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)

Abordaje abierto versus laparoscópico para la reconstitución del tránsito luego de la cirugía de Hartmann: resultados de una experiencia de 10 años / Open versus laparoscopic approach for Hartmann's reversal: results of a 10-year retrospective cohort study

Resumen Objetivo: El objetivo de este estudio es comparar los resultados perioperatorios del abordaje abierto (AA) con el abordaje laparoscópico (AL) para la reconstitución de tránsito (RT), y determinar factores de riesgo asociados a morbilidad posoperatoria. Material y Métodos: Se estudiaron pacientes consecutivos sometidos a RT entre enero de 2007 y diciembre de 2016 en nuestro centro. Se excluyeron aquellos con grandes hernias incisionales que requirieran reparación abierta simultánea. Se consignaron variables demográficas y perioperatorias, y se compararon ambos grupos. Además, se realizó una regresión logística para la identificación de factores de riesgo asociados a morbilidad posoperatoria en la serie. Resultados: Se realizaron 101 RT en el período. Se excluyeron 14 casos por hernia incisional, por lo que se analizaron 87 casos (46 AA y 41 AL). Diez pacientes en el grupo AL (24,4%) requirieron conversión, principalmente por adherencias. La morbilidad total de la serie fue de 36,8%, siendo mayor en el AA (50% vs 21,9%, p = 0,007). Hubo una filtración anastomótica en cada grupo. La estadía posoperatoria fue de 5 (3-52) días para el AL y 7 (4-36) días para el AA (p < 0,001). En la regresión logística, sólo el AA fue un factor de riesgo independientemente asociado a morbilidad posoperatoria (OR 2,89, IC 95% 1,11-7,49; p = 0,029). Conclusión: El abordaje laparoscópico se asocia a menor morbilidad y estadía posoperatoria que el abordaje abierto para la reconstitución del tránsito pos-Hartmann. En nuestra serie, el abordaje abierto fue el único factor independientemente asociado a morbilidad posoperatoria.

Introduction: Hartmann's reversal (HR) is considered a technically demanding procedure and is associated with high morbidity rates. Aim: The aim of this study is to compare the perioperative results of the open approach (OA) with the laparoscopic approach (LA) for HR, and to determine the risk factors associated with postoperative morbidity. Material and Methods: Consecutive patients undergoing HR between January 2007 and December 2016 at a university hospital were included. Patients with large incisional hernias that required an open approach a priori were excluded from the analysis. Demographic and perioperative variables were recorded. Analytical statistics were carried out to compare both groups, and a logistic regression was performed to identify risk factors associated with postoperative morbidity in the series. Results: A hundred and one HR were performed during the study period. Fourteen cases were excluded due to large incisional hernias, so 87 cases (46 OA and 41 LA) were analyzed. Ten patients in the LA group (24.4%) required conversion, mainly due to adhesions. The total morbidity of the series was 36.8%, being higher in the OA group (50% vs. 21.9%, p = 0.007). There was one case of anastomotic leakage in each group. The length of stay was 5 (3-52) days for LA and 7 (4-36) days for OA (p < 0.001). In the logistic regression, the OA was the only independent risk factor associated with postoperative morbidity in HR (OR 2.89, IC 95% 1.11-7.49; p = 0.029). Conclusion: A laparoscopic approach is associated with less morbidity and a shorter length of stay compared to the open approach for Hartmann's reversal. An open approach was the only factor independently associated with postoperative morbidity in our series.

Proteína C reactiva y su relación con las complicaciones posoperatorias en cirugía colorrectal electiva / Association between C-reactive protein and postoperative complications in elective colorectal surgery

RESUMEN Antecedentes: el uso de la proteína C reactiva (PCR) ha adquirido relevancia como identificador de complicaciones posoperatorias La morbilidad en cirugía colorrectal se estima en un 30% de los pacientes operados, lo que demanda medidas para su temprana identificación y terapéutica. Objetivo: describir las curvas de mediciones sucesivas de PCR y su relación con el desarrollo de complicaciones posoperatorias y niveles de glóbulos blancos en una serie de pacientes operados de cirugía colorrectal. Materiales y métodos: se realizó una revisión retrospectiva sobre un registro prospectivo de 2205 pacientes operados por la División de Cirugía Gastroenterológica del Hospital de Clínicas, entre enero de 2019 y julio de 2020. Se incluyeron 69 pacientes que cumplieron con los criterios de selección. Se consignaron datos del seguimiento clínico y dosaje de PCR, recuento de glóbulos blancos, vía de abordaje y desarrollo de complicaciones. Resultados: el promedio de edad fue de 59 años (DS 13,6; rango 33-85), 31 fueron hombres (43%). La tasa de complicaciones fue del 13,04%; más frecuente fue la fístula anastomótica (fístula, colección), seguida por complicaciones de la herida (hematoma, evisceración). Todos los pacientes mostraron un ascenso inicial del valor de PCR entre el 2° y 3er día, en relación con la lesión quirúrgica, los no complicados presentaron una cinética de descenso y los complicados. curvas de segundo ascenso o no descenso en las mediciones seriadas de PCR, y exhibían valores superiores de PCR cada día Se advirtieron diferencias estadísticamente significativas entre los valores de proteína C reactiva al 5° día posoperatorio en el subgrupo de pacientes complicados con respecto a aquellos con un curso indolente (28 mg/dL vs. 6,1 mg/dL, p < 0,001; IC: 11,24-39,61). hubo diferencia significativa al 5o día entre complicados y no complicados, independientemente de la vía de abordaje. con un valor de corte de PCR de 10,92 mg/dL obtuvimos una sensibilidad del 87,50% y una especificidad del 100% para excluir complicaciones. Conclusiones: la medición de la proteína C reactiva de forma seriada en los posoperatorios de cirugía colorrectal mostró un correlato con la identificación temprana de las complicaciones en nuestra serie, tanto en sus valores absolutos diarios como en la cinética de su comportamiento. se formula el uso de valores de corte para el alta segura.

