Surgery In Spain Research Articles

El futuro de la cirugía oncoplástica en España

Throughout all the articles in this Supplement of the Senology and Breast Pathology journal, the different techniques of Oncoplastic Surgery (OC) that are currently being developed in the world of Breast Surgery have been described. In this article we will describe the current situation of Oncoplastic surgery in Spain and the possibilities to improve in the future through specific training proposals and projects.

Effect of COVID-19 on Thoracic Oncology Surgery in Spain: A Spanish Thoracic Surgery Society (SECT) Survey.

Simple SummaryAfter the first wave of COVID-19, the Spanish Society of Thoracic Surgeons (SECT) surveyed its members to assess the impact of the pandemic on thoracic oncology surgery in one of the counties most affected by the virus. In May 2020, all SECT members were invited to complete a 40-item, multiple choice questionnaire by e-mail. The response rate was 19.0%. Surgical activity decreased by 95.7%, with 41.5% of centers performing surgery only in oncologic cases and 11.7% only in emergencies. More than half (56%) of multidisciplinary tumour board meetings (56%) were cancelled or conducted online. Standard protocols for early-stage disease were modified in 62.9% of centers. The results of this survey show that the COVID-19 pandemic severely limited thoracic oncology surgery activity. Here we describe and discuss the impact of the pandemic on thoracic surgery in Spain.After the first wave of COVID-19, the Spanish Society of Thoracic Surgeons (SECT) surveyed its members to assess the impact of the pandemic on thoracic oncology surgery in Spain. In May 2020, all SECT members were invited to complete an online, 40-item, multiple choice questionnaire. The questionnaire was developed by the SECT Scientific Committee and sent via email. The overall response rate was 19.2%. The respondents answered at least 91.5% of the items, with only one exception (a question about residents). Most respondents (89.3%) worked in public hospitals. The reported impact of the pandemic on routine clinical activity was considered extreme or severe by 75.5% of respondents (25.5% and 50%, respectively). Multidisciplinary tumour boards were held either with fewer members attending or through electronic platforms (44.6% and 35.9%, respectively). Surgical activity decreased by 95.7%, with 41.5% of centers performing surgery only on oncological patients and 11.7% only in emergencies. Nearly 60% of respondents reported modifying standard protocols for early-stage cancer and in the preoperative workup. Most centers (≈80%) reported using full personal protective equipment when operating on COVID-19 positive patients. The COVID-19 pandemic severely affected thoracic oncology surgery in Spain. The lack of common protocols led to a variable care delivery to lung cancer patients.

Implementación tecnológica en los servicios de Cirugía General y del Aparato Digestivo en España. Encuesta nacional y resultados

Technology is one of the pillars of surgery in the 21st century and is a key factor in achieving better surgical results. The current surgical process involves not only surgical techniques, but also a very high degree of specialisation and the knowledge and use of techniques and devices from other fields. In Spain, there are no studies published at a national level in this regard.From the Minimally Invasive Surgery and Technological Innovation section of the Spanish Association of Surgeons we have designed a study whose main objective is to evaluate the degree of technological implantation in the specialty of General Surgery in Spain, as well as to analyze the devices available in the different centres of the country. We propose to make a detailed description of the applications of these devices and techniques by areas of interest, pointing out the pathologies and procedures in which this technology is used.

PP284 Volume-Result Relationship Analysis In Digestive Oncological Surgery In Spain By Using Health Data Records

