Effect of Preoperative Immunonutrition on Postoperative Major Morbidity after Cytoreductive Surgery and HIPEC in Patients with Peritoneal Metastasis.

The effect of preoperative immunonutrition intake on postoperative major complications in patients following cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) was assessed. The accuracy of C-Reactive Protein (CRP) for detecting postoperative complications was also analyzed. Patients treated within a peritoneal carcinomatosis program in which a complete or optimal cytoreduction was achieved were retrospectively analyzed. They were divided into two groups based on whether preoperative immunonutrition (IMN) or not (non-IMN) were administered. Clinical and surgical variables and postoperative complications were gathered. Predictive values of major morbidity of CRP during the first 3 postoperative days (POD) were also evaluated. A total of 107 patients were included, 48 belonging to the IMN group and 59 to the non-IMN group. In multivariate analysis immunonutrition (OR 0.247; 95%CI 0.071-0.859; p = 0.028), and the number of visceral resections (OR 1.947; 95%CI 1.086-3.488; p = 0.025) emerged as independent factors associated with postoperative major morbidity. CRP values above 103 mg/L yielded a negative predictive value of 84%. Preoperative intake of immunonutrition was associated with a decrease of postoperative major morbidity and might be recommended to patients with peritoneal carcinomatosis following CRS. Measuring CRP levels during the 3 first postoperative days is useful to rule out major morbidity.

Dolor anal crónico idiopático. Evaluación de los resultados diagnóstico-terapéuticos en una unidad de referencia de coloproctología / Chronic idiopathic anal pain. Results of a diagnostic-therapeutic protocol in a colorectal referral unit

INTRODUCCIÓN: En la actualidad, el dolor anal crónico idiopático (DACI) sigue siendo un diagnóstico de exclusión, cuyo estudio y manejo permanece carente de un protocolo estandarizado. El objetivo del presente estudio es evaluar los resultados obtenidos con el protocolo diagnóstico-terapéutico establecido en nuestro servicio. MATERIAL Y MÉTODOS: Realizamos un estudio retrospectivo de los pacientes diagnosticados de DACI en la Unidad de Coloproctología del Hospital General Universitario de Elche entre 2005 y 2011. RESULTADOS: Se evaluó a 57 pacientes, remitidos con el diagnóstico de dolor anal crónico (DAC) por trastornos funcionales anorrectales (TFAR). Tras la aplicación del protocolo diagnóstico establecido, se llegó a un diagnóstico en 43 casos (75%), incluyendo 22 casos de síndrome del periné descendente, 12 de proctalgia fugax, 2 de neuritis pudenda, 7 de coccigodinia; en 14 casos se realizó un diagnóstico de exclusión de DACI.Entre las medidas terapéuticas empleadas en los pacientes con DACI, el biofeedback combinado con medidas conservadoras mejoró la sintomatología en el 43% de los casos, valorándose la neuroestimulación de raíces sacras en pacientes resistentes a otros tratamientos. CONCLUSIÓN: Mediante una protocolizada anamnesis, exploración física y con ayuda de pruebas complementarias pudo especificarse el diagnóstico de DAC por TFAR, reduciéndose el diagnóstico de exclusión de DACI al 25% de los casos. Las medidas conservadoras junto con el biofeedback consiguieron una mejoría de los síntomas en más del 40% de los casos de DACI. En el resto de pacientes debe valorarse de forma individualizada la neuroestimulación de raíces sacras

