Anti-reflux surgery vs. bariatric surgery as anti-GERD and hiatal hernia treatment in obese patient. New surgical proposals.

The persistence of obesity favors the failure of the Fundoplication (FP) in the treatment of Gastroesophageal Reflux (GER). However, the weight loss obtained with the performance of a Gastric Bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of postoperative complications. All of this leads us to consider that while FP is the indication in patients with BMI < 30, in those patients with BMI > 35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI > 30. Although Sleeve Gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of postoperative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms. Likewise, if the existence of an Hiatal Hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.

Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines.

Sepsis of biliary origin is increasing worldwide and has become one of the leading causes of emergency department admissions. The presence of multi-resistant bacteria (MRB) is increasing, and mortality rates may reach 20%. This review focuses on the changes induced by the Tokyo guidelines and new concepts related to the early treatment of severe biliary disease. If cholecystitis or cholangitis is suspected, ultrasound is the imaging test of choice. Appropriate empirical antibiotic treatment should be initiated promptly, and selection should be performed while bearing in mind the severity and risk factors for MRB. In acute cholecystitis, laparoscopic cholecystectomy is the main therapeutic intervention. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for controlling the infection. Treatment of severe acute cholangitis is based on endoscopic or transhepatic bile duct drainage and antibiotic therapy. Endoscopic ultrasound and other new endoscopic techniques have been added to the arsenal as novel alternatives in high-risk patients. However, biliary infections remain serious conditions that can lead to sepsis and death. The introduction of internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a framework for their rapid diagnosis and treatment. Prompt assessment of patient severity, timely initiation of antimicrobials, and early control of the source of infection are essential to reduce morbidity and mortality rates.

Contemporary management of concomitant gallstones and common bile duct stones: a survey of Spanish surgeons.

BACKGROUND: Concomitant gallstones and common bile duct stones (CBDS) is a relatively frequent presentation. The optimal treatment remains controversial and the debate persists between two strategies. The one-stage approach: laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE) has been shown to be equally safe and more cost-effective than the more traditional two-stage approach: endoscopic retrograde cholangiography followed by laparoscopic cholecystectomy (ERCP + LC). However, many surgeons worldwide still prefer the two-stage procedure. This survey evaluated contemporary management of CBDS in Spain and assessed the impact of surgeon and hospital factors on provision of LCBDE. METHODS: A 25-item, web-based anonymous survey was sent to general surgeons members of the Spanish Surgeons Association. Descriptive statistics were applied to summarize results. RESULTS: Responses from 305 surgeons across 173 Spanish hospitals were analyzed. ERCP is the initial approach for preoperatively suspected CBDS for 86% of surgeons. LCBDE is the preferred method for only 11% of surgeons and only 11% treat more than 10 cases per year. For CBDS discovered intraoperatively, 59% of respondents attempt extraction while 32% defer to a postoperative ERCP. The main reasons cited for not performing LCBDE were lack of equipment, training and timely availability of an ERCP proceduralist. Despite these barriers, most surgeons (84%) responded that LCBDE should be implemented in their departments. CONCLUSIONS: ERCP was the preferred approach for CBDS for the majority of respondents. There remains limited use of LCBDE despite many surgeons indicating it should be implemented. Focused planning and resourcing of both training and operational demands are required to facilitate adoption of LCBDE as option for patients.

Tratamiento quirúrgico de la colecistitis aguda. Resultados de una encuesta a los cirujanos españoles / Surgical management of acute cholecystitis. Results of a nation-wide survey among Spanish surgeons

Existe una amplia variabilidad en el abordaje quirúrgico de la colecistitis aguda. Se presenta una encuesta a los miembros de la Asociación Española de Cirujanos (AEC) para analizar sus preferencias en el tratamiento de la colecistitis. La mayoría de los cirujanos que responden no declara ninguna superespecialidad (41,6%), el 21% son cirujanos hepatobiliopancreáticos, seguidos por cirujanos colorrectales y esofagogástricos. El 92,3% prefiere la colecistectomía durante el primer ingreso, aunque solo el 42,7% la realiza. Las razones más frecuentes para cambiar su práctica preferida son: pacientes no aptos para cirugía (43,6%) y poca disponibilidad de quirófano de urgencias (35,2%). El 88,9% realiza la colecistectomía por laparoscopia. La mayoría de cirujanos de la AEC aconseja la colecistectomía en el primer ingreso para la colecistitis, pero solo la mitad de ellos la aplica en su entorno clínico. Existen diversos puntos de mejora en el tratamiento de la colecistitis aguda en los hospitales españoles