ABSTRACT Background: The use of C-reactive protein (CRP) has gained relevance as a marker of marker of postoperative complications. As the incidence of complications of colorectal surgery is estimated to be of 30%, measures should for their early identification and treatment. Objective: To describe the performance of consecutive CRP determinations and their relationship with the development of postoperative complications and with white blood cell count in a series of patients undergoing colorectal surgery. Materials and methods: A retrospective review was performed using a prospective registry of 2205 patients operated on at the Department of Digestive Surgery of Hospital de Clínicas, between January 2019 and July 2020. A total of 69 patients fulfilling the selection criteria were included. Clinical follow-up data, CRP levels, white blood cell count, type of approach and development of complications were recorded. Results: Mean age was 59 years (SD 13.6; range 33-85) and 31 were men (43%). The complication rate was 13.04%. Anastomotic leak (fistula, fluid collection) was the most common complication, followed by surgical site complications (hematoma, evisceration). All patients showed an initial increase in CRP values between days 2 and 3, in relation with the surgical lesion, and then decreased in those without complications. Patients with complications had second rise or lack of decrease in serial CRP measurements, and higher CRP values each day. There were statistically significant differences between the CRP levels on postoperative day 5 in the subgroup of patients with complications compared with those with an indolent course (28 mg/dL vs. 6.1 mg/dL, p < 0.001; CI: 11.24-39.61). There was a significant difference on day 5 between patients with and without complications, irrespective of the approach. With a cut-off value of CRP of 10.92 mg/dL on postoperative day 5 we obtained a sensitivity of 87.50% and specificity of 100% to rule out complications. Conclusions: Serial determination of CRP in the postoperative period after colorectal surgery was associated with early identification of complications in our series, both in daily absolute values and in the kinetics of its performance. The use of cut-off values for safe discharge is proposed.

Abordaje quirúrgico y evolución posoperatoria en reintervenciones de complicaciones en cirugía colorrectal laparoscópica, 15 años de experiencia / Surgical approach and postoperative clinical course in reinterventions for complications following laparoscopic colorectal surgery: 15 years of experience

Resumen Objetivo: Comparar tres abordajes quirúrgicos (abierto, laparoscópico y laparoscópico convertido) para el manejo de complicaciones posoperatorias en cirugía colorrectal electiva realizadas primariamente por vía laparoscópica. Materiales y Método: Este estudio de cohorte retrospectivo incluyó pacientes reoperados después de una cirugía colorrectal laparoscópica electiva, agrupándose según la vía de abordaje de reoperación: abierta (RVA), laparoscópica (RVL) y laparoscópica convertida (RVLC). Las variables estudiadas fueron: preoperatorias (edad, sexo, puntuación ASA, IMC, comorbilidades e historia quirúrgica); operatorias (causa de reoperación, latencia para reoperación, tiempo operatorio, cirugía realizada y causa de conversión); y posoperatorias (tránsito intestinal, días de hospitalización, días de UCI, complicaciones médicas, infección del sitio quirúrgico, evisceración, transfusión y mortalidad a los 30 días). Resultados: Sin diferencias significativas para las variables preoperatorias y operatorias. En cuanto a las variables posoperatorias, el grupo de reoperaciones por vía laparoscópica, tuvo menos días de hospitalización (p = 0,012), menos días de UCI (p = 0,001) y un tránsito intestinal más rápido para reaparición de gases, heces y retorno a dieta sólida (p = 0,008, p = 0,029, p = 0,030, respectivamente). No hubo diferencias significativas en la infección del sitio quirúrgico, la evisceración, las complicaciones médicas, la transfusión y la mortalidad. Discusión y Conclusión: Este estudio reveló una mejor evolución clínica posoperatoria en el grupo de reoperación laparoscópica, con menor estancia hospitalaria y en UCI, y reducción del íleo posoperatorio, sin aumento de la morbimortalidad. Por lo tanto, la reoperación laparoscópica en cirugía colorrectal podría ser el abordaje más adecuado en pacientes debidamente seleccionados.

Aim: To compare three approaches (laparoscopic, open, and conversion of laparoscopic approach) for the management of intra-abdominal surgical complications after elective laparoscopic colorectal surgery. Materials and Method: This was a retrospective cohort study including patients who required reoperation due to an intra-abdominal surgical complication after initial elective laparoscopic colorectal surgery. Patients were grouped according to the reoperation approach-laparoscopic reoperation, laparoscopic reoperation that required conversion to open surgery, and open reoperation. Pre-operative variables (age, gender, ASA score, BMI, comorbidities, and surgical history), operative variables (cause of reoperation, latency for reoperation, operative time, surgery performed, and cause of conversion), and post-operative variables (intestinal transit, hospital days, ICU days, medical complications, surgical site infection, evisceration, transfusion and 30-day mortality), were compared between groups. Results: There were no significant differences between groups among the pre-operative and operative variables. In terms of post-operative variables, the laparoscopic reoperation group, had fewer hospital days (p = 0.012), fewer ICU days (p = 0.001), and faster intestinal transit regarding gas, stool and return to solid diet (p = 0.008, p = 0.029 and p = 0.030, respectively). However, there were no significant differences in surgical site infection, evisceration, medical complications, transfusion, and mortality. Discussion and Conclusión: This study revealed better post-operative clinical course in the laparoscopic reoperation group, with shorter hospital and ICU stay, and reduced postoperative ileus, without increased morbidity or mortality. Laparoscopic reoperation for complications after elective laparoscopic colorectal surgery may therefore be the preferred approach.

