Factores asociados con la conversión a técnica abierta en la colecistectomía laparoscópica / Factors associated with conversion to open technique in laparoscopic cholecystectomy

Introducción. La colecistectomía laparoscópica es el estándar de oro para el manejo de la patología de la vesícula biliar con indicación quirúrgica. Durante su ejecución existe un grupo de pacientes que podrían requerir conversión a técnica abierta. Este estudio evaluó factores perioperatorios asociados a la conversión en la Clínica Central OHL en Montería, Colombia. Métodos. Estudio observacional analítico de casos y controles anidado a una cohorte retrospectiva entre 2018 y 2021, en una relación de 1:3 casos/controles, nivel de confianza 95 % y una potencia del 90 %. Se caracterizó la población de estudio y se evaluaron las asociaciones según la naturaleza de las variables, luego por análisis bivariado y multivariado se estimaron los OR, con sus IC95%, considerando significativo un valor de p<0,05, controlando variables de confusión. Resultados. El estudio incluyó 332 pacientes, 83 casos y 249 controles, mostrando en el modelo multivariado que las variables más fuertemente asociadas con la conversión fueron: la experiencia del cirujano (p=0,001), la obesidad (p=0,036), engrosamiento de la pared de la vesícula biliar en la ecografía (p=0,011) y un mayor puntaje en la clasificación de Parkland (p<0,001). Conclusión. La identificación temprana y análisis individual de los factores perioperatorios de riesgo a conversión en la planeación de la colecistectomía laparoscópica podría definir qué pacientes se encuentran expuestos y cuáles podrían beneficiarse de un abordaje mínimamente invasivo, en búsqueda de toma de decisiones adecuadas, seguras y costo-efectivas

Introduction. Laparoscopic cholecystectomy is the gold standard for the management of gallbladder pathology with surgical indication. During its execution, there is a group of patients who may require conversion to the open technique. This study evaluated perioperative factors associated with conversion at the OHL Central Clinic in Montería, Colombia. Methods. Observational analytical case-control study nested in a retrospective cohort between 2018 and 2021, in a 1:3 case/control ratio, 95% confidence level and 90% power. The study population was characterized and the associations were evaluated according to the nature of the variables, then the OR were estimated by bivariate and multivariate analysis, with their 95% CI, considering a value of p<0.05 significant, controlling for confounding variables. Results. The study included 332 patients, 83 cases and 249 controls, showing in the multivariate model that the variables most strongly associated with conversion were: the surgeon's experience (p=0.001), obesity (p=0.036), gallbladder wall thickening on ultrasonography (p=0.011), and a higher score in the Parkland classification (p<0.001). Conclusions. Early identification and individual analysis of the perioperative risk factors for conversion in the planning of laparoscopic cholecystectomy could define which patients are exposed, and which could benefit from a minimally invasive approach, in search of making safe, cost-effective, and appropriate decisions

Internal hernia after laparoscopic left colectomy: case series and review of the literature

Objective: Laparoscopic colectomy has gained acceptance as a standard treatment for benign and malignant colorectal disease, such as diverticular disease and cancer, among others. Same as in open surgery, the laparoscopic approach carries a low risk of small bowel obstruction in the postoperative period, but in laparoscopic surgery, internal hernia after laparoscopic left colectomy may be a cause of small bowel obstruction with a significant risk of morbidity and mortality. This rare complication may be prevented with routine closure of the mesenteric defects created during the colectomy. Methods: We present four cases of internal herniation after laparoscopic colectomy. Two cases were after laparoscopic left colectomy and two after laparoscopic low anterior resection. All four cases had full splenic flexure mobilization. Routine closure of the mesenteric defect was not performed in the initial surgery. Results: The four patients were treated by laparoscopic reintervention with closure of the mesenteric defect. In two of them, conversion to open surgery was necessary. One of the patients developed recurrent internal herniation after surgical reintervention with mesenteric closure of the defect. All patients were managed without need for bowel resection, and mortality rate was 0%. Conclusion Internal herniation after laparoscopic colorectal surgery is a highly morbid complication that requires prompt diagnosis and management and should be suspected in the early postoperative period. Additional studies with extended follow-up are required to establish recommendations regarding its prevention and management. (AU)

¿Día o noche? El momento ideal para realizar la colecistectomía / Day or night? The right time to perform cholecystectomy

Introducción. La frecuencia de complicaciones postquirúrgicas de la colecistectomía realizada en la noche es un tema de controversia, siendo que se ha reportado una frecuencia mayor durante el horario nocturno. El objetivo de este estudio fue analizar la presentación de colecistectomía difícil dependiendo de la hora en que se realizó la cirugía, además de otras complicaciones, estancia intrahospitalaria postquirúrgica, reingreso a 30 días y reintervención. Métodos. Se realizó un estudio retrospectivo, observacional, analítico y transversal, comparando la presentación de colecistectomía difícil y su frecuencia en horario diurno (8:00 am a 7:59 pm) y nocturno (8:00 pm a 7:59 am), además de seroma, absceso, hematoma, fuga biliar, biloma, estancia intrahospitalaria postquirúrgica, reingreso a 30 días y reintervención. Resultados. Se incluyeron en el estudio 228 pacientes, 117 operados durante el día (52 %) y 111 durante la noche (48 %). La colecistectomía difícil se presentó 26 % vs 34 % de los casos intervenidos en el día y la noche, respectivamente. La complicación más frecuente fue seroma (14 %). La estancia hospitalaria media fue de 2,7 días en cirugías diurnas y de 2,5 en cirugías nocturnas; hubo 3 % de reintervenciones y 6 %, respectivamente. También hubo 2 % de reingresos a los 30 días entre los pacientes operados en el día y 3 % entre los operados en la noche. Conclusiones. La frecuencia de colecistectomía difícil y las complicaciones, la estancia intrahospitalaria postquirúrgica, el reingreso a 30 días y la necesidad de reintervención, no tuvieron diferencias significativas respecto al horario de la cirugía.

