Long-term results of giant hiatal hernia mesh repair and antireflux laparoscopic surgery for gastroesophageal reflux disease.

BACKGROUND: The application of mesh-reinforced hiatal closure has resulted in a significant reduction in recurrence rates. The most debated issue is the risk of complications related to the use of the prosthesis, which are thought to be the cause of higher dysphagia. PATIENTS AND METHODS: From January 2004 to December 2007, 198 consecutive patients underwent laparoscopic fundoplication for gastroesophageal reflux disease (GERD) with or without hiatal hernia. Fifty patients (25.3%) presented a giant hiatal hernia, defined as a hiatal defect over 5 cm. These 50 patients underwent primary simple suture of the crura and additional reinforcement with a Crurasoft mesh (Bard). Hiatal hernia or GERD symptoms recurrence, dysphagia, and mesh-related complications were investigated. RESULTS: Of the 50 patients undergoing mesh repair, there were 32 women and 18 men with a mean age of 63.2 years. Conversion rate was 2%. Intraoperative complications rate was 6%, all of them laparoscopically managed. Postoperative complications occurred in 1 patient (2%). Mortality rate was 2%. Median postoperative stay was 3 days. Median follow-up was 62 months. Two percent of the patients presented wrap migration, and 4% presented dysphagia. Six percent of cases presented recurrence of GERD manifestations. There have been no complications related to the use of the mesh. CONCLUSIONS: Laparoscopic antireflux surgery with a prosthetic mesh in cases of giant hiatal hernia is an effective and safe procedure, reducing the rate of postoperative hernia recurrence during long-term follow-up. The incidence of mesh-related complications is very low.

[Laparoscopic splenectomy: 7-year experience]. / Esplenectomía laparoscópica: Experiencia de 7 años.

BACKGROUND: Laparoscopic splenectomy is an effective and safe technique in the management of benign splenic pathologies. METHODS: We reviewed our 7-year experience to evaluate utility and safety of this procedure. RESULTS: Laparoscopic splenectomy was performed in 20 patients (13 women, 7 men), with a mean age of 49 years. Pathology included 19 cases of idiopathic thrombocytopenic purpura (ITP) and one case of autoimmune hemolytic anemia. Mean operative time was 165 min, including anesthetic procedure. There was only one conversion to open surgery. Accessory spleens were detected in 15% of patients. Early remission of hematological disorders was achieved in 70% of the cases and long-term remission in 90%. The complications rate was 20%, including two cases of subphrenic hematoma, one case of acute focal pancreatitis and one case of thrombosis of the portal venous system; all recovered with no sequelae. Mortality rate was 0%. CONCLUSIONS: Laparoscopic splenectomy obtains results identical to those of open surgery in terms of efficacy and safety but with the benefits of laparoscopic surgery. Therefore, it should be considered as the procedure of choice for the treatment of benign hematological pathologies unresponsive to medical therapy.

[Laparoscopic adrenalectomy]. / Adrenalectomía laparoscópica.

INTRODUCTION: In the last few years, laparoscopic adrenalectomy has become widely used in the management of adrenal disease. MATERIAL AND METHOD: We reviewed our experience of 24 patients who underwent laparoscopic adrenalectomy between 1998 and 2006. RESULTS: Surgery was indicated for Cushing's syndrome in 46% of the patients, aldosteronoma in 25%, incidentaloma in 21% and pheochromocytoma in 8%. A lateral transabdominal approach was employed in all patients. The mean age of the patients was 50.4 years (17 women and 7 men). Left unilateral adrenalectomy was performed in 63% of the patients, right unilateral adrenalectomy in 29% and bilateral adrenalectomy in 8%. The conversion rate was 4%. The mean operating time was 134 minutes in unilateral approaches and 245 minutes in bilateral approaches. The mean size of the gland was 4 cm. The complications rate was 4% and there was no mortality. Disease control was achieved in 96% of the patients after a mean follow-up of 49 months. CONCLUSIONS: Laparoscopic adrenalectomy should be considered the procedure of choice for the surgical management of benign adrenal disease.