Effect of duodenal stump reinforcement on postoperative complications in patients undergoing laparoscopic radical gastrectomy / 中华胃肠外科杂志

Objective: To evaluate the influence of duodenal stump reinforcing on the short-term complications after laparoscopic radical gastrectomy. Methods: A retrospective cohort study with propensity score matching (PSM) was conducted. Clinical data of 1204 patients with gastric cancer who underwent laparoscopic radical gastrectomy at the First Affiliated Hospital of Army Medical University from April 2009 to December 2018 were collected. The digestive tract reconstruction methods included Billroth II anastomosis, Roux-en-Y anastomosis and un-cut-Roux- en-Y anastomosis. A linear stapler was used to transected the stomach and the duodenum. Among 1204 patients, 838 were males and 366 were females with mean age of (57.0±16.0) years. Duodenal stump was reinforced in 792 cases (reinforcement group) and unreinforced in 412 cases (non-reinforcement group). There were significant differences in resection range and anastomotic methods between the two groups (both P<0.001). The two groups were matched by propensity score according to the ratio of 1∶1, and the reinforcement group was further divided into purse string group and non-purse string group. The primary outcome was short-term postoperative complications (within one month after operation). Complications with Clavien-Dindo grade ≥ III a were defined as severe complications, and the morbidity of complication between the reinforcement group and the non-reinforcement group, as well as between the purse string group and the non-purse string group was compared. Results: After PSM, 411 pairs were included in the reinforcement group and the non-reinforcement group, and there were no significant differences in baseline data between the two groups (all P>0.05). No perioperative death occurred in any patient.The short-term morbidity of postoperative complication was 7.4% (61/822), including 14 cases of anastomotic leakage (23.0%), 11 cases of abdominal hemorrhage (18.0%), 8 cases of duodenal stump leakage (13.1%), 2 cases of incision dehiscence (3.3%), 6 cases of incision infection (9.8%) and 20 cases of abdominal infection (32.8%). Short-term postoperative complications were found in 25 patients (6.1%) and 36 patients (8.8%) in the reinforcement group and the non-reinforcement group, respectively, without significant difference (χ2=2.142, P=0.143). Nineteen patients (2.3%) developed short-term severe complications (Clavien-Dindo grade ≥IIIa), while no significant difference in severe complications was found between the two groups (1.7% vs. 2.9%, χ2=1.347, P=0.246). Sub-group analysis showed that the morbidity of short-term postoperative complication of the purse string group was 2.6% (9/345), which was lower than 24.2% (16/66) of the non-purse string group (χ2=45.388, P<0.001). Conclusion: Conventional reinforcement of duodenal stump does not significantly reduce the incidence of duodenal stump leakage, so it is necessary to choose whether to reinforce the duodenal stump individually, and purse string suture should be the first choice when decided to reinforce.

Principais implicações terapêuticas à qualidade de vida de pacientes com câncer de colo uterino: uma revisão narrativa / Therapeutic implications to the quality of life of cervical cancer's patients: a narrative review

O câncer de colo uterino é o quarto tipo mais incidente e fatal entre as mulheres no Brasil e no mundo, o que representa mundialmente em torno de 600 mil novos casos e mais de 300 mil mortes a cada ano. Assim como o diagnóstico, o tratamento da doença pode impactar de forma significativa a qualidade de vida dessas pacientes. A aplicação de questionários que avaliem os diferentes aspectos da qualidade de vida das mulheres afetadas por esse câncer é uma ferramenta relevante, pois auxilia na compreensão e identificação dos principais danos relacionados ao tratamento. Este trabalho visa analisar a literatura atual que investiga e relata os principais efeitos à qualidade de vida de mulheres com câncer de colo uterino associados a diferentes modalidades terapêuticas e, desse modo, contribuir nas escolhas de tratamento e manejo clínico que resultem em menores impactos à qualidade de vida dessas mulheres.(AU)

Cervical cancer is the fourth most incident and fatal cancer type among women in Brazil and worldwide. This data represents around 600 thousand new cases worldwide each year and more than 300 thousand lives lost. Both diagnosis and treatment can significantly impact the quality of life of cervical cancer patients. The application of questionnaires that assess the different aspects of the quality of life of women affected by this cancer is a relevant tool, as it helps to understand and identify the main damages related to the treatment. This article aims to analyze the current literature that reports the main effects on the quality of life of women with cervical cancer associated with different therapeutic modalities. In this way, the review could assist in the treatment choices that imply less impact on the quality of life of these women.(AU)

Plicatura gástrica laparoscópica: seguimiento a largo plazo / Laparoscopic gastric plication: long-term follow-up

Resumen Introducción: La experiencia internacional no ha logrado reproducir los resultados de los primeros trabajos de plicatura gástrica laparoscópica (PGL). Objetivo: Analizar los resultados a largo plazo de pacientes sometidos a PGL. Materiales y Método: Estudio prospectivo y descriptivo, se incluyeron pacientes obesos adultos que cumplieron criterios universales para cirugía bariátrica. Se registraron datos epidemiológicos, comorbilidades, tiempo operatorio, estadía hospitalaria, porcentaje de pérdida de exceso de IMC (% PEIMC), complicaciones posoperatorias y resolución de comorbilidades. El seguimiento se efectuó con controles periódicos anuales hasta el año 2020. Resultados: Se inició la selección de pacientes durante el año 2010. Se realizaron 26 intervenciones desde enero de 2011 hasta mayo de 2012. Todas las pacientes fueron de género femenino. El IMC preoperatorio promedio fue 38,8 kg/m2 (DS 3,8). El % PEIMC promedio al año, 3 años y 9 años de posoperado, fue 62,2% (DS 27,1), 40,2% (DS 24,5) y 28% (DS 31,9), respectivamente. Las complicaciones, basadas en la clasificación de Clavien-Dindo (CD), durante los primeros 30 días de posoperatorio fueron 21 pacientes con tipo I, 1 con tipo II, y 2 pacientes con complicaciones tipo IVa. A los 9 años de posoperado, 9 pacientes presentaban efectos adversos tipo I. No hubo mortalidad. Hasta los 3 años hubo corrección de comorbilidades. Se objetivaron 3 pacientes diabéticas al final del estudio, 2 de ellas previamente sanas. Conclusiones: El % PEIMC a largo plazo fue insuficiente. El porcentaje de complicaciones es mayor que en otras técnicas. No recomendamos la realización de la PGL.