There is a wide variability in the management of acute cholecystitis. A survey among the members of the Spanish Association of Surgeons (AEC) analyzed the preferences of Spanish surgeons for its surgical management. The majority of the 771 responders did not declare any subspecialty (41.6%), 21% were HPB surgeons, followed by colorectal and upper-GI specialities. Early cholecystectomy during the first admission is the preferred method of management of 92.3% of surgeons, but only 42.7% succeed in adopting this practice. The most frequent reasons for changing their preferred practice were: patients not fit for surgery (43.6%) and lack of availability of emergency operating room (35.2%). A total of 88.9% perform surgery laparoscopically. The majority of AEC surgeons advise index admission cholecystectomy for acute cholecystitis, although only half of them succeed in its actual implementation. There is room for improvement in the management of acute cholecystitis in Spanish hospitals

Surgical management of acute cholecystitis. Results of a nation-wide survey among Spanish surgeons.

There is a wide variability in the management of acute cholecystitis. A survey among the members of the Spanish Association of Surgeons (AEC) analyzed the preferences of Spanish surgeons for its surgical management. The majority of the 771 responders didn't declare any subspecialty (41.6%), 21% were HPB surgeons, followed by colorectal and upper-GI specialities. Early cholecystectomy during the first admission is the preferred method of management of 92.3% of surgeons, but only 42.7% succeed in adopting this practice. The most frequent reasons for changing their preferred practice were: Patients not fit for surgery (43.6%) and lack of availability of emergency operating room (35.2%). A total of 88.9% perform surgery laparoscopically. The majority of AEC surgeons advise index admission cholecystectomy for acute cholecystitis, although only half of them succeed in its actual implementation. There is room for improvement in the management of acute cholecystitis in Spanish hospitals.

Tratamiento del dolor anal por patología anorrectal aguda en urgencias: ¿baños de asiento con agua fría o caliente? resultados de un ensayo clínico aleatorizado / Cold or hot sitz baths in the emergency t

Introducción: La creencia popular propugna el uso de baños de asiento con agua fría para el tratamiento del dolor anal agudo, pero las guías de práctica clínica recomiendan el uso de agua caliente por su efecto conocido sobre la presión anal de reposo. Objetivo: El objetivo fue estudiar el efecto analgésico, sobre la calidad de vida, datos de manometría y evolución clínica, de 2 temperaturas en los baños de asiento en enfermos con dolor anal. Material y métodos: Ensayo clínico aleatorizado en pacientes con dolor anal agudo por enfermedad hemorroidal o fisura anal divididos en Grupo 1: baños de asiento con agua a Ta inferior a 15°C y Grupo 2: baños con agua a Tasuperior a 30°C. La analgesia fue la misma en ambos grupos. Se analizó: el dolor durante 7 días (escala visual analógica), calidad de vida (SF-36), presión anal de reposo y evolución de la enfermedad. Resultados: De 27 pacientes elegibles, 24 fueron aleatorizados (Grupo 1: n=12 y Grupo 2: n=12). El dolor no mostró diferencias estadísticamente significativas, pero se mantuvo estable en el Grupo 1 y por el contrario fue disminuyendo progresivamente en los pacientes del Grupo 2, siendo la diferencia en los valores del dolor del primer día respecto al séptimo superior en el Grupo 2 (p=0,244). El resto de variables fueron similares. Conclusión: No hubo diferencias estadísticamente significativas en el control del dolor del 1.er al 7 día en el Grupo con baños de asiento con agua caliente (AU)