IntroductionIn order to improve patients’ health outcomes, it is important to know the available evidence regarding centralization of surgical interventions for digestive cancer in hospitals with the highest volume of cases. We aim to describe and identify the number of annual interventions recommended by hospitals in order to maximize the health outcomes and efficiency for patients undergoing digestive cancer surgery during 2013–2016 in centers belonging to the Spanish National Health System (SNS).MethodsThe study design was a retrospective cohort study (patients aged ≥18 years). Data from Spanish public hospitals’ basic minimum set of data at hospital discharge for esophagus, stomach, liver, pancreas and rectum cancers was used. Age, sex primary/secondary diagnosis and procedures (Charlson index) were included. Reinterventions, hospital stay and in-hospital mortality were considered as the outcomes and measures of efficiency. Hospitals were grouped as low-/medium-/high-volume according to the number of annual procedures. Descriptive analysis and logistic and Poisson regression models with Stata16 were undertaken.ResultsHigh-volume hospitals performed between 67.4 (rectum) and 88.6 (liver) percent of interventions. The percentage of in-hospital mortality for all cancers was lower in high-volume centers (9.6% esophagus, 6.6% stomach, 7.1% pancreas, 4.2% liver and 2.2% rectum), showing a negative association between center volume and in-hospital mortality, which was statistically significant for esophagus (odds ratio [OR] = 0.48; 95% confidence interval [CI]: 0.28–0.81), stomach (OR = 0.51; 95% CI: 0.39–0.68) and rectum (OR = 0.63; 95% CI: 0.48–0.83) cancers. A non-statistically significant lower in hospital stay was observed in high-volume hospitals.ConclusionsThese results indicate that in Spain there is a negative association between the number of digestive oncological interventions per hospital and in-hospital mortality. This could help to define a threshold or cut-off point for the concentration of digestive cancer surgery in the SNS that might result in an improvement of lower in-hospital mortality and/or hospital stay.

Multicentric survey on the use of intraoperative echocardiography in cardiovascular surgery in Spain

Transesophageal echocardiography (TEE) is an essential tool in the intraoperative and postoperative period of cardiac surgery with recently wide diffusion. We aimed to know the current situation of TEE in the field of cardiovascular anesthesiology in Spain through a national survey that explores the availability of equipment, indication and use of this technique as well as the training and accreditation of professionals involved. The findings show that in Spain intraoperative TEE is an integral part of cardiovascular procedures today and in most centers it is performed by anesthesiologists highly involved in this type of surgery. Despite the absence of structured training in the curriculum of our specialty, anesthesiologists acquire the skills through specific short-term rotations and a high percentage of them have obtained official accreditation. La ecocardiografía transesofágica (ETE) es una herramienta fundamental en el intraoperatorio y postoperatorio de cirugía cardiaca con una gran difusión en los últimos años. El objetivo de este trabajo es conocer la situación actual de la ETE en el ámbito de la anestesiología en cirugía cardiaca en España a través de una encuesta nacional que explora la disponibilidad de equipos, indicación y utilización de dicha técnica, así como la formación y acreditación de los profesionales responsables. Los hallazgos muestran que en España la ETE intraoperatoria es parte integral de los procedimientos cardiovasculares hoy en día y en la mayor parte de los centros es realizada por anestesiólogos altamente involucrados en este tipo de cirugías. A pesar de la ausencia de formación estructurada en el currículum formativo de nuestra especialidad, los anestesiólogos adquieren las competencias mediante rotaciones específicas de corta duración y un alto porcentaje de ellos ha obtenido la acreditación oficial.

Prophylaxis of venous thromboembolism in general surgery in Spain. Analysis of a national survey

IntroductionVenous thromboembolism (VTE) represents a serious postoperative complication that can be prevented by adequate thromboprophylaxis. Surveys provide relevant information about clinician’s attitudes and preferences regarding VTE prophylaxis. MethodsTransversal, descriptive study based on a survey sent to general surgeons members of the Spanish Association of Surgeons (AEC), that included 31 questions regarding postoperative VTE and its prevention, as well as three clinical scenarios. Results530 surgeons, 21.8% of the 2429 invited by electronic mail to participate, completed the survey. Most of the answering clinicians work on in big teaching hospitals, and 28.5% are residents. VTE represents a serious problem for 28% of participants. Although 81% consider that their knowledge on the prevention of postoperative VTE is adequate, a similar percentage recognizes the need for further education. The vast majority (98.7%) use low molecular weight heparins, which are considered the most effective and safe modality, followed by mechanical methods. The Caprini risk assessment score is used by 81% of surgeons, who usually start pharmacological prophylaxis preoperatively. However, there are remarkable differences in the dosing of heparins, timing of initiation, and duration, especially in non-oncologic surgical patients. ConclusionsMost Spanish surgeons are interested in the prevention of postoperative VTE. Overall, the level of knowledge on thromboprophylaxis is adequate. However, our results indicate that there is a need for better education on relevant practical aspects of prophylaxis that could be achieved by incorporating recommendations from recent guidelines to local hospital-based protocols.

