Can physiological stimulation prior to ileostomy closure reduce postoperative ileus? A prospective multicenter pilot study.

BACKGROUND: The aim of this study was to assess the impact of ileostomy closure following preoperative physiological stimulation (PPS) on postoperative ileus (POI) in patients with loop ileostomy after low anterior resection for rectal cancer. METHODS: Patients who underwent ileostomy closure between January 2017 and February 2020 in two tertiary referral centers were prospectively included. PPS stimulation was compared to standard treatment. Stimulation was carried out daily during the 15 days prior to ileostomy closure by the patient's self-instillation of 200 ml of fecal contents from the ileostomy bag via the efferent loop, using a rectal catheter. Standard treatment (ST) consisted of observation. Outcomes measures were POI, morbidity, stimulation feasibility, and predictors to ileus. RESULTS: A total of 58 patients were included [42 males and 16 females, median age 67 (43-85) years]. PPS was used in 24 patients, who completed the entire stimulation process, and ST in 34 patients. No differences in preoperative factors were found between the two groups. POI was significantly lower in the PPS group (4.2%) vs the ST group (32.4%); p < 0.01, OR: 0.05 (CI 95% 0.01-0.65). The PPS group had a shorter time to restoration of bowel function (1 day vs 3 days) p = 0.02 and a shorter time to tolerance of liquids (1 day vs 2 days), p = 0.04. Age (p = 0.01), open approach at index surgery, p = 0.03, adjuvant capecitabine (p = 0.01). and previous abdominal surgeries (p = 0.02) were associated with POI in the multivariate analysis. C-reactive-protein values on the 3rd (p = 0.02) and 5th (p < 0.01) postoperative day were also associated with POI. CONCLUSIONS: PPS for patients who underwent ileostomy closure after low anterior resection for rectal cancer is feasible and might reduce POI.

Long-term results and complications related to Crurasoft® mesh repair for paraesophageal hiatal hernias.

PURPOSE: The application of mesh-reinforced hiatal closure has resulted in a significant reduction in recurrence rates in comparison with primary suture repair. However, the use of meshes has not completely extended in all the cases of large paraesophageal hiatal hernias (LPHH) due to the complications related to them. The aim of this study is to present our long-term results and complications related to Crurasoft® mesh (Bard) for the treatment of LPHH. METHODS: From January 2004 to December 2014, 536 consecutive patients underwent open or laparoscopic fundoplication for gastroesophageal reflux disease or LPHH at Ramón y Cajal University Hospital. Primary simple suture of the crura and additional reinforcement with a Crurasoft® mesh (Bard) was performed in 93 patients (17.35 %). Radiologic hiatal hernia recurrence and mesh-related complications were investigated. RESULTS: Of the 93 patients undergoing mesh repair, there were 28 male and 65 female with a mean age of 67.27 years (range 22-87 years). Laparoscopic surgery was attended in 88.2 % of the cases, and open surgery in the rest 11.8 %. Mean operative time was 167.05 min (range 90-370 min). Median postoperative stay was 4.79 days (range 1-41 days). Conversion rate was 8.53 % (7 patients). Intraoperative complications were described in 10.75 % (10 patients), but all of them, except in one case, could be managed laparoscopically. Overall postoperative complications rate was 28 %. Early postoperative complications occurred in 11 patients (12 %), respectively, for grades 2 (6 cases), 3b (1 case) and 5 (4 cases) according to the Clavien-Dindo classification. Late postoperative complications occurred in 15 patients (16 %), respectively, for grades 1 (7 cases), 2 (2 cases), 3b (5 cases) and 5 (1 case) according to the Clavien-Dindo classification. Thirty day-mortality rate was 4.3 %. Mortality rate specific associated with the mesh was 1 %. Reoperation rate was 5.4 %. After a median follow-up of 76.33 months (range 3-130 months), 8 patients (9 %) developed a recurrent hiatal hernia. Mesh was removed in three cases (3.22 %). CONCLUSIONS: In our experience, the recurrence rate in patients with a Crurasoft® (Bard) is acceptable. However, the rate of postoperative complications and mortality is excessive. The use of meshes in the hiatus keeps on being controversial due to the severe complications related to them. It would be advisable to compare our results in the non-mesh group in terms of recurrences and complications, to determine if meshes in the hiatus should be given in these patients due to its high rate of complications.