INTRODUCTION: Chronic idiopathic anal pain (CIAP) remains a diagnosis of exclusion. Its study and management still lack a standardized protocol. The aim of this study is to evaluate the results obtained with the diagnostic-therapeutic protocol established in our service. MATERIAL AND METHODS: We performed a retrospective study of patients diagnosed with CIAP at the Colorectal Unit of the General University Hospital of Elche, between 2005 and 2011.ResultsWe evaluated 57 patients with a diagnosis of chronic anal pain for functional anorectal disease (FAD). After the application of our diagnostic protocol, final diagnosis of chronic anal pain (CAP) was achieved in 43 cases (75%), including 22 cases of descending perineum syndrome, 12 of proctalgia fugax, 2 of pudendal neuritis and 7 of coccydynia. In 14 patients exclusion diagnosis of CIAP was established. Among the therapies used on patients with CIAP, biofeedback combined with conservative measures improved symptoms in 43% of the cases. Sacral nerve stimulation was assessed in patients who did not respond to other treatments. CONCLUSION: Through proper anamnesis, physical examination and complementary tests, a specific diagnosis of the cause of CAP by FAD can be achieved, reducing exclusion diagnosis of CIAP to 25% of cases. Conservative measures combined with biofeedback achieved an improvement in pain in more than 40% of the cases of CIAP in our study. Sacral nerve stimulation can be considered as a treatment option in refractory cases

Chronic idiopathic anal pain. Results of a diagnostic-therapeutic protocol in a colorectal referral unit.

INTRODUCTION: Chronic idiopathic anal pain (CIAP) remains a diagnosis of exclusion. Its study and management still lack a standardized protocol. The aim of this study is to evaluate the results obtained with the diagnostic-therapeutic protocol established in our service. MATERIAL AND METHODS: We performed a retrospective study of patients diagnosed with CIAP at the Colorectal Unit of the General University Hospital of Elche, between 2005 and 2011. RESULTS: We evaluated 57 patients with a diagnosis of chronic anal pain for functional anorectal disease (FAD). After the application of our diagnostic protocol, final diagnosis of chronic anal pain (CAP) was achieved in 43 cases (75%), including 22 cases of descending perineum syndrome, 12 of proctalgia fugax, 2 of pudendal neuritis and 7 of coccydynia. In 14 patients exclusion diagnosis of CIAP was established. Among the therapies used on patients with CIAP, biofeedback combined with conservative measures improved symptoms in 43% of the cases. Sacral nerve stimulation was assessed in patients who did not respond to other treatments. CONCLUSION: Through proper anamnesis, physical examination and complementary tests, a specific diagnosis of the cause of CAP by FAD can be achieved, reducing exclusion diagnosis of CIAP to 25% of cases. Conservative measures combined with biofeedback achieved an improvement in pain in more than 40% of the cases of CIAP in our study. Sacral nerve stimulation can be considered as a treatment option in refractory cases.

Prophylactic mesh vs suture in the closure of the umbilical trocar site after laparoscopic cholecystectomy in high-risk patients for incisional hernia. A randomized clinical trial.

BACKGROUND: Prosthetic repair has become the standard method for hernia repair. Mesh placement for the prevention of trocar site incisional hernia (TSIH) is still a controversial issue. We tested the hypothesis that closure with an intraperitoneal prophylactic mesh of the umbilical trocar after a laparoscopic cholecystectomy can reduce the incidence of a TSIH in high-risk patients. STUDY DESIGN: A randomized clinical trial was conducted among patients undergoing elective laparoscopic cholecystectomy who presented the following high-risk factors for incisional hernia, according to the literature: age 65 years and older, diabetes mellitus, chronic pulmonary disease, and obesity (ie, body mass index ≥30 kg/m(2)). Patients were assigned to have closure of the umbilical trocar site with either nonabsorbable sutures (group A) or intraperitoneal polypropylene omega-3 mesh (group B). Trocar site incisional hernia, pain, and surgical complications were evaluated at the early postoperative course and at 1, 6, and 12 months after surgery. RESULTS: A total of 106 patients were randomized into the study and 92 patients were finally analyzed, including 47 in group A and 45 in group B. The TSIH rate was higher in group A (31.9%) than in group B (4.4%) (odds ratio = 10.1; 95% CI, 2.15-47.6; p < 0.001)). The wound infection rate was 4.3%; 8.5% in group A and 0% in group B (odds ratio = 2.04; 95% CI, 1.7-2.5; p = 0.045). Median postoperative pain evaluated by a visual analogue scale was 3 in group A and 2 in group B (p = 0.05). No differences were observed in complication rate, operative time, or hospital stay between the groups. CONCLUSIONS: Prosthetic closure of the umbilical trocar site after laparoscopic surgery could become the standard method for preventing TSIH in high-risk patients.