Introduction. The frequency of post-surgical complications of cholecystectomy performed overnight is a matter of controversy, and a higher rate has been reported during the night shift. The objective of this study was to analyze the presentation of difficult cholecystectomy depending on the time the surgery was performed, in addition to other complications, postoperative hospital stay, 30-day readmission, and reintervention. Methods. A retrospective, observational, analytical and cross-sectional study was carried out, comparing the presentation of difficult cholecystectomy and its frequency during daytime (8:00 am to 7:59 pm) and at night (8:00 pm to 7:59 am), in addition of seroma, abscess, bile leak, biloma, hematoma, post-surgical hospital stay, 30-day readmission, and reintervention.Results. A total of 228 patients were included in the study, 117 patients operated during the day (52%), and 111 at night (48%). Difficult cholecystectomy occurred in 26% vs. 34% of the cases operated on during the day and at night, respectively. The most frequent complication was seroma (14%). The mean hospital stay was 2.7 days in day surgeries and 2.5 in night surgeries; there were also 2% readmission at 30 days among patients operated during the day and 3% among those operated on at night. Conclusions. The frequency of difficult cholecystectomy and complications, postoperative hospital stay, 30-day readmission, and the need of reintervention, did not have significant differences with respect to the time of surgery.

Pyélolithotomie par chirurgie ouverte (PLCO) par lombotomie: indications et résultats au service d'urologie du CHU de Conakry / Pyelolithotomy: Indications and Results at the Urology Department of the Conakry University Hospital

Objectif. Le but de cette étude était d'évaluer les résultats de la pyélolithotomie par chirurgie ouverte au service d'Urologie de l'hôpital national Ignace Deen, CHU de Conakry. Méthodes. Il s'agissait d'une étude prospective et descriptive portant sur les patients opérés de lithiase pyélique du 1er janvier 2018 au 31 décembre 2020. Les variables étudiées étaient sociodémographique, clinique, paraclinique et thérapeutique. Résultats. Dans notre étude la lithiase pyélique a occupé la première place parmi les lithiases du haut appareil urinaire n=50 (56%) et le deuxième rang par rapport à l'ensemble des calculs urinaires n=28 (29,9%). La tranche d'âge la plus touchée était celle de 31 à 40 ans avec 32,1%. Le sexe ratio était de 18 hommes pour 10 femmes. La douleur lombaire était le principal motif de consultation. L'examen cytobactériologique des urines a mis en évidence une infection chez 24 patients soit 85,7%. L'UIV avait permis de poser le diagnostic dans 85,7% des cas. La taille moyenne des calculs était de 24,1 ± 6,7 mm de diamètre. La durée moyenne d'intervention était de 103±38mn. En peropératoirenous avons enregistré deux cas d'ouverture accidente du péritoine, un cas d'avulsion de l'uretère, et un cas de lésion du pelvis rénal. La principale complication post-opératoire, était l'infection du site opératoire dans 28,6% des cas Conclusion. La pyélolithotomie par chirurgie ouverte garde encore ses indications dans certains pays du tiers monde comme le nôtre. De nos jours elle est de plus en plus rare au profi t des techniques mini- invasives (LEC ; Endo- urologie)

Surgery for lumbar disc herniation: open x minimally invasive technique / Cirurgia de hérnia discal lombar: técnica aberta x minimamente invasiva / Cirugía de hernia discal lumbar: técnica abierta x mínimamente invasiva

ABSTRACT Objective: In Brazil, there are no studies comparing endoscopic treatment of lumbar disc herniation with the conventional open technique in SUS (Unified Health System) with regard to hospitalization time and complications occurring within one year, which is the objective of this study. Methods: A survey of 32 surgeries performed in 2019 (11 open and 21 endoscopic) to evaluate pain parameters before and after surgery (VAS), days of hospitalization, and complications. The data were submitted to statistical analysis (ANOVA) using the Kruskal-Wallis test. Results: Fourteen patients were female and eighteen were male, with a mean age of 41.35 years (p> 0.05 between sexes). The pre- and postoperative VAS for pain radiating to the lower limb were similar between the groups: 8.5 ± 0.82 with the open technique and 8.19 ± 1.15 with endoscopic technique. In both groups there was an improvement in the pain pattern with a significant reduction in the VAS (p < 0.05) and there was no statistical relevance between the groups in terms of pain improvement. There was statistical relevance between the groups in the comparison of days of hospitalization required, with the group submitted to endoscopic surgery having a lower number of days. The complications reported were compatible with those found in the literature (postoperative dysesthesia, new herniation). Conclusions: The endoscopic technique resulted in an important reduction in the number of days of hospitalization, a factor with a high impact on the costs of any surgical procedure, which can be a determining factor in the feasibility of minimally invasive techniques. Level of evidence IV; Therapeutic Study.

