Cost-benefit analysis and short-term outcomes after implementing an ERAS protocol for colorectal surgery: a propensity score-matched analysis.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has become increasingly popular in the post-operative management of abdominal surgery. Published data suggest that patients on ERAS protocols have fewer minor and major complications, and highlight a reduction in medical morbidity (such as urinary and respiratory infections). Limited data is available on surgical complications. The aim of the study was to evaluate the impact of the ERAS protocol on post-operative complications and length of hospital stay. Furthermore, we aimed to determine the impact of this protocol on cost-effectiveness. MATERIAL AND METHODS: From January 2016 to December 2022, 532 colectomies for colorectal cancer (CRC) were performed. A prospective observational study was conducted in a tertiary hospital on the cohort of patients, aged 18 years and older, operated on for non-urgent colorectal cancer. The impact on post-operative complications, hospital stay and economic impact was analysed in two groups: patients managed under ERAS and non-ERAS protocol. A propensity score-matching analysis was performed between the two groups. RESULTS: After propensity score matching 1:1, each cohort included 71 patients, and clinicopathological characteristics were well balanced in terms of tumour type, surgical technique and surgical approach. ERAS patients experienced fewer infectious complications and a shorter postoperative stay (p < 0.001). In particular, they had an 8.5% reduction in anastomotic dehiscence (p = 0.012) and surgical wound infections (p = 0.029). After analysis of medical complications, no statistically significant differences were identified in urinary tract infections, pneumonia, gastrointestinal bleeding or sepsis. ERAS protocol was more efficient and cost-effective than the control group, with an overall savings of 37,673.44€. CONCLUSIONS: The implementation of an enhanced recovery protocol for elective colorectal surgery in a tertiary hospital was cost-effective and associated with a reduction in post-operative complications, especially infectious complications.

Incidence and risk factors for incisional hernia after temporary loop ileostomy closure: choosing candidates for prophylactic mesh placement.

OBJECTIVES: The primary aim of this study was to identify the incisional hernia rate after temporary loop ileostomy closure. Secondary outcomes were determining the risk factors linked to this incisional hernia, which could improve the patient selection for mesh prophylaxis. METHODS: Retrospective cohort study of all consecutive patients with temporary loop ileostomy reversal through a peristomal incision from 1st January 2011 to 1st January 2017 at our centre. Data were extracted from electronic clinical records: baseline patient characteristics, surgical factors and postoperative events. CT scans performed during follow-up were precisely analysed. Survival analysis was applied to identify risk factors for hernia development. RESULTS: 129 patients were analysed of whom 15 (11.6%) developed an incisional hernia at previous ileostomy site. The median time for incisional hernia development was 11 months (IQR = 7-21) and the median follow-up time was 37 months (IQR = 22-57). The identified patient risk factors for hernia development in survival analysis were female sex, older age, higher Body Mass Index, clinically significant parastomal hernia, clinically detectable midline incisional hernia and major postoperative complications ranked as Clavien-Dindo grade III and IV. CONCLUSIONS: Incisional hernia after temporary loop ileostomy is a relevant problem that affects at least one in every ten patients. The previously cited risk factors might favour its development, therefore the use of a prophylactic mesh should be considered in those high-risk patients.

Portal vein arterialization in liver transplantation: an option to restore arterial flow: a case report.

We report a 66-year-old woman who underwent emergency orthotopic liver transplantation due to acute liver failure. The donor's liver graft displayed extensive arteriosclerosis, involving the celiac trunk and hepatic artery. Arterial revascularization of the graft could not be achieved, requiring an arterioportal shunt between the gastroduodenal artery and the portal vein of the recipient. During the early postoperative period, the patient's clinical condition and liver function tests improved rapidly; the patient was discharged on postoperative day 30. Two months later, she developed acute cholangitis. Ischemic-type stenosis of the intrahepatic biliary tree was present, so successful elective retransplantation was undertaken at the ninth postoperative month. In our experience, portal vein arterialization may be useful as a bridging therapy in extreme situations.

Massive low gastrointestinal bleeding due to a Dieulafoy rectal lesion.

Massive low gastrointestinal bleedings are often difficult diagnostically and in terms of management. Sometimes, it is not possible to identify the bleeding point after performing diverse diagnostic tests and the patient undergoes a blind subtotal colectomy. With rectal bleeding, this form of surgery is completely useless, as it will not solve the cause of the haemorrhage. The Dieulafoy lesion has been widely described in the stomach, but in the rectum is a very rare entity that can cause massive lower gastrointestinal bleeding. In the literature, there are only 25 described cases of rectal Dieulafoy lesion.

Posthemipelvectomy hernia.

We report the case of a white male who underwent a classic hemipelvectomy due to a femur fibrosarcoma with inguinal metastases, which 33 years later, developed into a posthemipelvectomy hernia in the amputation stump that impaired the use of his Canadian prosthesis. The hernia was repaired with a polypropylene mesh in a subaponeurotic position. A seroma was drained in the postoperative and it was only 2 months after the operation that he could use his prosthesis with any difficulty. A year after the operation, the hernia had not recurred. Only seven similar cases have been published, and there are only four cases with details of their correction, two with a mesh as was our case, and the rest with a primary suture of the aponeurotic borders. A brief review of the bibliography is given on this subject.