Effect of implant rehabilitation on oral health-related quality of life with three different implant strategies.

Design Non-randomised controlled trial.Case selection Patients requiring dental implants were recruited from a private dental surgery in Spain. According to the clinical diagnosis and patient preference, patients were assigned to one of the following three treatment protocols: the conventional treatment (CGCL), in which implants were inserted after flap elevation without guiding templates; the guided surgery/conventional loading group (GSCL); and the guided surgery/immediate loading group (GSIL).Data analysis An oral examination and a questionnaire-based interview were carried out at baseline and three months after the delivery of the definitive prosthetic rehabilitation. Two complementary indicators, Oral Impacts on Daily Performances (OIDP) and Oral Satisfaction Scale (OSS) were used to assess the changes in oral health-related quality of life (OHQoL). Paired t-tests were used to compare the within-subject change scores. ANOVA tests were used to compare quantitative variables between groups. Chi-square tests were used to compare the distribution of data between groups. Effect size was used to assess the relative responsiveness of different health indicators and to compare the amount of change resulting from different treatment protocols. A forward stepwise logistic regression analysis was performed to predict the risk of having impact after treatment.Results A total of 104 patients were recruited: CGCL (n = 40), GSCL (n = 35) and GSIL (n = 29). At baseline, the OHQoL was significantly greater among those assigned to CGCL (2.4 ± 1.3) than those assigned to GSCL (3.3 ± 1.3), which were both greater than those patients assigned to GSIL (4.6 ± 2.0). After implant therapy, the oral wellbeing was significantly better than at baseline, and patient satisfaction was greater when the implants were loaded immediately (8.7 ± 1.1) than if the prosthetic rehabilitation was delayed (8.3 ± 1.1). In the GSIL group, the effect size of the OIDP exceeded the threshold value of 0.8 for all of the OIDP domains and for the total OIDP score and patient satisfaction.Conclusions A global improvement in the OHQoL scores and patient satisfaction was observed after implant therapy, but the change was marked greater in the GSIL group.

An overview of the situation of hand surgery in Spain during the peak of COVID-19 pandemic

Since the first cases were detected in China in December 2019, the COVID-19 pandemic has spread rapidly, collapsing many healthcare systems, and forcing them to adapt. Hand surgery has been indirectly affected by this scenario. This article aims to provide an overview on how Spanish hand surgeons have modified their daily practice. Based on a survey conducted nationwide, we observed a decrease in the number of emergency cases and cancellation of elective cases, shift to a more conservative treatment approach, use of personal protective equipment, and decrease in the number of outpatient visits and tests. Without definitive evidence at this point, knowing how we have dealt with the situation so far will help us adopt the needed measures to ensure both the patient's and surgeon's safety and manage available resources in future pandemics.

Obesity Surgery in Spain

Obesity Surgery in Spain

Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain.

Introduction: a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten years later we sent a questionnaire to check the current situation. Methods: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. Results: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95% CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95% CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95% CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2% of the sites used nutritional support (< 50% used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4% tried to use early oral feeding, but 88.2% of the surveyed teams used some nutritional support; 26.5% of respondents used TPN in 100% of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6% used TPN always, and EN in 19.3% of cases. Conclusions: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4% of the units used early oral feeding, and 32.3% used EN; 22.6% used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country.