RESUMO Objetivos: No Brasil, não há estudos que comparem o tratamento endoscópico de hérnia de disco lombar no SUS (Sistema Único de Saúde) com a técnica aberta convencional, no que diz respeito aos resultados com relação ao tempo de internação e complicações ocorridas em um ano, o que vem a ser o objetivo deste estudo. Métodos: Levantamento de 32 cirurgias realizadas em 2019 (11 por via aberta e 21 por via endoscópica) para avaliar os parâmetros de dor antes e depois da cirurgia (EVA), dias de internação e complicações. Os dados foram submetidos à análise estatística (ANOVA) com o teste de Kruskal-Wallis. Resultados: Catorze pacientes eram do sexo feminino e 18 do sexo masculino, com média de idade de 41,35 anos (p > 0,05 para os dois sexos). A EVA de dor irradiada para o membro inferior no pré e pós-operatório foi semelhante entre os grupos: 8,5 ± 0,82 com a técnica aberta e 8,19 ± 1,15 com a técnica endoscópica. Em ambos os grupos houve melhora do padrão de dor com redução significativa da EVA (p < 0,05) e não houve relevância estatística entre os grupos quanto à melhora do dor. Na comparação das diárias de internação necessárias houve relevância estatística entre os grupos, sendo que o grupo submetido à endoscopia teve número menor de diárias. As complicações relatadas são compatíveis com as encontradas na literatura (disestesia pós-operatória, nova herniação). Conclusões: A técnica endoscópica resultou em redução importante do número de dias de internação, fator com alto impacto nos custos de qualquer procedimento cirúrgico, que pode ser determinante para viabilizar técnicas minimamente invasivas. Nível de evidência IV; Estudo Terapêutico.

RESUMEN Objetivos: En Brasil, no hay estudios que comparen el tratamiento endoscópico de hernia de disco lumbar en el SUS (Sistema Único de Salud) con la técnica abierta convencional, en lo que refiere a los resultados con relación al tiempo de internación y complicaciones ocurridas en un año, lo que viene a ser el objetivo de este estudio. Métodos: Levantamiento de 32 cirugías realizadas en 2019 (once por vía abierta y veintiuna por vía endoscópica) para evaluar los parámetros de dolor antes y después de la cirugía (EVA), días de internación y complicaciones. Los datos fueron sometidos a análisis estadístico (ANOVA) con el test de Kruskal-Wallis. Resultados: Catorce pacientes eran del sexo femenino y dieciocho del sexo masculino con promedio de edad de 41,35 años (p>0,05 para los dos sexos). La EVA de dolor irradiado para el miembro inferior en el pre y postoperatorio fue semejante entre los grupos: 8,5±0,82 con la técnica abierta y 8,19±1,15 con la técnica endoscópica. En ambos grupos hubo mejoras del patrón de dolor con reducción significativa de la EVA (p<0,05) y no hubo relevancia estadística entre los grupos cuanto a la mejora del dolor. En la comparación de los días de internación necesarios hubo relevancia estadística entre los grupos, siendo que el grupo sometido a la endoscopia tuvo número menor de días de internación. Las complicaciones relatadas son compatibles con las encontradas en la literatura (disestesia postoperatoria, nueva herniación). Conclusiones: La técnica endoscópica resultó en reducción importante del número de días de internación, factor con alto impacto en los costos de cualquier procedimiento quirúrgico, que puede ser determinante para viabilizar técnicas mínimamente invasivas. Nivel de evidencia IV; Estudio Terapéutico.

Colecistectomía subtotal: una alternativa en el manejo de la colecistectomía difícil / Subtotal cholecystectomy: an alternative in the management of difficult cholecystectomy

Introducción. Alrededor de un 10 % de las laparoscopias se convierten a cirugía abierta por dificultades en obtener una visión crítica durante la colecistectomía en colecistitis severas. La colecistectomía subtotal es una posibilidad terapéutica disponible, que disminuye la tasa de conversión en cirugía laparoscópica y mantiene bajas tasas de morbilidad y mortalidad. Métodos. Estudio descriptivo, retrospectivo, de pacientes sometidos a colecistectomía subtotal en la Clínica CES (Medellín, Colombia) entre enero y diciembre de 2015. Se identificaron variables demográficas, detalles de la cirugía, morbilidad y mortalidad. Resultados. De un total de 710 colecistectomías en dicho periodo, a 17 (2,4 %) se les realizó colecistectomía sub-total. Quince (88 %) de ellas fueron por laparoscopia y dos requirieron conversión. La distribución en cuanto a sexo fue similar (10 mujeres / 7 hombres) y la edad promedio fue de 51 años. El tiempo quirúrgico promedio fue de 119 minutos. En 14 (82 %) pacientes se dejó drenaje subhepático. Dos pacientes presentaron fístula biliar y un paciente reingresó por un hematoma; no se presentaron otras complicaciones. La estancia hospitalaria promedio fue de 5,2 días. Discusión. La colecistectomía subtotal es una alternativa en pacientes con colecistectomía difícil y en nuestra experiencia presenta una alta tasa de éxito

Introduction. About 10% of laparoscopies are converted to open surgery due to difficulties in obtaining critical vision during cholecystectomy in severe cholecystitis. Subtotal cholecystectomy is an available therapeutic possibi-lity, which decreases the conversion rate in laparoscopic surgery and maintains low morbidity and mortality rates.Methods. Descriptive, retrospective study of patients who underwent subtotal cholecystectomy between January and December 2015. Demographic variables, details of surgery, morbidity and mortality were identified.Results. Of a total of 710 cholecystectomies in that period, 17 (2.4%) underwent subtotal cholecystectomy. Fifteen (88%) of them were by laparoscopy and two required conversion. The gender distribution was similar (10 women/7 men) and the average age was 51 years. The average surgical time was 119 minutes. Subhepatic drainage was left in 14 (82%) patients. Two patients had a biliary fistula and one patient was readmitted for a hematoma; there were no other complications. The average hospital stay was 5.2 days.Discussion. Subtotal cholecystectomy is an alternative in patients with difficult cholecystectomy and in our experience, it has a high success rate