Background: The international experience has failed to reproduce the first studies of laparoscopic gastric plication (LGP). Aim: The objective is to analyze the outcomes after 10 years of follow-up of patients subjected to LGP. Materials and Method: Prospective and descriptive study, in which obese adult patients who met universal criteria for bariatric surgery were included. Epidemiological data, comorbidities, operating time, hospital stay, percentage of excess BMI loss (% EBMIL) and resolution of comorbidities were collected. The follow-up was realized by annual periodic controls until 2020. Results: Patient selection began in 2010. A total of 26 interventions were performed from January 2011 to May 2012. All patients were female. The average preoperative Body Mass Index (BMI) was 38.8 kg/m2 (SD 3.8). The average % EBMIL at 1st, 3rd and 9 th postoperative years was 62.2% (SD 27.1), 40.2% (SD 24.5) and 28% (SD 31.9), respectively.Complications, based in Clavien Dindo classification, during the first 30 postoperative days was: 21 patients with type I, 1 type II, and 2 patients with complications type IVa. At 9 th postoperative year, 9 patients presented adverse effect type I. There was no mortality. Until the 3rd year there was correction of comorbidities. Three diabetic patients were observed at the end of the study, 2 previously healthy. Conclusions: The long term % EBMIL was insufficient. The percentage of complications is higher than in other techniques. We do not recommend the LGP.

Comparación de los desenlaces clínicos con cuatro técnicas de apendicetomía laparoscópica tras la implementación de políticas de reúso de dispositivos médicos / Comparison of clinical outcomes with four laparoscopic appendectomy techniques after implementation of medical devices reuse policy

Resumen Objetivo: En este estudio se comparan los desenlaces clínicos de cuatro técnicas de apendicectomía laparoscópica utilizadas en una institución colombiana para el manejo de la apendicitis aguda tras la adopción de políticas de reúso y reprocesamiento de dispositivos médicos para la Región de las Américas (2014). Materiales y Método: Mediante el análisis de varianza de una vía (ANOVA) y la prueba de Kruskal Wallis, se compararon las tasas de infección de sitio operatorio (ISO), reoperación no planeada, readmisión y mortalidad (en los primeros 30 días del postoperatorio) de las siguientes técnicas: Técnica 1: Ligadura del muñón apendicular con endonudo y disección del mesenterio apendicular con electrocoagulación bipolar convencional; Técnica 2: Clipaje del muñón con endoclip de polímero y disección del mesenterio con electrocoagulación bipolar convencional; Técnica 3: Clipaje del muñón con endoclip de polímero y disección del mesenterio con electrocoagulación monopolar; Técnica 4: Clipaje del muñón y disección roma y ligadura del mesenterio con endoclip de polímero. Resultados: Se incluyeron 551 pacientes. No se encontraron diferencias en los ANOVAs en cuanto a las características demográficas de los pacientes por cada técnica. Los desenlaces globales fueron: ISO (5,44%), reoperación no planeada (3,08%), readmisión (15,97%) y mortalidad (0,18%). Se encontraron diferencias significativas (p < 0,05) en estos desenlaces explicados por mayores tasas de ISO y reoperación con la Técnica-1. Conclusiones: Los desenlaces globales de la apendicectomía laparoscópica tras la adopción de políticas de reúso de dispositivos médicos se encuentran dentro de los aceptados globalmente cuando se utilizan las Técnicas 2-3-4 en poblaciones equivalentes de pacientes con apendicitis aguda. En este contexto, nuestros resultados invitan a utilizar con precaución la Técnica-1.

Aim: The present study sought to compare the clinical outcomes between four operative techniques for laparoscopic appendectomy in a Colombian institution, following the adoption of reuse and reprocessing policies for medical devices in the Region of Americas (2014). Materials and Methods: One-way analysis of variance (ANOVA) and Kruskal Wallis tests were used to compare the rates of Surgical Site Infection (SSI), unplanned reoperation, readmission and mortality (confined to 30 days after surgery) of these operative techniques: Technique 1: Ligature of appendiceal stump with endo stitch plus mesenteric dissection with conventional bipolar electrocoagulation; Technique 2: Clipping of stump with polymer endoclip plus mesenteric dissection with conventional bipolar electrocoagulation; Technique 3: Clipping of stump with polymer endoclip plus mesenteric dissection with monopolar electrocoagulation; Technique 4: Clipping of stump plus mesenteric dissection with polymer endoclip. Results: A total of 551 patients were included. No differences were found in the demographic characteristics of the patients between techniques during ANOVAs. The global outcomes were SSI (5.44%), unplanned reoperation (3.08%), readmission (15.97%) and mortality (0.18%). Significant differences were found (p < 0.05) in these outcomes explained by higher rates of SSI and unplanned reoperation with Technique 1. Conclusions: The overall outcomes of laparoscopic appendectomy, after the adoption of policies for the reuse and reprocessing of medical devices, are similar to those accepted globally when using operative techniques 2-3-4 in equivalent populations of patients with acute appendicitis. In this context, our results invite to use with caution technique-1.