¿Podría englobarse la fibromatosis agresiva dentro del espectro de los tumores del estroma gastrointestinal? / Could aggressive fibromatosis be considered whitin the spectrum of gstrointestinal stromal tumors?

Los tumores desmoides aparecen como resultado de la proliferación fibroblástica, sin signos histológicos de malignidad pero localmente muy agresivos. Se han descrito casos de fibromatosis tras extirpación de GIST. Presentamos el caso de un GIST gástrico operado, que a los 18 meses se realiza laparotomía exploradora por sospecha de recurrencia y tras hallazgos histológicos definitivos, se diagnostica de fibromatosis intra-abdominal agresiva. Se discute la valoración clínico-oncológica de la fibromatosis como forma de recurrencia local del GIST

Desmoid tumors appear as a result of fibroblastic proliferation without histological signs of malignancy but locally aggressive. Fibromatosis have been described after removing a gastrointestinal stromal tumor (GIST). We present a case of a resected gastric GIST and eigthteen months after surgery, a exploratory laparotomy was performed suspecting recurrence and after definitive histological findings, the diagnosis was aggressive intra-abdominal fibromatosis. Clinical-oncological assessment of fibromatosis is discussed as a form of GIST local recurrence

Results of laparoscopic cholecystectomy in a third-level university hospital after 17 years of experience.

OBJECTIVE: The aim of the study is to determine the results obtained with laparoscopic cholecystectomy at Ramón y Cajal Hospital after 17 years of experience, comparing current results with those at the beginning of the experience. MATERIAL AND METHODS: Between 1991 and December 2007, 3,933 laparoscopic cholecystectomies were performed at the "Ramón y Cajal Hospital"; 1,849 patients were operated on between 1991 and 2000, and 2,084 between 2001 and 2007. Patients studied included 69.8% of women and 30.2% of men, with a mean age of 56.95 years (range 9-94 years). In all, 54.68% of patients had a concomitant disease before surgery (hypertension, diabetes, ischemic heart disease, respiratory disease). Surgery was performed by a staff surgeon for 58.04% of cases, and by a resident in the remaining 41.96%. Surgical indications were cholelithiasis in 75.5%, pancreatitis in 13.3%, cholecystitis in 6.3%, choledocholithiasis in 3.05%, and others in 1.2% of cases. RESULTS: Mean hospital stay was 3.06 days. Conversion to open surgery was required for 8.3% of cases (331 patients). The major surgical complication rate was 2.34%, with the most frequent being hemoperitoneum (1%). Common bile duct injury occurred in thirteen cases (0.3%), 51 patients (1.3%) were soon re-operated, and 5 patients died (0.13%). When the results of both decades (1991-2000 vs. 2001-2007) were compared, we observed differences in the number of procedures performed by residents (31.7 vs. 51.1%, p = 0.00001), number of laparoscopic cholecystectomies for cholecystitis (4.9 vs. 7.53%, p = 0.001), conversion rate (5.46 vs. 11%, p = 0.000001), and mean hospital stay (2.43 vs. 3.7 days, p = 0.001). CONCLUSION: These results should be interpreted with caution as this is a retrospective study with multiple uncontrolled variables (high number of surgeons and continuous learning curve). The lower conversion rate and mean hospital stay in the first decade of the learning curve are amazing, although this could be related to better patient selection and a lower number of cholecystites operated using a laparoscopic approach in the initial series. In general, these results are acceptable and concur with the rest of the literature.