¿Es más difícil la colecistectomía laparoscópica después de una colangiopancreatografía retrógrada endoscópica? Experiencia en un hospital de tercer nivel / Is the laparoscopic cholecystectomy more difficult after endoscopic retrograde cholangiopancreatography? Experience in a third level hospital

Introducción. La colecistectomía laparoscópica es el tratamiento estándar para la colecistitis aguda. En pacientes con coledocolitiasis, la colangiopancreatografía retrógrada endoscópica es el tratamiento de elección. Se ha reportado que, después de este procedimiento endoscópico, la colecistectomía laparoscópica es más difícil y son mayores las tasas de conversión, hemorragia y tiempo operatorio. El objetivo de este estudio fue determinar si en nuestro medio las colecistectomías laparoscópicas posteriores a este procedimiento endoscópico presentan más complicaciones posquirúrgicas y mayor dificultad técnica. Métodos. Estudio de cohorte prospectivo, en el que se comparó un grupo de pacientes sometidos a colecistectomía laparoscópica previa colangiopancreatografía retrógrada endoscópica, contra un grupo homogéneo de pacientes sin colangiografía previa, para evaluar la dificultad en la colecistectomía laparoscópica, la conversión, la reintervención y las complicaciones. Resultados. El 45,4 % de las cirugías fueron difíciles.No hay relación entre la realización previa de colangio-pancreatografía retrógrada endoscópica y la dificultad de la colecistectomía laparoscópica. Con el modelo de regresión logística, se encontraron como factores predictores para una cirugía difícil, la edad, el sexo masculino, la cirugía abdominal previa, la colecistitis aguda y la mayor gravedad de la colecistitis aguda. Conclusión. La colangiopancreatografía retrógrada endoscópica en nuestro medio no constituye un factor de riesgo para dificultad en la colecistectomía laparoscópica. Debe prestarse especial cuidado al sexo masculino, la gravedad de la colecistitis aguda, los antecedentes de cirugía abdominal y la presencia de comorbilidades a la hora de planear una colecistectomía laparoscópica, tomando precauciones adicionales en estos casos para prevenir complicaciones

Introduction: Laparoscopic cholecystectomy is the standard treatment for acute cholecystitis. In patients who also have choledocholithiasis, endoscopic retrograde cholangiopancreatography is the treatment of choice. In some studies, it has been reported that, after this endoscopic examination, laparoscopic cholecystectomy is more difficult, and conversion rates, bleeding and operative time are higher. The objective of this study was to determine whether laparoscopic cholecystectomies after this endoscopic procedure present more postoperative complications and greater technical difficulty in our setting.Methods: Prospective cohort study, in which a group of patients who underwent laparoscopic cholecystectomy prior endoscopic retrograde cholangiopancreatography was compared against a homogeneous group of patients without previous cholangiography, to assess the difficulty of laparoscopic cholecystectomy, conversion, reoperation and complications.Results: 45.4 % of the surgeries were difficult. There is no relationship between the previous performance of ERCP and the difficulty of laparoscopic cholecystectomy. With the logistic regression model, age, male gender, previous abdominal surgery, acute cholecystitis and greater degree of severity of acute cholecystitis were found as predictive factors for difficult surgery.Conclusion: ERCP in our setting is not a risk factor for difficult laparoscopic cholecystectomy. Special care should be taken to the male gender, the severity of acute cholecystitis, the history of abdominal surgery and the presence of comorbidities when planning a laparoscopic cholecystectomy, taking additional precautions in these cases to prevent complications

Tasas de conversión de colecistectomía laparoscópica a colecistectomía abierta y factores asociados, en un hospital de mediana complejidad / Conversion rates from laparoscopic cholectistectomy to open cholecistectomy and associated factors, in a medium complexity hospital

OBJETIVO: Determinar tasa de conversión de colecistectomía laparoscópica, y su distribución por edad, sexo, y comorbilidades. Materiales y método: Estudio descriptivo de corte transversal. Se seleccionó pacientes sobre 50 años que requirieron colecistectomía laparoscópica. Fue determinado el porcentaje de conversión general y por grupo etario. Finalmente se calculó el porcentaje de conversiones según sexo, patologías asociadas y carácter de la cirugía. Resultados: De 175 colecistectomías, 17 (9,1%) requirieron conversión. También se determinó que a mayor edad, mayor tasa de conversión. Pacientes femeninas presentaron menor tasa de conversión que masculinos. Discusión: Los resultados demuestran tasa de conversión baja en comparación con lo expuesto por la literatura. Sexo masculino, edad extrema y presencia de complicaciones son posiblemente de mayor riesgo. Creemos relevante realizar más estudios, ahondando en la evolución postoperatoria.