Quistectomía laparoscópica en quiste hidatídico hepático / Laparoscopic cystectomy in hidatidid cyst

Resumen Objetivo: Describir resultados en términos de morbilidad y mortalidad del tratamiento de quistes hidatídicos hepáticos (QHH) por vía laparoscópica en una serie de pacientes consecutivos. Comparar calidad de vida (CV) de pacientes sometidos a quistectomía laparoscópica (QL) con pacientes llevados a colecistectomía laparoscópica. Materiales y Método: Serie de casos con seguimiento de pacientes con QHH, sometidos a QL. Analizamos datos con Stata® 10.0, mediante medidas de tendencia central y dispersión. Describimos 4 variables, realizando seguimiento con tomografía computada (TC) abdominal. Aplicamos encuesta de calidad de vida SF-36. Resultados: Incluimos 12 pacientes, 58,3% de género femenino. Número de quistes 2,02 ± 1,56, volumen quístico mayor 809,16 ± 766,05 ml, diámetro de quiste mayor 11,77 ± 4,33 cm, predominando en lóbulo hepático derecho (58%). Tiempo operatorio promedio 234,1 ± 52,9 minutos. Estadía hospitalaria promedio 11,5 ± 14,5 días. Morbilidad en 16,6%, sin mortalidad posoperatoria. Seguimiento con imágenes promedio fue 7,9 ± 4,3 meses, encontrando cavidades residuales pequeñas y asintomáticas en 50% de pacientes. No reportamos recidivas. Al comparar CV con grupo de colecistectomía sólo encontramos diferencia respecto a vitalidad (p = 0,04). Discusión: Aunque nuestra serie es pequeña y presenta mayor tiempo quirúrgico (por selección de pacientes) y mayor estancia hospitalaria que en otras series de QL, presenta menor porcentaje de recidivas, de fístulas biliares y no presenta mortalidad, concordando con otras series de QL que la recomiendan como opción terapéutica. Conclusiones: La QL para el tratamiento de los QHH resulta una cirugía aceptable, con morbilidad y mortalidad comparable con reportes de cirugía abierta.

Aim: To describe results in morbidity and mortality terms of the hepatic hydatidosis (HHC) treatment by laparoscopic route in selected patients. In addition, compare the quality of life (QL) of cystomectized vs cholecystectomized patients, both laparoscopically. Materials and Method: Case series with follow-up of patients with HHC, undergoing laparoscopic cystectomy (LC). Data analysis, through measures of central tendency and dispersion, performed with Stata® 10.0. Analyzing 4 variables followed-up with abdominal computed tomography. A quality of life survey SF-36" was applied. Results: 12 patients were included, 58.3% female gender. Cysts number 2.02 ± 1.56, largest cystic volume 809.16 ± 766.05 ml, larger cyst diameter 11,77 ± 4,33 cm. Right hepatic lobe is predominantly 58%. Surgical time, 234.16 ± 52.95 minutes. Hospital stay, 11.58 ± 14.55 days. Morbidity 16.6%, with no postoperative mortality. Follow-up, performed at 7.9 ± 4.3 months, finding residual cavity in 50%, no recurrences were reported. At comparing QL with cholecystectomy group, we only found differences at the vitality item (p = 0,04). Discussion: Although our series is small and has a longer surgical time (by patient selection) and a longer hospital stay than in other LC series, it has a lower recurrences percentage, biliary fistulas, and no mortality, agreeing with other LC series that recommend it as a therapeutic option. Conclusions: The laparoscopic approach for the HHC treatment, is an acceptable surgery, with morbidity and mortality comparable to the reports of laparotomy surgery.

The effect of prophylactic rewarming on postoperative nausea and vomiting among patients undergoing laparoscopic hysterectomy: a prospective randomized clinical study

ABSTRACT BACKGROUND: Postoperative nausea and vomiting (PONV) is a common complication from general anesthesia that impacts on postoperative recovery. OBJECTIVE: To evaluate prophylactic rewarming following general anesthesia, so as to decrease the incidence of PONV among patients undergoing laparoscopic hysterectomy. DESIGN AND SETTING: Prospective randomized clinical study at a hospital in China. METHODS: Sixty-two patients were randomly assigned into two groups. The forced air warming (FAW) group received pre-warmed Ringer's solution with FAW until the end of surgery. The control group received Ringer's solution without FAW. The pre-warmed Ringer's solution was stored in a cabinet set at 40 °C. The FAW tube was placed beside the patient's shoulder with a temperature of 43 °C. RESULTS: Sixty patients completed the study. The FAW group showed significant differences versus the controls regarding temperature. At 6, 24 and 48 hours postoperatively, the incidences of PONV were 53.3%, 6.7% and 3.3% in the FAW group versus 63.3%, 30% and 3.3% in the controls. VAS scores were significantly lower in the FAW group than in the controls at 24 hours (P= 0.035). Forty-item questionnaire total scores in the FAW group were significantly higher than in the controls. The physical independence and pain scores at 24 hours and emotional support and pain scores at 48 hours in the FAW group were higher than in the controls (P < 0.05). There was no difference in hemodynamics or demographics between the two groups (P > 0.05). CONCLUSIONS: Prophylactic rewarming relieved PONV and improved the quality of postoperative recovery. CHINESE CLINICAL TRIAL REGISTER (ChiCTR): ChiCTR-IOR-17012901.