Beginnings of bariatric and metabolic surgery in Spain

Beginnings of bariatric and metabolic surgery in Spain

Implementación de las recomendaciones para la prevención de infección de localización quirúrgica en España: encuesta para evaluación de discrepancias con la práctica clínica en cirugía cardiovascular

IntroductionA panel constituted by experts from various surgical scientific societies have expressed their concern on the lack of knowledge of the implementation of evidence-based recommendations as regards surgical site infection (SSI) prevention in different surgical specialties in Spain. MethodsThis expert panel designed an on-line questionnaire (SurveyMonkey©) consisting of 59 general questions for any surgical specialty, plus 5 more specific questions for Cardiac Surgery. ResultsThe questionnaire was completed by 82 cardiovascular surgeons from all over Spain, equally distributed into 1-10 years of experience (43%), 11-20 years (27%), and>20 years (30%). There was a high level of knowledge of specific protocols for patient surgical preparation (99%), patient safety in the operating room (87%), and contact isolation (96%). The results showed a lack of agreement between daily clinical practice and evidence-based recommendations in 4 strong recommendations of the World Health Organisation: screening/treatment of methicillin-resistant Staphylococcus aureus, hair removal, type/use of skin antiseptics, and duration of antibiotic prophylaxis. There were differences in another 4 conditional recommendations: preoperative nutritional status assessment, intraoperative glycaemic control, prophylactic use of negative pressure therapies, and antibiotic coated sutures. ConclusionSeveral important improvement areas have been detected towards SSI prevention in Cardiovascular Surgery in Spain, as there are important differences between daily clinical practice and evidence-based recommendations for surgical site infection prevention.

Revisional Bariatric Surgery Due to Failure of the Initial Technique: 25 years of Experience in a Specialized Unit of Obesity Surgery in Spain

ObjectivesTo evaluate the effectiveness of conversion surgery in a bariatric surgery unit with 25 years of experience. MethodRetrospective observational study of patients with type II obesity or higher who were reoperated by means of conversion surgery due to weight regain, residual body mass index (BMI) >35 kg/m2 or <50% of excess weight loss. The demographic and anthropometric data, comorbidities and perioperative data were analyzed in 5 periods of time: initial, post-surgery1, pre-surgery2, post-surgery2 and current. ResultsA total of 112 patients were included, with a mean age of 40.2 years, who initially underwent vertical banded gastroplasty (VBG) (32.1%), gastric banding (GB) (23.2%), Roux-en-Y gastric bypass (RYGB) (21.4%) and sleeve gastrectomy (SG) (23.2%). The conversion techniques, with a median time between the two surgeries of 70 months, included: RYGB, SG, one-anastomosis gastric bypass (OAGB), shortening of the common loop (SCL) and biliopancreatic diversion (BPD). There was a reduction of the initial weight from 144.2 ± 30.3 Kg to 101.5 ± 21.8 after surgery-1; from 115.6 ± 24.0–91.5 ± 19.0 after surgery-2. The weight at present is 94.7 ± 16.4, with a median follow-up of 27.5 months. Similar results were seen with the BMI. The improvement of comorbidities mainly occurred after the first intervention. ConclusionsConversion surgery causes a weight reduction that does not exceed the loss achieved after the first surgery; however, it does manage to stabilize weight over time. The perioperative morbidity rate is acceptable and would justify its application, despite the limited impact on comorbidities.

A 1-Year Cost Analysis of Spinal Surgical Procedures in Spain: Neurosurgeons Versus Orthopedic Surgeons.