OBJETIVE: Establish conversion rates of laparoscopic cholecystectomy, and its distribution by age, sex, and comorbidities. Materials and Method: Descriptive cross-sectional study. We selected patients over 50 years old, who needed laparoscopic cholecystectomy. Rates of conversion were determined. Finally, the proportions according to sex, associated pathologies and urgency of the surgery were determined. Results: From 175 cholecystectomies, 17 (9,1%) needed conversion. It was also determined that higher age relates to higher conversion rate. Female patients had lower conversion rate than males. Discussion: The results obtained, show low conversion rates comparing with those featured in literature. Males, extreme ages and presence of complications are possibly at greater risk. We believe it's important to perform more studies involving postoperative evolution

Intraoperative serious complications of laparoscopic urological surgeries: a single institute experience of 4, 380 procedures

ABSTRACT This study aimed to share a single institute experience of 4,380 procedures about in-traoperative serious complications of laparoscopic urological surgeries. From January 2005 to December 2013, 4,380 cases of laparoscopic urological surgeries were recruited in our department. The distribution, incidence, and characteristics of intraoperative serious complications were retrospectively sorted out and analyzed. The surgeries were divided into three groups: very difficult (VD), difficult (D), and easy (E). The com¬plication at Satava class II was defined to be serious. One hundred thirty one cases with intraoperative serious complications were found (3.0%). The incidence of these complications was significantly increased along with the difficulty of the surgeries (P<0.05). The highest morbidity of serious complication belonged to total cystectomy with a ratio of about 17% as compared with other surgeries (P<0.05). The types of these complications included small vascular injury demanding blood transfusion (101 cases, 77.1%), large vascular (venous and artery) injury (16 cases), hypercapnia & acidosis (8 cases), and organ injury (6 cases). The cases of conversion to open surgery were 37 (≤1%). There was no significant difference in the rates of conversion to open surgery among the three groups (P>0.05). The overall tendency of the intraoperative serious complications was decreasing with the time from 2005 to 2013. In conclusion, through standardized training including improving the surgical technique, being familiar with the anatomic relationship, and constantly summarizing the experience and lessons, laparoscopic surgery could be safe and effective with not only minimal invasion but also few complications.

Long-term Survival Outcomes of Laparoscopic Gastrectomy for Advanced Gastric Cancer: Five-year Results of a Phase II Prospective Clinical Trial

PURPOSE: Despite an increased acceptance of laparoscopic gastrectomy (LG) in early gastric cancer (EGC), there is insufficient evidence for its oncological safety in advanced gastric cancer (AGC). This is a prospective phase II clinical trial to evaluate the feasibility of LG with D2 lymph node dissection (LND) in AGC. MATERIALS AND METHODS: The primary endpoint was set as 3-year disease-free survival (DFS). The eligibility criteria were as follows: 20-80 years of age, cT2N0-cT4aN3, American Society of Anesthesiologists score of 3 or less, and no other malignancy. Patients were enrolled in this single-arm study between November 2008 and May 2012. Exclusion criteria included cT4b or M1, or having final pathologic results as EGC. All patients underwent D2 lymphadenectomy. Three-year DFS rates were estimated by the Kaplan-Meier method. RESULTS: A total of 157 patients were enrolled. The overall local complication rate was 10.2%. Conversion to open surgery occurred in 11 patients (7.0%). The mean follow-up period was 55.0±20.4 months (1–81 months). The cumulative 3-year DFS rates were 76.3% for all stages, and 100%, 89.3%, 100%, 88.0%, 71.4%, and 35.3% for stage IB, IIA, IIB, IIIA, IIIB, and IIIC, respectively. Recurrence was observed in 37 patients (23.6%), including hematogenous (n=6), peritoneal (n=13), locoregional (n=1), distant node (n=8), and mixed recurrence (n=9). CONCLUSIONS: In addition to being technically feasible for treatment of AGC in terms of morbidity, LG with D2 LND for locally advanced gastric cancer showed acceptable 3-year DFS outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01441336

Feasibility of transanal total mesorectal excision in cases with challenging patient and tumor characteristics

PURPOSE: To assess the feasibility of transanal total mesorectal excision in difficult cases including obese patients or patients with bulky tumors or threatened mesorectal fascias. METHODS: We performed laparoscopy-assisted transanal total mesorectal excision in patients with biopsy-proven rectal adenocarcinoma located 3–12 cm from the anal verge as part of a prospective, single arm, pilot trial. The primary endpoint was resection quality and circumferential resection margin involvement. Secondary endpoints included the number of harvested lymph nodes and 30-day postoperative complications. RESULTS: A total of 12 patients (9 men and 3 women) were enrolled: one obese patient, 7 with large tumors and 8 with threatened mesorectal fascias (4 patients had multiple indications). Tumors were located a median of 5.5 cm from the anal verge, and all patients received preoperative chemoradiotherapy. Median operating time was 191 minutes, and there were no intraoperative complications. One patient needed conversion to open surgery for ureterocystostomy after en bloc resection. Complete or near-complete excision and negative circumferential resection margins were achieved in all cases. The median number of harvested lymph nodes was 15.5. There was no postoperative mortality and 3 cases of postoperative morbidity (1 postoperative ileus, 1 wound problem near the stoma site, and 1 anastomotic dehiscence). CONCLUSION: This pilot study showed that transanal total mesorectal excision is also feasible in difficult laparoscopic cases such as in obese patients or those with bulky tumors or tumors threatening the mesorectal fascia. Additional larger studies are needed.