Three ports placed in the linea alba of the abdomen (three-midline-ports technique): an alternative approach for laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy is the commonest operation performed laparoscopically worldwide. In this study, we compared a three-midline-ports approach with the standard "French" method for laparoscopic cholecystectomy. PATIENTS AND METHODS: A prospective, randomized study was performed between March 2010 and January 2011. One hundred consecutive patients undergoing elective cholecystectomy for symptomatic gallstones were included. The patients were randomized into two groups: those patients undergoing laparoscopic cholecystectomy following the "French" technique with three ports (Group 1) and those ones undergoing the three-midline-ports approach (Group 2). RESULTS: Mean operation time was 70.1±19.15 minutes in Group 1 versus 65.9±17.03 minutes in Group 2 (not significant). Complications appeared in 1 patient (2%) in each group (not significant). There was no mortality. Median hospital stay was 1.5 days in both groups. Median postoperative pain evaluated by visual analog scale was 4 (range, 1-7) in Group 1 and 2.5 (range, 0-4) in Group 2 (P=.002). In both groups, the most painful port was the subumbilical one, followed by the 10-mm port and then the 5-mm one. The visual analog scale evaluation separately of the 10-mm port was 2.5 in Group 1 versus 1.5 in Group 2 (P=0.04). CONCLUSIONS: The three-midline-ports approach is a feasible technique, safe and easy to implement, associating lower postoperative pain than the standard "French" approach.

Microbiological spectrum of the intraperitoneal surface after elective right-sided colon cancer: are there differences in the peritoneal contamination after performing a stapled or a handsewn anastomosis?

BACKGROUND: Although colonic surgery is performed with strict aseptic measures, some contamination is nearly impossible to avoid. In stapled anastomosis, the hole opened in the colon is minimum, just necessary for introducing the parts of the mechanical devices. In handsewn anastomosis, the colonic lumen is more exposed to the peritoneum, despite colonic occlusion with clamps while the suture is performed. PATIENTS AND METHODS: A prospective, randomized study was performed between October 2009 and June 2011. Inclusion criteria were a diagnosis of right-sided colon cancer and having undergone an elective surgery with curative aims. The patients were divided into two groups: those patients undergoing a stapled ileocolonic anastomosis (group 1) and those undergoing a handsewn anastomosis (group 2). A microbiological sample was obtained from the peritoneal surface before opening the colon and after finishing the anastomosis in each group. Data were correlated with the wound infection and intra-abdominal infection rates. RESULTS: Eighty-four patients were included in the study: 42 patients in each group. There were two intra-abdominal abscesses (5 %) in each group (NS). Wound infection rate was 10 % in group 1 and 7 % in group 2 (NS). Mean operative time was 98.8 min in the stapled group and 105.2 min in the handsewn one (P = 0.013). Positive cultures were obtained in 79 % of the cases after stapled anastomosis and 73 % after handsewn ones (NS). CONCLUSION: Peritoneal contamination appears in over 70 % of cases after ileocolonic anastomosis. Significant differences in peritoneal contamination, wound infection, and intra-abdominal abscess between stapled and handsewn anastomoses could not be demonstrated.

¿Existe alguna indicación de colocación de drenaje en la colecistectomía laparoscópica electiva? / Is there any indication for inserting a drain in elective laparoscopic cholecystectomy?