Introduction: The popular belief advocates the use of sitz (sitting) baths with cold water for the treatment of acute anal pain, but clinical practice guides recommend the use of hot water for its known effect on the at-rest anal pressure. Aim: The objective of the study was to examine the analgesic effect on the quality of life, manometer data and clinical progress, of the two temperatures in sitz baths in patients with anal pain. Material and methods: A randomised clinical trial on patients with acute anal pain due to haemorrhoids or anal fissures, divided into Group 1: Sitz baths with water at a temperature of less than 15°C, and Group 2: Baths with a water temperature above 30°C. The analgesia was the same in both groups. An analysis was made of the pain at 7 days (visual analogue scale), quality of life (SF-36), anal at-rest pressure and disease progress. Results: Of the 27 eligible patients, 24 were randomised (Group 1: n=12 y Group 2: n=12). There were no statistical differences in pain, but it remained stable in Group 1, but gradually decreased in the patients of Group 2, the difference being in the pain scores on the first day compared to the seventh in Group 2 (p=0.244). The rest of the variables were similar. Conclusion: There were no statistically significant differences in pain control from day 1 to day 7 in the Group with sitz baths with hot water (AU)

[Cold or hot sitz baths in the emergency treatment of acute anal pain due to anorectal disease? Results of a randomised clinical trial]. / Tratamiento del dolor anal por patología anorrectal aguda en urgencias: ¿baños de asiento con agua fría o caliente? resultados de un ensayo clínico aleatorizado.

INTRODUCTION: The popular belief advocates the use of sitz (sitting) baths with cold water for the treatment of acute anal pain, but clinical practice guides recommend the use of hot water for its known effect on the at-rest anal pressure. AIM: The objective of the study was to examine the analgesic effect on the quality of life, manometer data and clinical progress, of the two temperatures in sitz baths in patients with anal pain. MATERIAL AND METHODS: A randomised clinical trial on patients with acute anal pain due to haemorrhoids or anal fissures, divided into Group 1: Sitz baths with water at a temperature of less than 15 degrees C, and Group 2: Baths with a water temperature above 30 degrees C. The analgesia was the same in both groups. An analysis was made of the pain at 7 days (visual analogue scale), quality of life (SF-36), anal at-rest pressure and disease progress. RESULTS: Of the 27 eligible patients, 24 were randomised (Group 1: n=12 y Group 2: n=12). There were no statistical differences in pain, but it remained stable in Group 1, but gradually decreased in the patients of Group 2, the difference being in the pain scores on the first day compared to the seventh in Group 2 (p=0.244). The rest of the variables were similar. CONCLUSION: There were no statistically significant differences in pain control from day 1 to day 7 in the Group with sitz baths with hot water. (ISRCTN Number: 50105150).

Preoperative risk factors for mortality after relaparotomy: analysis of 254 patients.

INTRODUCTION: The aim of this work was to analyze preoperative mortality risk factors after relaparotomy for abdominal surgery in a unit of General Surgery at a University Hospital. METHODS: A total of 314 relaparotomies in 254 patients were performed between February 2004 and February 2008. We analyzed data about past medical history, first operation, as well as clinical and biochemical parameters previous to reoperation. RESULTS: Indications for relaparotomy were peritonitis, bleeding, abscess, exploratory laparotomy, and evisceration. Overall mortality was 22%. Mortality of the patients with a single relaparotomy was 20% vs. 44% if they were reoperated upon twice. Mortality was associated with age, past history of cardiovascular disease, active neoplasm, previous treatment with platelet anti-aggregant drugs, first surgery American Society of Anesthesia score, and the presence of an anastomosis. Preoperative data associated with mortality were the number of systemic inflammatory response syndrome criteria, suture dehiscense, ileus, positive blood cultures, mechanical ventilation, artificial nutrition, antibiotics or vasoactive drugs, tachycardia, and abnormal body temperature. High white blood cell count or bilirrubin levels and low albumin or prothrombin time were also associated with mortality. Multivariate logistic regression analysis isolated age (P = 0.02), abnormal body temperature (P = 0.02), and the need of mechanical ventilation (P = 0.004) as independent preoperative variables predictive for mortality after relaparotomy. CONCLUSIONS: Advanced age, the presence of either fever or hypothermia, and the need of mechanical ventilation are preoperative risk factors associated with mortality after relaparotomy and should be considered when planning reintervention.