Mucinous carcinoma is a predictive factor for the risk of open conversion from laparoscopic colectomy in colorectal cancer

PURPOSE: Although laparoscopic surgery is widely accepted in the treatment of colorectal cancer, conversion to open surgery is associated with the rate of unfavorable outcomes. The aim of this study was to determine the factors associated with open conversion from laparoscopic surgery for colorectal cancer.METHODS: A total of 3,002 patients who underwent laparoscopic colectomy as an initial plan for the treatment of colorectal cancer located from the sigmoid colon to the rectum were retrospectively evaluated between January 2009 and December 2018 at Samsung Medical Center in Korea. Risk factors significantly associated with open conversion were determined using univariate and multivariate regression models.RESULTS: Among the 3,002 patients, open conversion was performed in 120 patients (4%). Age >60 years (adjusted odds ratio [AOR], 2.370), preoperative bowel obstruction (AOR, 2.348), clinical T4 stage (AOR, 2.201), and serum carcinoembryonic antigen level >5 ng/mL (AOR, 2.289) were significantly associated with open conversion. Moreover, mucinous carcinoma was a significantly more frequent histopathologic type than adenocarcinoma (10.0% vs. 3.2%, P<0.001) in the open conversion group with an AOR of 2.549 (confidence interval, 1.259–5.159; P=0.009).CONCLUSION: The present study presented a novel finding, i.e. mucinous carcinoma as the histopathologic type could be an independent predictive factor for conversion from laparoscopic colectomy to open surgery. Identifying patients with mucinous carcinoma will help stratify the risk of open conversion preoperatively.

Feasibility and Safety of Single-Incision Laparoscopic Appendectomy by a Surgical Resident under Supervision of a Staff Surgeon

PURPOSE: This study was aimed at reporting our experience with single-incision laparoscopic appendectomies (SILA) performed by a surgical resident, and to evaluate the safety and feasibility of the procedure, together with a comparison of the outcomes of the same procedure performed by a staff surgeon. METHODS: We conducted a retrospective case series analysis of 60 consecutive patients who underwent SILA. Two surgeons, an attending staff surgeon and a second-year surgical resident, performed the SILA procedures. SILA procedures performed by the resident were intraoperatively guided and supervised by the staff surgeon. RESULTS: A total of 60 case-matched patients with acute appendicitis underwent a SILA performed by either the resident or attending staff. There was no difference in patient demographics between the two groups of patients. The mean operation time was longer in the resident group than in the staff group (43.2±6.0 minutes vs. 32.9±10.5 minutes, p<0.001). There was no significant difference in the operative data between the two groups. No conversion to an open procedure occurred in either group. Postoperative pain, time to onset of oral intake, and number of days of postoperative hospital stay were similar in both groups. CONCLUSION: SILA procedures performed by a resident are safe and feasible despite longer operation times. Perioperative supervision and guidance by an attending staff surgeon may facilitate surgical outcomes.

A Single Center Experience for a Feasibility of Totally Laparoscopic Living Donor Right Hepatectomy

PURPOSE: Donor safety is the most important problem of living donor liver transplantation (LDLT). Although laparoscopic liver resection has gained popularity with increased surgical experience and the development of laparoscopes and specialized instruments, a totally laparoscopic living donor right hepatectomy (LDRH) technique has not been investigated for efficacy and feasibility. We describe the experiences and outcomes associated with LDRH in adult-to-adult LDLT in order to assess the safety of the totally laparoscopic technique in donors. METHODS: Between May 2016 and July 2017, we performed hepatectomies in 22 living donors using a totally laparoscopic approach. Among them, 20 donors underwent LDRH. We retrospectively reviewed the medical records to ascertain donor safety and the reproducibility of LDRH; intra-operative and post-operative results including complications were demonstrated after performing LDRH. RESULTS: The median donor age was 29 years old and the median body mass index was 22.6 kg/m2. The actual graft weight was 710 g and graft weight/body weight (GRWR) was 1.125. No donors required blood transfusion, conversion to open surgery, or reoperation. The postoperative mortality was nil and postoperative complications were identified in two donors. One had fluid collection in the supra-pubic incision site for graft retrieval and the second had a minor bile leakage from the cutting edge of the right hepatic duct stump. All the liver function tests returned to normal ranges within one month. CONCLUSION: LDRH is a feasible operation owing to low blood loss and few complications. However, LDRH can be initially attempted after attaining sufficient experience in laparoscopic hepatectomy and LDLT techniques.

Tasa de conversión y morbilidad en el abordaje laparoscópico en pacientes seleccionados con obstrucción intestinal adherencial / Morbidity and Conversion Rate in Laparoscopy Approach in Selected Patients with Adhesive Intestinal Obstruction

Introducción: El síndrome adherencial es la causa más frecuente de obstrucción de intestino delgado. La laparotomía es el abordaje estándar. El avance de la cirugía mínimamente invasiva hace posible la resolución de cuadros obstructivos por laparoscopia. Objetivo: Analizar el abordaje laparoscópico de la obstrucción intestinal y compararlo con la vía abierta. Método: Análisis retrospectivo de los pacientes tratados de obstrucción intestinal aguda mediante laparoscopia en nuestro hospital desde 2012 hasta 2016. Se utilizó como referencia un grupo de pacientes tratados desde 2002 hasta 2005, cuando sólo se usaba el abordaje abierto. Se analizaron datos demográficos, riesgo quirúrgico, comorbilidades, métodos diagnósticos y complicaciones (Clavien). Resultados: De los 134 pacientes intervenidos de obstrucción intestinal aguda, se inició un abordaje laparoscópico en 47 (35 pr ciento). Por esta vía sólo se completaron 32 pacientes (68 por ciento). La tasa de conversión fue del 32 por ciento, estos pacientes fueron eliminados del estudio. En el grupo de referencia se analizaron al azar 32 pacientes. Ambos grupos son comparables. El grupo tratado con abordaje laparoscópico tuvo un 9 por ciento de complicaciones y un 3 por ciento de reintervenciones, con una sola lesión inadvertida. El grupo laparoscópico tuvo un 12,5 por ciento de reintervenciones, todas por evisceración, pero tuvo una lógica mayor tasa de resecciones intestinales. No hubo mortalidad hospitalaria. Conclusión: Los resultados en los pacientes en que se ha completado la cirugía por laparoscopia se comparan favorablemente con los del abordaje abierto en un grupo histórico homogéneo de referencia, y sin el riesgo añadido de evisceración(AU)