Adrenalectomía laparoscópica / Laparoscopic adrenalectomy

Introducción. La adrenalectomía laparoscópica es una técnica que se ha popularizado en los últimos años en el manejo de la afección adrenal. Material y método. Revisamos nuestra experiencia de 24 casos de adrenalectomía laparoscópica entre 1998 y 2006. Resultados. En el 46% de los casos la indicación fue por síndrome de Cushing; en el 25%, aldosteronoma; en el 21%, incidentaloma, y en el 8%, feocromocitoma. El abordaje fue por vía transabdominal lateral en todos los pacientes. La media de edad de los pacientes fue 50,4 años y se trataba de 17 mujeres y 7 varones. Se realizó adrenalectomía unilateral izquierda en el 63% de los casos, unilateral derecha en el 29% y bilateral en el 8%. La tasa de conversión a cirugía abierta fue el 4%. La duración media de la intervención fue 134 min en los abordajes unilaterales y 245 min en los bilaterales. El tamaño medio de la glándula fue 4 cm. La tasa de complicaciones fue del 8% y no hubo mortalidad. Se consiguió control de la enfermedad de base en el 96% de los pacientes tras un seguimiento medio de 49 meses. Conclusiones. La adrenalectomía laparoscópica debe ser considerada como el procedimiento de elección para el tratamiento quirúrgico de las enfermedades adrenales benignas (AU)

Introduction. In the last few years, laparoscopic adrenalectomy has become widely used in the management of adrenal disease. Material and method. We reviewed our experience of 24 patients who underwent laparoscopic adrenalectomy between 1998 and 2006. Results. Surgery was indicated for Cushing's syndrome in 46% of the patients, aldosteronoma in 25%, incidentaloma in 21% and pheochromocytoma in 8%. A lateral transabdominal approach was employed in all patients. The mean age of the patients was 50.4 years (17 women and 7 men). Left unilateral adrenalectomy was performed in 63% of the patients, right unilateral adrenalectomy in 29% and bilateral adrenalectomy in 8%. The conversion rate was 4%. The mean operating time was 134 minutes in unilateral approaches and 245 minutes in bilateral approaches. The mean size of the gland was 4 cm. The complications rate was 4% and there was no mortality. Disease control was achieved in 96% of the patients after a mean follow-up of 49 months. Conclusions. Laparoscopic adrenalectomy should be considered the procedure of choice for the surgical management of benign adrenal disease (AU)

Portal vein thrombosis after laparoscopic splenectomy in benign hematologic diseases.

INTRODUCTION: Portal vein thrombosis is an unfrequent, but potentially deadly, complication of the laparoscopic splenectomy procedure. The laparoscopic approach has shortened the duration of hospital stay; portal vein thrombosis may appear after the patient has left the hospital, determining a later diagnosis. Because of the mild, nonspecific symptoms, the diagnosis can even be missed and only achieved when chronic complications take place. OBJECTIVES: In this study, we aimed to determine the appearance of portal vein thrombosis in a consecutive series of patients who underwent laparoscopic splenectomy by performing a contrast-enhanced computed tomography (CT) scan postoperatively. MATERIALS AND METHODS: A transversal study was established, performing in 2005 a contrast-enhanced CT scan on 20 patients who underwent laparoscopic splenectomy between 1999 and 2005 at Ramón y Cajal University Hospital (Madrid, Spain). The presence of thrombosis in the splenoportomesenteric axis was investigated. RESULTS: Two (2) cases (10%) of portal vein thrombosis were detected: 1 symptomatic case, 7 days after surgery, was treated with anticoagulation, resulting in the disappearance of the thrombus in a new CT scan 6 months later; the second case was asymptomatic and was discovered during the performance of this study. CONCLUSIONS: The contrast-enhanced CT scan shows the best accuracy for the diagnosis of portal vein thrombosis, and it must be performed when any clinical manifestation appear; also, it must still be determined if a contrast-enhanced CT scan should be systematically performed in high-risk thromboembolic patients. An ultrasound Doppler may present many diagnostic errors. It is probably advisable to prolong the antithromboembolic prophylaxis.