Introducción Clásicamente, se colocaba un drenaje subhepático de forma sistemática en la colecistectomía para prevenir los abscesos intraabdominales, posibles sangrados postoperatorios y fístulas biliares. Con el tiempo se ha ido demostrando que el uso sistemático de drenaje no aporta beneficios, pero muchos estudios concluyen que, en circunstancias especiales (sangrado, signos inflamatorios en la vesícula biliar, apertura incidental o sospecha de fuga biliar) y según la experiencia de cada cirujano, la indicación de colocación de un drenaje puede tener cabida. Material y métodos Realizamos un estudio prospectivo de 100 colecistectomías laparoscópicas consecutivas, intervenidas de forma electiva por colelitiasis sintomática o pólipos vesiculares. En 15 de ellas se colocó un drenaje subhepático. Las indicaciones para colocarlo fueron: en 11 pacientes como «testigo» por sangrado del lecho vesicular controlado intraoperatoriamente y en 4 por apertura de la vesícula con salida de bilis de aspecto turbio-purulento. Las variables principales investigadas fueron la utilidad clínica que ha tenido la colocación del drenaje, la estancia hospitalaria y la cuantificación del dolor a las 24h de la intervención por parte del paciente mediante una escala analógico-visual. Resultados En ningún paciente la colocación del drenaje tuvo utilidad alguna. La mediana de estancia hospitalaria aumentó un día en los pacientes con drenaje (p=0,002). La mediana de dolor a las 24h de la intervención en los pacientes con drenaje fue mayor (p=0,018).Conclusión La colocación de un drenaje subhepático tras colecistectomía laparoscópica programada aumenta el dolor postoperatorio y prolonga la estancia hospitalaria, pero no previene la aparición de abscesos intraabdominales (AU)

Introduction Classically, a sub-hepatic drain was inserted routinely in a cholecystectomy to prevent intra-abdominal abscesses, possible post-surgical bleeding, and biliary fistulas. Over the years, it has been demonstrated that the systematic use of a drain does not have any benefits, and many studies conclude that, in special circumstances (bleeding, signs of gallbladder inflammation, incidental opening, or suspected bile leak), and depending on the experience of the individual surgeon, the insertion of a drain may be of use. Material y methods A prospective study was conducted on 100 elective laparoscopic cholecystectomies performed due to symptomatic cholelithiasis or gallbladder polyps. A sub-hepatic drain was inserted in 15 of them. The indications for inserting it were: in 11 patients as a "control" due to a gallbladder bed bleed controlled during surgery, and in 4 due to a gallbladder opening with the excretion of turbid-purulent bile. The main outcomes investigated were the clinical benefit achieved by the insertion of the drain, the hospital stay, and the quantifying of the pain by the patients 24h after surgery, using a visual analogue scale. Results The insertion of a drain was of no benefit to any patient. The median hospital stay increased by 1 day in patients with a drain (P=.002). The median pain score at 24h was higher in patients with a drain inserted (P=.018).Conclusion The insertion of a sub-hepatic drain after elective laparoscopic cholecystectomy increases post-surgical pain and prolongs hospital stay, and does not prevent the occurrence of intra-abdominal abscesses (AU)

Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results.

OBJECTIVE: To evaluate the long-term clinical and manometric results of fistulotomy and sphincter reconstruction for the treatment of complex fistula-in-ano. BACKGROUND: Complex fistula-in-ano is difficult to treat due to the occurrence of postoperative anal incontinence and the high rate of recurrence. METHODS: Seventy patients who were diagnosed with complex fistula-in-ano and underwent fistulotomy and sphincter reconstruction between October 2000 and October 2006 were analyzed in the present study. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Appointments were scheduled every 6 months during the first and second year of treatment and every 2 years thereafter. Recurrence and incontinence were evaluated during each visit. Continence was assessed according to the Wexner continence grading scale. Anal manometry was performed 3 and 12 months after treatment and every 2 years thereafter. Anal endosonography was conducted 6 months after treatment. RESULTS: Fistulas were classified as medium-high trans-sphincteric in 64 patients (91.42%) and were recurrent in 22 patients (32%). Before surgery, 22 patients (32%) reported fecal incontinence, which improved after surgery in 15 cases (70%), from 6.75 to 1.88 (P < 0.005) on the Wexner Scale. Eight preoperative continent patients (16.6%) reported postoperative incontinence (Wexner Score < 3), and 6 patients (8.5%) had recurrent incontinence. Among these patients, 2 developed recurrent incontinence 6 months after treatment, 2 developed recurrent incontinence 1 year after treatment, 1 developed recurrent incontinence 2 years after treatment, and 1 developed incontinence 5 years after treatment. CONCLUSIONS: Fistulotomy with sphincter reconstruction is an effective technique for the treatment of complex fistula-in-ano. Continence and anal manometry results were improved in incontinent patients and were not jeopardized in continent ones. Fistulotomy with sphincter reconstruction is an especially suitable technique for incontinent patients with recurrent fistulas.