Resultados de la colecistectomía laparoscópica en un hospital universitario de tercer nivel tras 17 años de experiencia / Results of laparoscopic cholecystectomy in a third-level university hospital after 17 years of experience

Objetivo: el objetivo del estudio es conocer los resultados obtenidos con la colecistectomía laparoscópica en el Hospital Ramón y Cajal en sus 17 años de experiencia, comparando los resultados actuales con los del inicio de la experiencia. Material y métodos: entre enero de 1991 y diciembre de 2007 se efectuaron en el Hospital Ramón y Cajal un total de 3.933 colecistectomías laparoscópicas. Fueron intervenidos 1.849 pacientes entre 1991-2000 y 2.084 entre 2001-2007. Un 69,8% eran mujeres y un 30,2% varones con una edad media de 56,95 años (rango 9-94 años). Un 54,68% de pacientes presentaban antecedentes personales de forma previa a la intervención (hipertensión, diabetes, cardiopatía isquémica, bronquitis...). La cirugía fue efectuada por un personal del staff en el 58,04% de los casos y por un residente de cirugía en el 41,96%. Las indicaciones quirúrgicas fueron colelitiasis 75,5%, pancreatitis 13,3%, colecistitis 6,3%, coledocolitiasis 3,05% y otros 1,2%. Resultados: la estancia media postoperatoria fue de 3,06 días. La tasa de conversión a cirugía abierta de 8,3% (331 pacientes) y la de complicaciones quirúrgicas mayores del 2,34%, siendo la más frecuente el hemoperitoneo (1%). Se produjeron 13 lesiones de la vía biliar durante la cirugía laparoscópica (0,3%), 51 pacientes (1,3%) fueron reintervenidos precozmente tras la cirugía (hemo-/coleperitoneo) y fallecieron un total de 5 pacientes (0,13%). Cuando comparamos los resultados entre ambas décadas (1991-2000 vs. 2001-2007), observamos que existen diferencias estadísticamente significativas en cuanto al número de intervenciones realizadas por el residente (31,7 vs. 51,1%, p = 0,00001), el número de colecistitis abordadas por vía laparoscópica (4,9 vs. 7,53%, p = 0,001), la tasa de conversión (5,46 vs. 11%, p = 0,000001) y la estancia media postoperatoria (2,43 días vs. 3,7 días p = 0,001)...(AU)

Objective: the aim of the study is to determine the results obtained with laparoscopic cholecystectomy at Ramón y Cajal Hospital after 17 years of experience, comparing current results with those at the beginning of the experience. Material and methods: between 1991 and December 2007, 3,933 laparoscopic cholecystectomies were performed at the "Ramón y Cajal Hospital"; 1,849 patients were operated on between 1991 and 2000, and 2,084 between 2001 and 2007. Patients studied included 69.8% of women and 30.2% of men, with a mean age of 56.95 years (range 9-94 years). In all, 54.68% of patients had a concomitant disease before surgery (hypertension, diabetes, ischemic heart disease, respiratory disease...). Surgery was performed by a staff surgeon for 58.04% of cases, and by a resident in the remaining 41.96%. Surgical indications were cholelithiasis in 75.5%, pancreatitis in 13.3%, cholecystitis in 6.3%, choledocholithiasis in 3.05%, and others in 1.2% of cases. Results: mean hospital stay was 3.06 days. Conversion to open surgery was required for 8.3% of cases (331 patients). The major surgical complication rate was 2.34%, with the most frequent being hemoperitoneum (1%). Common bile duct injury occurred in thirteen cases (0.3%), 51 patients (1.3%) were soon re-operated, and 5 patients died (0.13%). When the results of both decades (1991-2000 vs. 2001-2007) were compared, we observed differences in the number of procedures performed by residents (31.7 vs. 51.1%, p = 0.00001), number of laparoscopic cholecystectomies for cholecystitis (4.9 vs. 7.53%, p = 0.001), conversion rate (5.46 vs. 11%, p = 0.000001), and mean hospital stay (2.43 vs. 3.7 days, p = 0.001)...(AU)

[Multidisciplinary approach to the treatment of rectal cancer: the benefits of neoadjuvant therapy]. / Abordaje multidisciplinar en el tratamiento del cáncer de recto: eficacia del tratamiento neoadyuvante.