Complicaciones quirúrgicas intraoperatorias en laparoscopía ginecológica en el Hospital Padre Hurtado / Intraoperative surgical complications in gynecological laparoscopy at Padre Hurtado Hospital

INTRODUCCIÓN: Actualmente la cirugía laparoscópica es el gold standard de la mayoría de las cirugías ginecológicas benignas. Se estima una tasa de complicaciones en cirugía ginecológica por laparoscopía de 3.2 por 1000 pacientes, donde alrededor del 50% ocurren al momento de la primera entrada. Existen numerosas clasificaciones de las complicaciones quirúrgicas, entre ellas, la clasificación Clavien-Dindo se centra en el tratamiento postquirúrgico y tiene como objetivo unificar criterios y hacerlas comparables entre distintos centros. OBJETIVO: Describir las complicaciones en cirugía laparoscópica ginecológica en el Hospital Padre Hurtado, destacando el subgrupo de primera entrada y su clasificación Clavien-Dindo. METODOLOGÍA: Cohorte retrospectiva que incluyó a todas las pacientes operadas por laparoscopía en el pabellón de ginecología del Hospital Padre Hurtado desde el año 2014 al 2017. Se utilizó el software SPSS statistics v25, con prueba X2 para el análisis de las variables no paramétricas y t de Student para las variables paramétrica, considerando una significación estadística con p<0,05. RESULTADOS: De las 513 cirugías laparoscópicas ginecológicas realizadas en el período evaluado, sólo el 4,3% del total de las pacientes tuvieron complicaciones. De éstas, un 9% fueron de primera entrada, y en todos los casos fueron complicaciones menores o Clavien-Dindo I y II. Hubo 2 complicaciones Clavien-Dindo >III B, lo que correspondió a un 0,39%. CONCLUSIÓN: En nuestro grupo hubo una baja incidencia de complicaciones quirúrgicas y de primera entrada lo que es comparable con otras series publicadas.

INTRODUCTION: Laparoscopic surgery is currently the gold standard of most benign gynecological surgeries. A complication rate in gynecological laparoscopy is 3.2 per 1000 patients, where around 50% occur at the time of the first entry. There are numerous classifications of surgical complications, among them, Clavien-Dindo classification focuses on post-surgical treatment and aims to unify criteria and lets compare between different centers. OBJECTIVE: To describe the complications in gynecological laparoscopic surgery at the Padre Hurtado Hospital, highlighting the first entry subgroup and Clavien-Dindo classification. METHODOLOGY: Retrospective cohort that included all gynecological laparoscopy patients in Padre Hurtado Hospital from 2014 to 2017. The SPSS statistics v25 software was used, with X2 test for the analysis of non-parametric variables and t Student for the parametric variables, considering a statistical significance with p <0.05. RESULTS: 513 gynecological laparoscopic surgeries was performed in the evaluated period, only 4.3% of the total patients had complications. Of these, 9% were first entry, and in all cases were minor complications or Clavien-Dindo I and II. There were 2 patients with Clavien-Dindo complications > III B, which corresponded to 0.39%. CONCLUSION: In our group there was a low incidence of surgical complications and first entry which is comparable with other published series.

Ergonomía en cirugía laparoscópica ginecológica / Ergonomics and gynecologic laparoscopic surgery

INTRODUCCIÓN Y OBJETIVOS: Están demostradas las ventajas de la cirugía laparoscópica para el paciente en términos de dolor, rápida recuperación y precisión quirúrgica, sin embargo, no existen estudios nacionales respecto al impacto en los cirujanos. El objetivo de este trabajo es realizar un estudio prospectivo de evaluación ergonómica de ginecólogos que operan cirugía laparoscópica. MÉTODOS: Se utilizaron métodos de evaluación específica por ergónomo experto y percepción de los participantes. Se evaluaron, carga global de trabajo (NASA-tlx), carga bio-mecánica (REBA) y la percepción de molestias músculo-esqueléticas (Escala de Discomfort Corporal). Se recogieron datos personales y de la cirugía, para explorar la existencia de dificultades técnicas. RESULTADOS: 86,7% de los ginecólogos evidenciaron altos niveles de carga global de trabajo, siendo las variables esfuerzo y rendimiento, las de mayor puntaje. El nivel de riesgo bio-mecánico, fue catalogado como medio en la totalidad de la población. 60% manifestó discomfort corporal durante la cirugía. En cuanto a las dificultades técnicas, el efecto fulcrum estuvo presente en el 46% de los cirujanos, el mismo porcentaje tuvo síntomas de ojo seco. El 68% alguna vez accionó el pedal equivocado y ha sentido parestesia del pulgar. CONCLUSIONES: La cirugía laparoscópica ginecológica, presenta una elevada carga global de trabajo. El ginecólogo percibe un importante discomfort corporal y algunas dificultades técnicas. Es necesario incorporar medidas ergonómicas, para minimizar y/o disminuir los factores de riesgo mental y físicos, y así prevenir el desgaste precoz y lesiones a futuro en los cirujanos.

INTRODUCTION AND OBJECTIVES: Laparoscopic surgery had demonstrated advantages such as less pain, rapid recovery and surgical precision. There are no national data regarding the impact on surgeon's health. This is a prospective study on ergonomic evaluation and laparoscopic surgery performed by gynecologists. METHODS: Specific evaluation methods were used such as Global workload (NASA-tlx), bio-mechanical load (REBA) and the perception of musculoskeletal discomfort (Body Part Discomfort Scale). Personal opinions and surgery data were collected to explore the existence of technical difficulties. RESULTS: 86.7% of gynecologists cataloged surgery as high level of global workload. Effort and performance variables were most important. Bio-mechanical risk level was classified as medium in the entire population. 60% showed body discomfort during surgery. Regarding technical difficulties, fulcrum effect was present in 46% of surgeons, the same percentage had dry eye symptoms. 68% have a pedal error activation during surgery and felt paresthesia of the thumb. CONCLUSIONS: Gynecological laparoscopic surgery has a high overall workload. The gynecologist perceives an important body discomfort and some technical difficulties. It is necessary to incorporate ergonomic measures, to minimize and / or reduce mental and physical risk factors, and thus prevent early wear and future injuries in surgeons.