Dos casos extremos de presentación de tumores pancreáticos / Two exceptional cases of pancreatic tumor

El cáncer de páncreas es un tumor de mal pronóstico y la resección quirúrgica es el único tratamiento potencialmente curativo, pero pocos casos son candidatos por su presentación en estadios avanzados. Exponemos 2 casos extremos de presentación de tumores pancreáticos. Caso 1: varón de 59 años que presenta heces melénicas recidivantes a pesar de esclerosis endoscópica de ulcus duodenal. Se objetivó mediante tomografía computarizada (TC) una masa en cabeza pancreática con infiltración de la segunda porción del duodeno. La biopsia duodenal mostró carcinoma pobremente diferenciado. Se realizó duodenopancreatectomía paliativa. Caso 2: varón de 49 años con episodios esporádicos de dolor en hipocondrio derecho y antecedentes familiares de primero y segundo grado fallecidos de cáncer de páncreas. La TC y la resonancia magnética mostraron en la cabeza pancreática una lesión quística inferior de 1 cm. Una punción-aspiración con aguja fina mostró material mucoide y papilas con atipia celular. Ante el diagnóstico probable de cistoadenoma mucinoso se decidió realizar pancreatoduodenectomía (AU)

Pancreatic cancer carries a poor prognosis. The only potentially curative treatment is surgical resection. However, this procedure can only be performed in a few cases due to presentation of the tumor in advanced stages. We present 2 exceptional cases of pancreatic cancer presentation. Case 1: A 59-year-old man presented with recurrent melena despite endoscopic sclerosis of a duodenal ulcer. A computed tomography (CT) scan revealed a 7-cm mass in the head of the pancreas infiltrating the second portion of the duodenum. Duodenal biopsy showed a poorly differentiated carcinoma. Palliative pancreatoduodenectomy was performed. Case 2: A 49-year-old man presented with sporadic pain in the right hypochondrium and a familial history of pancreatic cancer in first and second degree relatives. CT and magnetic resonance imaging revealed a 1-cm cystic lesion in the head of the pancreas. Cytology showed mucoid material and atypia. Given a probable diagnosis of mucinous cystoadenoma, pancreatoduodenectomy was performed (AU)

[Laparoscopic vs open splenectomy in the treatment of idiopathic thrombocytopenic purpura]. / Esplenectomía laparoscópica o esplenectomía abierta en el tratamiento de la púrpura trombocitopénica idiopática.

INTRODUCTION: Laparoscopic splenectomy (LS) is gaining acceptance as an effective and safe alternative to open splenectomy (OS) in the treatment of benign hematologic disorders unresponsive to medical treatment. Among these disorders, the most important is idiopathic thrombocytopenic purpura (ITP). PATIENTS AND METHOD: We compared a cohort of 20 patients who had undergone LS in the previous 7 years, with a historical cohort of 38 patients who underwent OS between 1985 and 1999. All patients in the two groups were diagnosed with ITP unresponsive to medical treatment. RESULTS: The mean age of the patients was 41 years in the LS group and 39.7 in the OS group. Mean spleen size and weight were 11 cm and 150 g in the LS group and 9.9 cm and 190 g in the OS group. Preoperative platelet count was 78 x 10(9) in the LS group and 69 x 10(9) in the OS group. Accessory spleens were detected in 15% of patients in the LS group and in 16% of those in the OS group. The mean operative time was 180 minutes in LS and 85 minutes in OS (p < 0.001). The complications rate was 25% in LS and 21% in OS. The mean length of hospital stay was 3 days in the LS group and 9.4 days in the OS group (p < 0.001). No differences were observed in early and complete long-term remission. CONCLUSIONS: Compared with OS, LS requires a longer operative time and reduces hospital stay. Detection of accessory spleens, complication rates, and effectiveness in terms of early and long-term remission are similar in both procedures. In our opinion, LS should be considered the procedure of choice for the treatment of benign hematological disorders unresponsive to medical therapy.