OBJECTIVE: the aim of this study was to assess the impact of neoadjuvant treatment on rectal cancer following involvement of a multidisciplinary team (MDT). MATERIALS AND METHODS: between January 2000 and December 2005, 90 patients with rectal adenocarcinoma were evaluated by a MDT and operated on after receiving neoadjuvant treatment with radiochemotherapy (RTCT) -67% were men and 33% were women, with a mean age of 65.04 years (21-83 years). Surgery was low anterior resection in 50% and abdominoperineal amputation in 42.2%. RESULTS: the rate of complications associated with neoadjuvant treatment was 54.4%, with gastrointestinal complications being most frequent. However, this toxicity was tolerated by most patients. It was severe in two cases (2.2%), leading to chemotherapy discontinuation. A histological analysis of specimens showed a complete pathologic response in 10 cases (11.1%) and a partial response (downstaging of T) in 32 cases (35.6%), hence overall response to neoadjuvant treatment was 46.6%. Postoperative complications included anastomotic leakage in 8.3%, perineal wound complications in 34.2%, and urinary disease in 12.2%. The surgical mortality rate was 0%. Local recurrence occurred in 4.4%, and distant metastases were found in 22.2%. Both overall and disease-free survivals were 80 and 64%, respectively. CONCLUSIONS: neoadjuvant treatment results in low local recurrence rates and optimal survival rates, with no increase in morbidity or mortality. A systematic evaluation by a MDT in the context of a clinical protocol offers better cure rates.

Chyle fistula in right cervical area after thyroid surgery

Thoracic duct injury is an infrequent (1-2.5%) but severe complication after neck surgery, leading to nutritional, metabolic and immunologic deficiencies. We report a case of a 34-year-old woman with a right thoracic duct injury after surgery of a thyroid medullar cancer effectively treated with conservative management (parenteral nutrition and intravenous somatostatin). Optimal treatment of these patients is unclear, without a clear limit between conservative and surgical treatment (AU)

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[Causes of conversion in laparoscopic surgery for gastroesophageal reflux disease: an analysis of our experience]. / Causas de conversión en la cirugía laparoscópica de la enfermedad por reflujo gastroesofágico: análisis de nuestra experiencia.

BACKGROUND: since its introduction in 1991 laparoscopic antireflux surgery has gained great success and popularity among surgeons, and now it is the gold standard for the treatment of gastroesophageal reflux disease (GERD). AIM: to identify and evaluate the causes of conversion in the laparoscopic surgery of GERD and hiatus hernia. MATERIAL AND METHODS: since January 1993 to August 2007 606 laparoscopic antireflux procedures were performed in our hospital. There were 296 women and 310 men with a median age of 53.5 years. The main indication for surgery was evidence of intractable or recurrent GERD symptoms after adequate medical treatment with associated hiatal hernia. The preoperative workup included manometry, pH-metry, oral endoscopy, and barium swallow. The surgical technique was mainly the Nissen-Rossetti procedure. RESULTS: mean postoperative hospital stay was 2.7 days. The operation had to be converted to an open procedure in 43 cases (7%). Conversions were more frequent in the first decade of the learning curve (26 vs. 17, p < 0.016), and fewer among the group of experts in advanced laparoscopic surgery (15 vs. 28, p < 0.017). In 17 cases conversions were due to an intraoperative complication whereas in 26 cases a conversion was done because of technical difficulties. Esophageal perforation and pneumothorax rates were 0.8 and 1%, respectively, and mortality and morbidity rates were 0.1 and 12%. CONCLUSION: the rate of conversion is acceptable and significantly decreases with surgeon experience.