Cirugía laparoscópica en cáncer de colon / Laparoscopic surgery in colonic cancer

Resumen La primera colectomía laparoscópica se realizó hace casi 30 años. La adopción como estándar de tratamiento ha sido lenta, a pesar de compartir los beneficios de la cirugía con invasión mínima, como el menor dolor, estadía hospitalaria y recuperación precoz. Esto se explica por el temor generado por reportes iniciales que señalaban la aparición de implantes en los sitios de inserción de los trocares y las dudas sobre la seguridad oncológica. Distintos ensayos clínicos aleatorizados finalmente confirmaron su seguridad y eficacia en el tratamiento del cáncer de colon con resultados comparables a la cirugía abierta. La curva de aprendizaje prolongada, dada por la complejidad técnica, ha incentivado el aprendizaje supervisado por un entrenador experto en el contexto de programas de formación de subespecialidad. Nuestro objetivo es realizar una revisión de los resultados a corto y largo plazo y algunas consideraciones generales y perspectivas futuras.

The first laparoscopic colectomy was performed almost 30 years ago, its expansion has been slow and it did not have the explosive development that laparoscopic cholecystectomy and appendectomy had, despite sharing its benefits such as lower pain, hospital stay and early recovery. This is explained, in part, by the initial fear of implants at trocar sites and the lack of oncological safety. Randomized clinical trials confirmed the safety and efficacy of laparoscopic surgery with short-term and oncological results, comparable to open surgery. The slow learning curve, given by technical complexity, has encouraged learning supervised by an expert coach in the context of subspecialty training programs. Our aim is to review the short-term and oncological results, some general considerations and future perspectives.

Infarto esplénico como complicación de gastrectomía vertical laparoscópica. Reporte de caso / Splenic infarction as a complication of laparoscopic vertical gastrectomy. Case report

La gastrectomía vertical laparoscópica es actualmente la cirugía bariátrica más empleada a nivel mundial. Aunque es un procedimiento seguro y efectivo pueden ocurrir complicaciones mayores. En el presente trabajo reportamos el caso de un infarto y absceso esplénico como una rara complicación de esta técnica, que requirió finalmente de esplenectomía como tratamiento definitivo. Caso clínico: Mujer de 22 años con obesidad grado I, a quien se le practicó gastrectomía vertical laparoscópica con buena evolución intrahospitalaria y egreso a las 48 horas. Al 4to día posoperatorio consultó por fiebre, dolor abdominal, taquipnea y taquicardia. Mediante tomografía computada de abdomen se diagnosticó infarto esplénico parcial. Recibió tratamiento médico con remisión inicial de los síntomas, los cuales reaparecieron a la 3era semana. Se reinició el tratamiento médico, esta vez sin respuesta, y con evolución al absceso esplénico. Se decidió esplenectomía como tratamiento definitivo logrando la recuperación completa de la paciente. Conclusión: El infarto esplénico es una complicación infrecuente de la gastrectomía vertical. Su tratamiento inicial es médico, reservando la esplenectomía para los casos que no responden(AU)

Laparoscopic sleeve gastrectomy is currently the most performed bariatric surgery worldwide. Although it is an effective and safe procedure major complications can occur. In the present manuscript we report a case of splenic infarct and abscess as a rare complication of laparoscopic sleeve gastrectomy, finally requiring a splenectomy as a definitive treatment. Case report: A 22 years old woman with grade I obesity underwent laparoscopic sleeve gastrectomy with good hospital evolution and 48 hours discharge. On the 4th postoperative day she return because fever, abdominal pain, tachypnea and tachycardia. By means of a computed tomography a splenic infarct was diagnosed. She received medical treatment with initial remission of symptoms, which reappear at the third week. Medical treatment was restarted, this time without success, and with progression to splenic abscess. We decided a splenectomy as definitive treatment achieving a complete patient recovery. Conclusion: Splenic infarction is a rare complication after sleeve gastrectomy. The treatment is non surgical, reserving the splenectomy for the non responded cases(AU)

When should be converted laparoscopic sleeve gastrectomy to laparoscopic roux-en-y gastric bypass due to gastroesophageal reflux? / Quando deve ser convertida a gastrectomia vertical laparoscópica para gastroplastia em y-de-roux devido ao refluxo gastroesofágico?

ABSTRACT Background: Gastroesophageal reflux (GER) is one of the most common indications for conversion of sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGBP). Objective evaluations are necessary in order to choose the best definitive treatment for these patients. Aim: To present and describe the findings of the objective studies for gastroesophageal reflux disease performed before LSG conversion to LRYGBP in order to support the indication for surgery. Method: Thirty-nine non-responder patients to proton pump inhibitors treatment after LSG were included in this prospective study. They did not present GER symptoms, esophagitis or hiatal hernia before LSG. Endoscopy, radiology, manometry, 24 h pH monitoring were performed. Results: The mean time of appearance of reflux symptoms was 26.8+24.08 months (8-71). Erosive esophagitis was found in 33/39 symptomatic patients (84.6%) and Barrett´s esophagus in five. (12.8%). Manometry and acid reflux test were performed in 38/39 patients. Defective lower esophageal sphincter function was observed independent the grade of esophagitis or Barrett´s esophagus. Pathologic acid reflux with elevated DeMeester´s scores and % of time pH<4 was detected in all these patients. more significant in those with severe esophagitis and Barrett´s esophagus. Radiologic sleeve abnormalities were observed in 35 patients, mainly cardia dilatation (n=18) and hiatal hernia (n=11). Middle gastric stricture was observed in only six patients. Conclusion: Patients with reflux symptoms and esophagitis or Barrett´s esophagus after SG present defective lower esophageal sphincter function and increased acid reflux. These conditions support the indication of conversion to LRYGBP.