ObjectiveTo evaluate the direct costs of various spinal surgical procedures within 1 year of follow-up and to compare the profiles of neurosurgeons and orthopedic surgeons. MethodsAll spinal procedures performed within a 10-month period in patients covered by a private insurance company were included. Costs related to the spinal interventions were systematically registered in the company database. Associated costs during the 1-year follow-up were recorded. ResultsIn total, 1,862 patients were included, with a total cost of €11,050,970, of whom 34.8% underwent noninstrumented lumbar decompression (€3,473), 27.1% dorsolumbar instrumented fusion (€6,619), 14.6% nucleoplasty (€1,323), 13.5% cervical surgery (€4,463), 3.4% kyphoplasty (€4,200), 2.9% scoliosis (€15,414), 1.2% oncologic surgery (€5,590), 0.5% traumatic compression (€7,844), and 4.7% (€1,343) other minor interventions (mainly rhizotomies). Approximately 42% of patients required reinterventions within the first year, with a global extra cost of €7,280,073; 11% were referred to the pain clinic, with a €114,663 cost; 55.5% were men; and the most common age range of patients who received an intervention was 65–75 years. Neurosurgeons performed 60% of all interventions. Noninstrumented lumbar operations were performed by neurosurgeons twice as often as instrumented operations, and they performed 76% of cervical operations. Orthopedic surgeons performed 2.5 times more instrumented than noninstrumented lumbar operations, and almost all scoliosis and rhizotomy procedures. ConclusionThe direct costs of spinal surgery in Spain were generally lower than those reported in other European Union countries and the United States. Neurosurgeons and orthopedic surgeons had different spine surgical profiles and costs.

Reconstructive Head and Neck Surgery in Spanish Otorhinolaryngology—Head and Neck Surgery Departments: Current State of the Art

Advances in oncological head and neck surgery evidenced in the last decades have been linked to the progression in the reconstruction capacity of the defects resulting from resection of advanced tumors, allowing the improvement of both esthetic and functional results, as well as decrease the rate of postoperative complications in rescue surgery. To understand the situation of head and neck reconstruction across the country. a questionnaire about the current state of head and neck reconstructive surgery in Spain in otorhinolaryngology and head and neck surgery departments was distributed via email. Eighty (25.5%) of 313 ENT departments in Spain carry out some type of reconstruction in oncological surgery of the head and neck. Forty-four (55%) departments use regional pedicled flaps as a single reconstruction strategy, while 36 (45%) departments also employed the use of microvascular free flaps. Fifty-six (70%) departments perform 10 or less regional pedicled flaps per year, while 21 (29.6%) perform 10 or more flaps per year, with an average of 9.91 ± 11.73 flaps/year (min. 2, max. 40). Seven (8.75%) departments perform 10 or more free flaps a year, while the other 29 (36.25%) perform 10 or less, with an average of 4.96 ± 5.1 free flaps microvascular year (min. 2, max 20). In our country, head and neck cancer surgeries are performed in a tertiary level hospital and patients benefit from the reconstruction of post-surgical defects, through the use of regional pedicled or microvascular free flaps.

Hand surgery in Spain.

Hand surgery in Spain.