Abordaje multidisciplinar en el tratamiento del cáncer de recto: eficacia del tratamiento neoadyuvante / No disponible

Objetivo: evaluar el papel de la terapia neoadyuvante en eltratamiento del cáncer de recto en nuestro hospital, tras la implantaciónde un grupo multidisciplinar de trabajo (MDT).Material y métodos: desde enero de 2000 hasta diciembrede 2005 se ha evaluado en sesión clínica por el grupo MDT untotal de 90 pacientes diagnosticados de adenocarcinoma de rectoe intervenidos quirúrgicamente tras recibir tratamiento neoadyuvantecon radioquimioterapia (QMRT). La edad media fue de65,04 años (21-83 años), siendo un 67% varones y un 33% mujeres.Los procedimientos quirúrgicos realizados fueron fundamentalmenteresección anterior baja en un 50% y amputación abdominoperinealen un 42,2%.Resultados: la tasa de complicaciones asociada al uso del tratamientoneoadyuvante fue del 54,44%, siendo más frecuenteslas gastrointestinales. Sin embargo, esta toxicidad fue bien toleradaen la mayor parte de los casos, siendo grave y acarreando lasuspensión del tratamiento quimioterápico en 2 pacientes (2,2%).El análisis anatomopatológico de las piezas resecadas demostróuna respuesta completa en 10 casos (11,1%) y una respuesta parcial(disminución del parámetro T de la clasificación TNM) en 32casos (35,6%), con lo que la respuesta global del tratamiento neoadyuvantefue del 46,6%. Entre las complicaciones postoperatoriasse produjeron un 8,3% de dehiscencias anastomóticas, un34,2% de complicaciones de la herida perineal y un 12,2% decomplicaciones urinarias. La mortalidad quirúrgica fue del 0%. Latasa de recidiva pélvica fue del 4,4% y la sistémica del 22,2%. Lasupervivencia actuarial global y libre de enfermedad a los 5 añosfue del 80 y 64% respectivamente.Conclusión: el tratamiento QMRT neoadyuvante proporcionauna cifras bajas de recidiva pélvica junto con buenas tasas desupervivencia, no añadiendo una morbimortalidad importante alacto quirúrgico. La evaluación sistemática por un grupo MDT enel contexto de un protocolo clínico parece ofrecer al paciente mejoresoportunidades de curación

Objective: the aim of this study was to assess the impact ofneoadjuvant treatment on rectal cancer following involvement of amultidisciplinary team (MDT).Materials and methods: between January 2000 and December2005, 90 patients with rectal adenocarcinoma were evaluatedby a MDT and operated on after receiving neoadjuvant treatmentwith radiochemotherapy (RTCT) –67% were men and33% were women, with a mean age of 65.04 years (21-83 years).Surgery was low anterior resection in 50% and abdominoperinealamputation in 42.2%.Results: the rate of complications associated with neoadjuvanttreatment was 54.4%, with gastrointestinal complicationsbeing most frequent. However, this toxicity was tolerated by mostpatients. It was severe in two cases (2.2%), leading to chemotherapydiscontinuation. A histological analysis of specimens showeda complete pathologic response in 10 cases (11.1%) and a partialresponse (downstaging of T) in 32 cases (35.6%), hence overallresponse to neoadjuvant treatment was 46.6%. Postoperativecomplications included anastomotic leakage in 8.3%, perinealwound complications in 34.2%, and urinary disease in 12.2%.The surgical mortality rate was 0%. Local recurrence occurred in4.4%, and distant metastases were found in 22.2%. Both overalland disease-free survivals were 80 and 64%, respectively.Conclusions: neoadjuvant treatment results in low local recurrencerates and optimal survival rates, with no increase in morbidityor mortality. A systematic evaluation by a MDT in the contextof a clinical protocol offers better cure rates

Causas de conversión en la cirugía laparoscópica de la enfermedad por reflujo gastroesofágico: análisis de nuestra experiencia / No disponible