[Is there any indication for inserting a drain in elective laparoscopic cholecystectomy?]. / ¿Existe alguna indicación de colocación de drenaje en la colecistectomía laparoscópica electiva?

INTRODUCTION: Classically, a sub-hepatic drain was inserted routinely in a cholecystectomy to prevent intra-abdominal abscesses, possible post-surgical bleeding, and biliary fistulas. Over the years, it has been demonstrated that the systematic use of a drain does not have any benefits, and many studies conclude that, in special circumstances (bleeding, signs of gallbladder inflammation, incidental opening, or suspected bile leak), and depending on the experience of the individual surgeon, the insertion of a drain may be of use. MATERIAL AND METHODS: [corrected] A prospective study was conducted on 100 elective laparoscopic cholecystectomies performed due to symptomatic cholelithiasis or gallbladder polyps. A sub-hepatic drain was inserted in 15 of them. The indications for inserting it were: in 11 patients as a "control" due to a gallbladder bed bleed controlled during surgery, and in 4 due to a gallbladder opening with the excretion of turbid-purulent bile. The main outcomes investigated were the clinical benefit achieved by the insertion of the drain, the hospital stay, and the quantifying of the pain by the patients 24h after surgery, using a visual analogue scale. RESULTS: The insertion of a drain was of no benefit to any patient. The median hospital stay increased by 1 day in patients with a drain (P=.002). The median pain score at 24h was higher in patients with a drain inserted (P=.018). CONCLUSION: The insertion of a sub-hepatic drain after elective laparoscopic cholecystectomy increases post-surgical pain and prolongs hospital stay, and does not prevent the occurrence of intra-abdominal abscesses.

Effect of peritoneal lavage with clindamycin-gentamicin solution on infections after elective colorectal cancer surgery.

BACKGROUND: Colorectal surgery may lead to infections because despite meticulous aseptic measures, extravasation of microorganisms from the colon lumen is unavoidable. STUDY DESIGN: A prospective, randomized study was performed between January 2010 and December 2010. Patient inclusion criteria were a diagnosis of colorectal neoplasms and plans to undergo an elective curative operation. Patients were divided into 2 groups: Group 1 (intra-abdominal irrigation with normal saline) and Group 2 (intraperitoneal irrigation with a solution of 240 mg gentamicin and 600 mg clindamycin). The occurrence of wound infections and intra-abdominal abscesses were investigated. After the anastomosis, a microbiologic sample of the peritoneal surface was obtained (sample 1). A second sample was collected after irrigation with normal saline (sample 2). Finally, the peritoneal cavity was irrigated with a gentamicin-clindamycin solution and a third sample was obtained (sample 3). RESULTS: There were 103 patients analyzed: 51 in Group 1 and 52 in Group 2. There were no significant differences between the groups in age, sex, comorbidities, or type of colorectal surgery performed. Wound infection rates were 14% in Group 1 and 4% in Group 2 (p = 0.009; odds ratio [OR] 4.94; 95% CI 1.27 to 19.19). Intra-abdominal abscess rates were 6% in Group 1 and 0% in Group 2 (p = 0.014; OR 2.14; 95% CI 1.13 to 3.57). The culture of sample 1 was positive in 68% of the cases, sample 2 was positive in 59%, and sample 3 in 4%. CONCLUSIONS: Antibiotic lavage of the peritoneum is associated with a lower incidence of intra-abdominal abscesses and wound infections.