1077. Heart Transplantation as Salvage Treatment for Intractable Infective Endocarditis

BackgroundInfective endocarditis (IE) remains a severe disease with contemporary in-hospital mortality rates of 20%. Although valvular replacement is performed in 50% of patients during the acute phase, heart transplantation remains the last resort in selected patients with extensive perivalvular lesions or end-stage cardiac failure.MethodsCases were identified through the International Collaboration on Endocarditis (ICE) network. All patients who underwent heart transplantation during the acute phase of IE, with at least three months follow-up, were enrolled. Data were extracted from medical charts on a standardized questionnaire. Only patients who fulfilled Duke criteria for definite IE were enrolled.ResultsBetween 1991 and 2017, 19 patients (6 women, 13 men), with a median age of 52 years (interquartile range, 41–61) underwent heart transplantation for IE refractory to optimized medical treatment and/or other cardiac surgery in Spain (n = 9), France (n = 6), and Colombia, Croatia, Switzerland, and the United States (one patient each). IE affected prosthetic (n = 10), native valves (n = 9), primarily aortic (56%), and mitral (28%). Pathogens were oral streptococci (n = 7), Staphylococcus aureus (n = 5, including two methicillin-resistant), Enterococcus faecalis (n = 2), and Mycoplasma hominis, Haemophilus para-influenzae, Candida albicans (one patient each). Two cases were not documented. Main cardiac lesions were vegetations (n = 17), severe regurgitation (n = 15), peri-annular abscesses (n = 9), prosthetic valve desinsertion (n = 4), and intra-cardiac fistula (n = 1). Seventeen patients underwent cardiac surgery at least once before transplantation, and four patients were on circulatory assistance (left ventricular assist-device, or extra-corporeal membrane oxygenation, two patients each). Median delay between first cardiac surgery and transplantation was 28 days (IQR, 18–71). Six patients died (32%), including four during the first month post-transplant. Thirteen patients survived, with a median follow-up of 44 months post-transplantation (IQR, 13–88).ConclusionHeart transplantation may be considered as salvage treatment in highly selected patients with intractable infective endocarditis.Disclosures All authors: No reported disclosures.

Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain

Rationale: We performed a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 and realize that few surgical groups followed the ESPEN guidelines published in 2006. Ten years later we sent a questionnaire to check the current situation.

Outcome Quality Standards in Pancreatic Oncologic Surgery in Spain

IntroductionTo establish quality standards in oncologic surgery is a complex but necessary challenge to improve surgical outcomes. Unlike other tumors, there are no well-defined quality standards in pancreatic cancer. The aim of this study is to identify quality indicators in pancreatic oncologic surgery in Spain as well as their acceptable limits of variability. MethodsQuality indicators were selected based on clinical practice guidelines, consensus conferences, reviews and national publications on oncologic pancreatic surgery between the years 2000 and 2016. Variability margins for each indicator have been determined by statistical process control techniques and graphically represented with the 99.8 and 95% confidence intervals above and below the weighted average according to sample size. ResultsThe following indicators have been determined with their weighted average and acceptable quality limits: resectability rate 71% (>58%), morbidity 58% (<73%), mortality 4% (<10%), biliary leak 6% (<14%), pancreatic fistula rate 18% (<29%), hemorrhage 11% (<21%), reoperation rate 11% (<20%) and mean hospital stay (<21 days). ConclusionsTo date, few related series have been published, and they present important methodological limitations. Among the selected indicators, the morbidity and mortality quality limits have come out higher than those obtained in international standards. It is necessary for Spanish pancreatic surgeons to adopt homogeneous criteria regarding indicators and their definitions to allow for the comparison of their results.

Estándares de calidad en la cirugía oncológica pancreática en España

IntroductionTo establish quality standards in oncologic surgery is a complex but necessary challenge to improve surgical outcomes. Unlike other tumors, there are no well-defined quality standards in pancreatic cancer. The aim of this study is to identify quality indicators in pancreatic oncologic surgery in Spain as well as their acceptable limits of variability. MethodsQuality indicators were selected based on clinical practice guidelines, consensus conferences, reviews and national publications on oncologic pancreatic surgery between the years 2000 and 2016. Variability margins for each indicator have been determined by statistical process control techniques and graphically represented with the 99.8 and 95% confidence intervals above and below the weighted average according to sample size. ResultsThe following indicators have been determined with their weighted average and acceptable quality limits: resectability rate 71% (>58%), morbidity 58% (<73%), mortality 4% (<10%), biliary leak 6% (<14%), pancreatic fistula rate 18% (<29%), hemorrhage 11% (<21%), reoperation rate 11% (<20%) and mean hospital stay (<21 days). ConclusionsTo date, few related series have been published, and they present important methodological limitations. Among the selected indicators, the morbidity and mortality quality limits have come out higher than those obtained in international standards. It is necessary for Spanish pancreatic surgeons to adopt homogeneous criteria regarding indicators and their definitions to allow for the comparison of their results.