Introducción: desde su introducción en 1991, la cirugía antirreflujopor vía laparoscópica ha ido adquiriendo gran popularidadhasta convertirse en el procedimiento de elección de la enfermedadpor reflujo gastroesofágico.Objetivo: identificar y analizar de forma retrospectiva las causasde conversión del abordaje laparoscópico en la cirugía de laenfermedad por reflujo gastroesofágico y de la hernia de hiato.Material y métodos: desde 1993 a agosto de 2007 se hanefectuado en nuestro centro 606 cirugías antirreflujo por vía laparoscópica,encontrando 296 mujeres y 310 varones con una edadmedia de 53,3 años. La indicación fundamental fue la existenciade un reflujo gastroesofágico resistente al tratamiento médico conhernia de hiato asociada. De forma preoperatoria se van a efectuarestudios manométricos y pH-métricos, endoscopia oral ytránsito esofagogastroduodenal. La técnica quirúrgica de elecciónfue mayoritariamente la funduplicatura tipo Nissen-Rossetti.Resultados: la estancia media postoperatoria fue de 2,7 días,realizándose conversión a cirugía abierta en 43 casos (7%). Lasconversiones fueron más frecuentes en la primera década de lacurva de aprendizaje (26 vs. 17 p < 0,016), y menores en el grupode cirujanos expertos en cirugía laparoscópica avanzada(15 vs. 28, p < 0,017). En 17 casos la conversión fue debida auna complicación intraoperatoria y en 26 casos a dificultades técnicas.Las tasas de perforación esofágica y de neumotórax fuerondel 0,8 y 1%, mientras que la tasa de mortalidad y morbilidad fuedel 0,1 y 12% respectivamente.Conclusión: la tasa de conversión está dentro de los límitesaceptables y ha disminuido con la experiencia

Background: since its introduction in 1991 laparoscopic antirefluxsurgery has gained great success and popularity amongsurgeons, and now it is the gold standard for the treatment of gastroesophagealreflux disease (GERD).Aim: to identify and evaluate the causes of conversion in thelaparoscopic surgery of GERD and hiatus hernia.Material and methods: since January 1993 to August 2007606 laparoscopic antireflux procedures were performed in ourhospital. There were 296 women and 310 men with a medianage of 53.5 years. The main indication for surgery was evidenceof intractable or recurrent GERD symptoms after adequate medicaltreatment with associated hiatal hernia. The preoperativeworkup included manometry, pH-metry, oral endoscopy, and bariumswallow. The surgical technique was mainly the Nissen-Rossettiprocedure.Results: mean postoperative hospital stay was 2.7 days. Theoperation had to be converted to an open procedure in 43 cases(7%). Conversions were more frequent in the first decade of thelearning curve (26 vs. 17, p < 0.016), and fewer among thegroup of experts in advanced laparoscopic surgery (15 vs. 28,p < 0.017). In 17 cases conversions were due to an intraoperativecomplication whereas in 26 cases a conversion was done becauseof technical difficulties. Esophageal perforation and pneumothoraxrates were 0.8 and 1%, respectively, and mortality andmorbidity rates were 0.1 and 12%.Conclusion: the rate of conversion is acceptable and significantlydecreases with surgeon experience

Littoral cell angioma of the spleen.

Littoral cell angiomas (LCAs) are rare splenic vascular neoplasms that arise from the cells lining the red pulp sinuses. The clinical course is benign and in most cases asymptomatic. However, as has been described in the literature, we have seen an association with malignant neoplasms and haematological disorders. The definitive diagnosis is made on histology and confirmed with immunohistochemistry. The use of percutaneous fine-needle aspiration biopsy (FNA) in preoperative diagnosis is controversial.

Littoral cell angioma of the spleen

Littoral cell angiomas (LCAs) are rare splenic vascular neoplasms that arise from the cells lining the red pulp sinuses. The clinical course is benign and in most cases asymptomatic. However, as has been described in the literature, we have seen an association with malignant neoplasms and haematological disorders. The definitive diagnosis is made on histology and confirmed with immunohistochemistry. The use of percutaneous fine-needle aspiration biopsy (FNA) in preoperative diagnosis is controversial (AU)

Apendicitis aguda en paciente con malrotación intestinal / Acute appendicitis in a patient with intestinal malrotation

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