Esplenectomía laparoscópica o esplenectomía abierta en el tratamiento de la púrpura trombocitopénica idiopática / Laparoscopic vs open splenectomy in the treatment of idiopathic thrombocytopenic purpura

Introducción. La esplenectomía laparoscópica está ganando aceptación como alternativa segura y efectiva a la esplenectomía abierta en el tratamiento de trastornos hemáticos benignos refractarios a tratamiento médico, de los que la púrpura trombocitopénica idiopática es el más importante. Material y método. Comparamos una cohorte de 20 pacientes sometidos a esplenectomía laparoscópica (EL) en los últimos 7 años con una cohorte histórica de 38 casos sometidos a esplenectomía abierta (EA) entre 1985 y 1999. Todos los casos de ambos grupos estaban diagnosticados de púrpura trombocitopénica idiopática refractaria a tratamiento médico. Resultados. La media de edad de los pacientes del grupo EL era de 41 años, frente a 39,7 en el grupo EA. El tamaño medio y el peso medio del bazo fueron de 11 cm y 150 g en EL y 10,9 cm y 190 g en EA. El recuento plaquetario preoperatorio fue 78 x 109 en EL y 69 x109 en EA. Se detectaron bazos accesorios en el 15% de los casos del grupo EL y el 16% en el grupo EA. La duración media de la cirugía fue 180 min en EL y 85 min en EA (p < 0,001). La tasa de complicaciones fue del 25% en EL y el 21% en EA. La estancia media hospitalaria fue 3 días en el grupo EL y 9,4 días en el grupo EA (p < 0,001). No se observaron diferencias en las tasas de remisión precoz y remisión completa a largo plazo. Conclusiones. Comparada con la EA, la EL precisa mayor tiempo operatorio, son similares en la detección de bazos accesorios, la tasa de complicaciones y la efectividad en la remisión precoz y la remisión completa a largo plazo, y conlleva un menor tiempo de hospitalización. En nuestra opinión, la EL debe ser considerada el procedimiento de elección en el tratamiento de afecciones hemáticas benignas que no responden a tratamiento médico (AU)

Introduction. Laparoscopic splenectomy (LS) is gaining acceptance as an effective and safe alternative to open splenectomy (OS) in the treatment of benign hematologic disorders unresponsive to medical treatment. Among these disorders, the most important is idiopathic thrombocytopenic purpura (ITP). Patients and method. We compared a cohort of 20 patients who had undergone LS in the previous 7 years, with a historical cohort of 38 patients who underwent OS between 1985 and 1999. All patients in the two groups were diagnosed with ITP unresponsive to medical treatment. Results. The mean age of the patients was 41 years in the LS group and 39.7 in the OS group. Mean spleen size and weight were 11 cm and 150 g in the LS group and 9.9 cm and 190 g in the OS group. Preoperative platelet count was 78 x 109 in the LS group and 69 x 109 in the OS group. Accessory spleens were detected in 15% of patients in the LS group and in 16% of those in the OS group. The mean operative time was 180 minutes in LS and 85 minutes in OS (p < 0.001). The complications rate was 25% in LS and 21% in OS. The mean length of hospital stay was 3 days in the LS group and 9.4 days in the OS group (p < 0.001). No differences were observed in early and complete long-term remission. Conclusions. Compared with OS, LS requires a longer operative time and reduces hospital stay. Detection of accessory spleens, complication rates, and effectiveness in terms of early and long-term remission are similar in both procedures. In our opinion, LS should be considered the procedure of choice for the treatment of benign hematological disorders unresponsive to medical therapy (AU)