Introduction: Adherence syndrome is the most frequent cause of small bowel obstruction. Laparotomy is the standard approach. The progress of minimally invasive surgery makes it possible to resolve obstructive frames by laparoscopy. Objective: To analyze the laparoscopic approach for intestinal obstruction and compare it with the open pathway. Method: Retrospective analysis of patients treated for acute intestinal obstruction by laparoscopy in our hospital, from 2012 to 2016. A group of patients treated from 2002 to 2005 were used as reference, when only the open approach was used. We analyzed demographic data, surgical risk, comorbidities, diagnostic methods and complications (Clavien). Results: Within the 134 patients operated for acute intestinal obstruction, a laparoscopic approach was started in 47 (35 percent). Only 32 patients (68 percent) were completed in this way. The conversion rate was 32 percent, these patients were eliminated from the study. In the reference group, 32 patients were randomly analyzed. Both groups are comparable. The group treated with laparoscopic approach had 9 por ciento complications and 3 percent reoperations, with a single unexpected lesion. The laparoscopic group had 12.5 of reintervention, all due to evisceration, but had a higher rate of intestinal resections. There was no hospital mortality. Conclusion: In patients who have completed laparoscopic surgery, the results are compared favorably with those of the open approach in a homogeneous historical reference group, and without the added risk of evisceration(AU)

Late open conversion in ruptured abdominal aortic aneurysm after endovascular repair / Conversão tardia para cirurgia aberta em um aneurisma roto da aorta abdominal após reparo endovascular

Abstract Despite technological advances, the long-term outcomes of endovascular aortic aneurysm repair (EVAR) are still debatable. Although most endograft failures after EVAR can be corrected with endovascular techniques, open conversion may still be required. A 70-year-old male patient presented at the emergency unit with abdominal pain. Twice, in the third and fourth years after the first repair, a stent graft had been placed over a non-adhesive portion of the stent graft due to type Ia endoleaks. In the most recent admission, a CT scan showed type III endoleak and ruptured aneurysm sac. On this occasion the patient underwent late open conversion. The failure was repaired with total preservation of the main endovascular graft body and interposition of a bifurcated dacron graft. This case demonstrates that lifelong radiographic surveillance should be considered in this subset of patients. Late open conversion following EVAR of ruptured abdominal aortic aneurysms can be performed safely.

Resumo Apesar dos avanços tecnológicos, os desfechos de longo prazo do reparo endovascular de aneurismas da aorta abdominal (endovascular aortic aneurysm repair - EVAR) ainda são objeto de debate. Embora a maioria das falhas de endoenxerto após EVAR possam ser corrigidas com técnicas endovasculares, conversão para cirurgia aberta ainda pode ser necessária. Um paciente de 70 anos de idade, do sexo masculino, apresentou-se no serviço de emergência com dor abdominal. Duas vezes, dois e quatro anos após o primeiro reparo, um enxerto foi colocado sobre uma porção não adesiva do stent devido a endoleak tipo Ia. Na mais recente hospitalização, a tomografia computadorizada mostrou endoleak tipo III e ruptura de um saco aneurismático. Nesta ocasião, o paciente foi submetido a conversão tardia para cirurgia aberta. A falha foi tratada com preservação total do corpo principal do enxerto endovascular e interposição de um enxerto tipo Dacron bifurcado. Este caso demonstra que a vigilância radiográfica ao longo de toda a vida deveria ser considerada nesse subgrupo de pacientes. Conversão tardia para cirurgia aberta após EVAR de aneurismas rotos da aorta abdominal pode ser realizada com segurança.

Predictors of Failed Laparoscopic Appendectomy in Perforated Appendicitis

PURPOSE: A recent internal review of a community-based hospital system revealed a 19.19% rate of conversion from a laparoscopic appendectomy to an open procedure. This study examined the preoperative risk factors for failed laparoscopic appendectomy requiring a conversion to a laparotomy. METHODS: A total of 198 patients presented with perforated appendicitis. Perforation was defined as a computed tomography (CT) scan interpretation, pathology findings, or surgical findings. Of these patients, 161 underwent a laparoscopic appendectomy or laparoscopy converted to an open procedure. The preoperative risk factors in the two groups were compared through a retrospective chart review. RESULTS: Through multivariant analysis, age greater than 45 was the greatest risk factor for the need to convert to an open procedure with an odds ratio (OR) of 3.51. A CT scan read of perforation was associated with a significant 2.65 OR. The C-reactive protein was 19.82 mg/L in the failed laparoscopic cases and 9.96 mg/L in the laparoscopic cases. CONCLUSION: Patients older than 45 years old with a CT radiologist's read of a perforation in multivariant analysis have an increased risk of failed laparoscopic surgery requiring conversion to open surgery.