RESUMO Racional: O refluxo gastroesofágico é uma das indicações mais comuns para a conversão da gastrectomia vertical (SG) em gastroplastia laparoscópica em Y-de-Roux (LRYGBP). Avaliações objetivas são necessárias para escolher o melhor tratamento definitivo para esses pacientes. Objetivo: Apresentar e descrever os achados objetivos da doença do refluxo gastroesofágico realizados antes da conversão do SG para o LRYGBP, a fim de apoiar a indicação cirúrgica. Método: Trinta e nove pacientes não respondedores ao tratamento com inibidores da bomba de prótons após SG foram incluídos neste estudo prospectivo. Eles não apresentavam sintomas de refluxo gastroesofágico, esofagite ou hérnia hiatal antes da SG. Endoscopia, radiologia, manometria, monitoramento de pH 24 horas foram realizados. Resultados: O tempo médio de aparecimento dos sintomas de refluxo foi de 26,8+24,08 meses (8-71). Esofagite erosiva foi encontrada em 33/39 pacientes sintomáticos (84,6%) e esôfago de Barrett em cinco (12,8%). A manometria e o teste de refluxo ácido foram realizados em 38/39 pacientes. A função alterada do esfíncter inferior do esôfago foi observada independentemente do grau de esofagite ou esôfago de Barrett. Em todos esses pacientes, foi detectado refluxo ácido patológico com escores elevados de DeMeester e % de tempo pH<4, mais significativo nos com esofagite grave e esôfago de Barrett. Anormalidades radiológicas SG foram observadas em 35 pacientes, principalmente dilatação da cárdia (n=18) e hérnia hiatal (n=11). Estenose gástrica foi observada em apenas seis pacientes . Conclusão: Pacientes com sintomas de refluxo e esofagite ou esôfago de Barrett após SG apresentam função do esfíncter esofágico inferior defeituosa e aumento do refluxo ácido. Esses sintomas e estudos objetivos apoiam a indicação de conversão para LRYGBP.

Lessons learned analyzing complications after laparoscopic total gastrectomy for gastric cancer / Lições aprendidas analisando complicações da gastrectomia total laparoscópica para câncer gástrico

ABSTRACT Background: Laparoscopic surgery has been gradually accepted as an option for the surgical treatment ofgastric cancer. There are still points that are controversial or situations that are eventually associated with intra-operative difficulties or postoperative complications. Aim: To establish the relationship between the difficulties during the execution of total gastrectomy and the occurrence of eventual postoperative complications. Method: The operative protocols and postoperative evolution of 74 patients operated for gastriccancer, who were subjected to laparoscopic total gastrectomy (inclusion criteria) were reviewed. The intraoperative difficulties recorded in the operative protocol and postoperative complications of a surgical nature wereanalyzed (inclusion criteria). Postoperative medical complications were excluded (exclusion criteria). For the discussion, an extensive bibliographical review was carried out. Results: Intra-operative difficulties or complications reported correspond to 33/74 and of these; 18 events (54.5%) were related to postoperative complications and six were absolutely unexpected. The more frequent were leaks of the anastomosis and leaks of the duodenal stump; however, other rare complications were observed. Seven were managed with conservative measures and 17 (22.9%) required surgical re-exploration, with a postoperative mortality of two patients (2.7%). Conclusion: We have learned that there are infrequent and unexpected complications; the treating team must be mindful of and, in front of suspicion of complications, anappropriate decision must be done which includes early re-exploration. Finally, after the experience reported, some complications should be avoided.

RESUMO Racional: A cirurgia laparoscópica tem sido gradualmente aceita como opção para o tratamento cirúrgico do câncer gástrico. Ainda existem pontos controversos ou situações eventualmente associadas a dificuldades intra-operatórias ou complicações pós-operatórias. Objetivo: Estabelecer a relação entre as dificuldades durante a execução da gastrectomia total e a ocorrência de eventuais complicações pós-operatórias. Método: Foram revisados ​​os protocolos operatórios e a evolução pós-operatória de 74 pacientes operados por câncer gástrico, submetidos à gastrectomia total laparoscópica (critérios de inclusão). Foram analisadas as dificuldades intraoperatórias registradas no protocolo operatório e as complicações pós-operatórias de natureza cirúrgica (critérios de inclusão). As complicações médicas pós-operatórias foram excluídas (critérios de exclusão). Para a discussão, foi realizada extensa revisão bibliográfica. Resultados: Dificuldades ou complicações intraoperatórias relatadas corresponderam a 33/74 e destas 18 (54,5%) foram relacionadas com complicações pós-operatórias e seis absolutamente inesperadas. As mais frequentes foram vazamentos da anastomose e do coto duodenal; no entretanto, outras complicações raras foram observadas. Sete foram tratados com medidas conservadoras e 17 (22,9%) necessitaram de re-exploração cirúrgica, com mortalidade pós-operatória de dois pacientes (2,7%). Conclusão: Aprendemos que existem complicações infrequentes e inesperadas; a equipe de tratamento deve estar atenta e diante da suspeita de complicação, decisão apropriada pode incluir uma nova exploração precoce. Finalmente, após a experiência relatada, algumas complicações devem ser evitadas.