREHD (Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas). IMIB (Instituto Murciano de Investigaciones Sanitarias), Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Beatriz Febrero
- Servicio de Cirugía General y del Aparato Digestivo, CIBEREHD (Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas). IMIB (Instituto Murciano de Investigaciones Sanitarias), Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - José Manuel Rodríguez
- Servicio de Cirugía General y del Aparato Digestivo, CIBEREHD (Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas). IMIB (Instituto Murciano de Investigaciones Sanitarias), Murcia, Spain
| | - Francisco Lloret
- Servicio de Radiología Intervencionista, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Pascual Parrilla
- Servicio de Cirugía General y del Aparato Digestivo, CIBEREHD (Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas). IMIB (Instituto Murciano de Investigaciones Sanitarias), Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
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Dávila-Torres J, Cruz-Vega F, Loría-Castellanos J, Franco-Bey R, Quiroz-Vasquez L, Cruz-Flores P. [Surgical Medical Meetings in the Mexican Social Security Institute: 17 years of existence]. CIR CIR 2014; 82:690-698. [PMID: 25393870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The Surgical Medical Meetings Program aims to make highly specialized medical services to the marginalized rural population. Surgical Medical Encounters highlight the experience and results of an innovative strategy characterized by continuous improvement and the desire to continue transcending health for the most vulnerable populations. During 17 years of its inception, it is interesting to describe the evolution and achievements of the program.
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Affiliation(s)
- Javier Dávila-Torres
- Dirección de Prestaciones Médicas, Instituto Mexicano del Seguro Social, México DF, Mexico
| | - Felipe Cruz-Vega
- Dirección de Prestaciones Médicas, Instituto Mexicano del Seguro Social, México DF, Mexico.
| | | | - Rubén Franco-Bey
- Dirección de Prestaciones Médicas, Instituto Mexicano del Seguro Social, México DF, Mexico
| | - Laura Quiroz-Vasquez
- Dirección de Prestaciones Médicas, Instituto Mexicano del Seguro Social, México DF, Mexico
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Valenzuela-Salazar C, Orozco-Tapia LM, de la Concha Blankenagel E, Gallardo-Ramírez MA, Blas-Franco M, Cárdenas-Lailson LE. [Sigmoid diverticulitis in adolescent. Case report]. CIR CIR 2013; 81:445-449. [PMID: 25125064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Few cases have been reported in children and adolescents of sigmoid diverticulitis. Most of the case reports in medical literature are associated with true congenital diverticula and genetic diseases of collagen synthesis. CLINICAL CASE 13 year-old female who was admitted to General and Endoscopic Surgery service with diagnosis of complicated appendicitis. Laparotomy was performed finding complicated sigmoid diverticular disease. Lavage, sigmoidectomy and primary anastomosis were performed. The histopathological findings reported a perforated pseudo-diverticulum of the sigmoid colon with peritonitis. The patient was discharged 72 hours after surgery and no complications were reported. CONCLUSION There are only case reports about colonic diverticulitis in children and adolescents, and its etiology has not yet been well established. This patient had sigmoid pseudo-diverticula and did not present genetic concomitant disease. This case is an exception to data reported on literature about diverticular disease in this population.
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Affiliation(s)
- Carlos Valenzuela-Salazar
- División de Cirugía General y Endoscópica, Hospital General Dr. Manuel Gea González, México DF, Mexico.
| | - Luis Manuel Orozco-Tapia
- División de Cirugía General y Endoscópica, Hospital General Dr. Manuel Gea González, México DF, Mexico
| | | | | | - Miguel Blas-Franco
- División de Cirugía General y Endoscópica, Hospital General Dr. Manuel Gea González, México DF, Mexico
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Herrera-Espiñeira C, Escobar A, Navarro-Espigares JL, Castillo JDDL, García-Pérez L, Godoy-Montijano A. [Total knee and hip prosthesis: variables associated with costs]. CIR CIR 2013; 81:207-213. [PMID: 23769249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The elevated prevalence of osteoarthritis in Western countries, the high costs of hip and knee arthroplasty, and the wide variations in the clinical practice have generated considerable interest in comparing the associated costs before and after surgery. OBJECTIVE To determine the influence of a number of variables on the costs of total knee and hip arthroplasty surgery during the hospital stay and during the one-year post-discharge. METHODS A prospective multi-center study was performed in 15 hospitals from three Spanish regions. Relationships between the independent variables and the costs of hospital stay and postdischarge follow-up were analyzed by using multilevel models in which the "hospital" variable was used to group cases. Independent variables were: age, sex, body mass index, preoperative quality of life (SF-12, EQ-5 and Womac questionnaires), surgery (hip/knee), Charlson Index, general and local complications, number of beds and economic-institutional dependency of the hospital, the autonomous region to which it belongs, and the presence of a caregiver. RESULTS The cost of hospital stay, excluding the cost of the prosthesis, was 4,734 Euros, and the post-discharge cost was 554 Euros. With regard to hospital stay costs, the variance among hospitals explained 44-46% of the total variance among the patients. With regard to the post-discharge costs, the variability among hospitals explained 7-9% of the variance among the patients. CONCLUSIONS There is considerable potential for reducing the hospital stay costs of these patients, given that more than 44% of the observed variability was not determined by the clinical conditions of the patients but rather by the behavior of the hospitals.
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Affiliation(s)
- Carmen Herrera-Espiñeira
- Servicio Reanimación de Traumatología, Hospital Universitario Virgen de las Nieves de Granada, Granada, Spain.
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Arroyo A, Andreu J, García P, Jover S, Arroyo M, Fernández A, Costa D, Oliver I, Hernández H, Schwartz H, Reillo M, Calpena R, Arenas C. [Analysis of a programme of direct referral between primary and specialist care in potential surgery patients]. Aten Primaria 2001; 28:381-5. [PMID: 11602117 PMCID: PMC7684138 DOI: 10.1016/s0212-6567(01)70399-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To describe the results of a programme of direct referral of potential surgery patients between primary and specialist care, designed to lessen waiting-times.Design. Prospective, longitudinal and descriptive study. SETTING Health Area N. masculine 19 (Valencian Health Service): Surgery Service of Elche Hospital and 6 Health Centres. PARTICIPANTS Patients with pathologies that do not need special techniques for diagnosis except examination and who have a clear irrefutable indication of surgery without risk factors (ASA I-II).Intervention. The referral protocol consists of: a) diagnosis of pathology and pre-operative study in primary care (PC); b) appointment made by phone for the surgery clinic at the hospital, where diagnosis and pre-operative study are confirmed; c) referral and operation in the unit of non-hospital major surgery (UCMA); d) monitoring post-operation by the home hospitalisation unit (HHU) or preferably by the health centre, and e) check-up at the surgery clinic. Main measurements. The degree of agreement between PC and the specialist, assessment of the pre-operative study, and waiting time. RESULTS 86 patients were referred (average age, 35; 76% male) by 28 doctors. The most common pathologies were hernia (36%), pilonidal sinus (23.2%) and miscellaneous (32.5%). There was general agreement in diagnosis in 90.7% of cases. 89.5% of patients brought the proper pre-operative study. Mean waiting time between the primary care consultation in the different procedures and the first hospital consultation was 19 days; with 44 more days elapsing till the surgical operation. CONCLUSIONS This new programme is effective and economic, in that there is <<adequate referral>> of patients, waiting time is reduced by over 7 months for pilonidal sinus and by over 2 years for hernia pathology, and the procedure can be used for a large number of patients, as the pathologies involved are very common.
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Affiliation(s)
- A Arroyo
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario, Elche.
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