Factores preoperatorios de riesgo asociados a conversión a técnica abierta en colecistectomía laparoscópica de urgencia / Preoperative risk factors associated with conversion to open technique in emergency laparoscopic cholecystectomy

Introducción. La colecistectomía laparoscópica es la técnica de elección en pacientes con indicación de extracción quirúrgica de la vesícula; sin embargo, en promedio, el 20 % de estos requieren conversión a técnica abierta. En este estudio se evaluaron los factores preoperatorios de riesgo para conversión en colecistectomía laparoscópica de urgencia. Metodología. Se llevó un estudio de casos y controles no pareado. Se obtuvo información sociodemográfica y de las variables de interés de los registros de las historias clínicas de los pacientes operados entre el 2013 y el 2016. Se identificaron los motivos de conversión de la técnica quirúrgica. Se caracterizó la población de estudio y se estimaron las asociaciones según la naturaleza de las variables. Mediante un análisis de regresión logística se ajustaron las posibles variables de confusión. Resultados. Se analizaron los datos de 444 pacientes (111 casos y 333 controles). La causa de conversión más frecuente fue la dificultad técnica (50,5 %). Se encontró que la mayor edad, el sexo masculino, el antecedente de cirugía abierta en hemiabdomen superior, el signo clínico de Murphy positivo, la dilatación de la vía biliar, la leucocitosis y la mayor experiencia del cirujano fueron los factores de riesgo para la conversión. Se encontró un área bajo la curva ROC de 0,743 (IC95% 0,692-0,794, p≤0,001). Discusión. Existen factores que se asocian a mayor riesgo de conversión en colecistectomía laparoscópica. La mayoría se relaciona con un proceso inflamatorio avanzado, por lo que la intervención temprana y oportuna debe ser el estándar de manejo en el abordaje de pacientes con patología quirúrgica de la vesícula

Introduction: Laparoscopic cholecystectomy is the preferred technique for patients with indication for gallbladder extraction. Nevertheless, up to near 20% of them require conversion to open surgery. In this study we evaluated preoperative risk factors for conversion in patients undergoing emergency laparoscopic cholecystectomy. Methodology: a case-control unmatched study was conducted. Sociodemographic Information and other variables were obtained from the medical records of patients that underwent surgery in the period 2013 to 2016. Reasons for conversion were identified and the study population was characterized. Correlations tests were established and logistic regression was performed for evaluating the role of confounding factors. Results: we analyzed the medical records of 444 patients (111 cases and 333 controls). The most common reasons for conversion were technical difficulty (50,5%), older age, male sex, previous open upper abdominal surgery, Murphy´s sign, bile duct dilation, total white cell count >12.000/mm3 , and a more experienced surgeon. Area under COR was 0.743 (CI95% 0.692­0.794, p= <0.001). Discussion: some factors increase the risk for conversion to open surgery in laparoscopic cholecystectomy. Most of them are related to an advanced gallbladder inflammatory process, thus early and timely intervention should be the gold standard in the management of patients with surgical gallbladder pathology

Feasibility of Emergency Laparoscopic Reoperations for Complications after Laparoscopic Surgery for Colorectal Cancer

PURPOSE: Laparoscopic surgery (LS) is an alternative to colorectal cancer surgery. Little evidence supports LS for emergency reoperation after laparoscopic colorectal surgery. The aim of this study was to assess perioperative outcomes of LS as an emergency reoperation for early complications after LS for colorectal cancer. METHODS: From June 2006 through December 2016, 732 consecutive patients underwent elective LS for colorectal cancer at Kyung Hee University Hospital, Seoul, Korea. Among these patients, we retrospectively reviewed data on those who received emergency laparoscopic reoperations for complications within 30 days after surgery. Variables associated with perioperative outcomes were analyzed. RESULTS: After exclusion of 50 patients (6.8%) who needed conversion to open surgery during LS, 79 of 682 patients (11.6%) received reoperation for complications, recurrence, and other benign diseases. Among them, 22 patients underwent emergency laparoscopic reoperation for early complications. Mean age of the patients was 62 years, and most underwent low anterior resection as a primary operation (n=17, 77.3%). Anastomotic leakage was the most common reason for reoperation (n=14, 63.6%). Postoperative complication occurred in 6 patients (27.3%), but none required further surgical intervention. Patients had first bowel movements at 2.8 days after reoperation, and length of hospital stay was 17.2 days after reoperation. CONCLUSION: Laparoscopic reoperation showed acceptable outcomes. LS as a reoperation for complications seemed to be feasible after LS for colorectal cancer.

Fístula biliopleurobronquial: reporte de un caso / Bronchobiliary fistula: Report of a case

La fístula biliopleurobronquial (FBB) es una comunicación anormal entre la vía biliar y el árbol bronquial. Es una condición infrecuente, generalmente secundaria a un proceso infeccioso local o a un evento traumático. La bilioptisis es patognomónica. Presentamos el caso de una mujer de 37 años con historia de cirrosis biliar secundaria, en lista para trasplante hepático, con múltiples episodios de colangitis previos y usuaria de derivación biliar externa, quien curso con bilioptisis y mediante gammagrafía HIDA con SPECT se confirmó fistula biliopleurobronquial. Éste caso se resolvió con derivación percutánea de la vía biliar

Bronchobiliary fistula (BBF) is an abnormal communication between the biliary tract and the bronchial tree. Is an infrequent condition, usually secondary to a local infectious process or a traumatic event. Bilioptisis is pathognomonic. We present the case of a 37 year old woman with secondary biliary cirrhosis, in list for liver transplantation, with several episodes of cholangitis and carrier of external biliary diverivation, who presented bilioptisis and HIDA scintigraphy with SPECT confirmed BBF. This case was resolved with percutaneous derivation of the biliary tract