Influence of size and complexity of the hospitals in an enhanced recovery programme for colorectal resection.

PURPOSE: The aim of this study was to see whether the application of the enhanced recovery programme for colorectal resection improves the results and, in turn, the influence of complexity and size of the hospitals in applying this and its results. METHODS: A multi-centric prospective study was controlled with a retrospective group. The prospective operation group included 300 patients with elective colorectal resection due to cancer. The centres were divided depending on size and complexity in large reference centres (group 1) and area and basic general hospitals (group 2). The retrospective control group included 201 patients with the same characteristics attended before the application of the programme. Completion of categories of the protocol, complications, perioperative mortality and stay in hospital were recorded. RESULTS: The introduction of the programme achieved a reduction in mortality (1 vs. 4 %), morbidity (26 vs. 39 %) and preoperative (<24 h vs. 3 days) and postoperative (7 vs. 11 days) stays (p < 0.01). There was greater fulfilment of protocol in group 2 with the mean number of items completed at 8.46 and 60 % completed compared with the hospitals in group 1 (7.70 completed items and 55 % completion). The size of the hospital had no relation to the rate of complications (21.3 vs. 26.5 %). In smaller sized and less complex hospitals, the average length of stay was 1.88 days less than in those of greater size (6.45 vs. 8.33 days). CONCLUSION: Patients treated according to an enhanced recovery programme develop significantly fewer complications and have a shorter hospital stay. The carrying out of protocol is greater in smaller and less complex hospitals and is directly related to a shorter stay in hospital.

A calcified foreign body in the bladder due to : an unusual complication after laparoscopic incisional hernia repair.

We report a rare complication caused by a displaced tack after laparoscopic incisional hernia repair. A 41-year-old woman treated 11 months earlier for a suprapubic incisional hernia (Pfannenstiel laparotomy) received a laparoscopic repair with a bilaminar mesh fixed with tacks. Seven months later, she presented miccional irritative symptoms and chronic lower abdominal pain. Leucocyturia and microhematuria were present, and computerized tomography showed 2 calcified nodules in the bladder wall. Cystoscopy confirmed 2 calcified foreign bodies in the bladder due the tack fixation. She underwent an intra-abdominal laparoscopic exploration, which showed the protrusion of a mesh in the urinary bladder. The tacks were removed and a partial laparoscopic cystectomy including mesh protrusion was performed. The patient was discharged from hospital 4 days later without postoperative complications. At follow-up 24 months after surgery, she remains well with no pain, urinary symptoms, or hernia recurrence.

Tratamiento laparoscópico de la acalasia. Análisis de resultados y reflexiones sobre la técnica / Laparoscopic treatment of achalasia: analysis of results and reflections on the technique

Introducción La miotomía de Heller por vía laparoscópica es el mejor tratamiento que podemos ofertar a los pacientes con acalasia. Al no actuar sobre la causa de la enfermedad sino que únicamente aliviamos la sintomatología la persistencia de los síntomas puede no desaparecer. Objetivo Analizar los resultados de nuestro grupo en el tratamiento de la acalasia por vía laparoscópica. Material y métodos Se revisan los resultados pre y postoperatorios de una serie de 20 pacientes intervenidos prospectivamente por vía laparoscópica de acalasia durante el período comprendido entre mayo de 2003 y abril de 2010. Para ello se ha utilizado una modificación de la escala de de gradación progresiva de los síntomas pre y postoperatorios descrita por Velanovich para el RGE (escala de 0-5). También se han recogido las complicaciones y estancia hospitalaria. Resultados Se ha practicado una miotomía de Heller amplia asociando un mecanismo anti-reflujo tipo Dor en todos los casos. No se han producido perforaciones esofágicas ni complicaciones intraoperatorias. Dos (10%) pacientes han presentado complicaciones postoperatorias. La estancia hospitalaria ha sido de 3,11±2,13 días. Tras un seguimiento medio de 55,8±14,1 meses los síntomas estudiados han disminuido significativamente tras la cirugía. Sólo 3 pacientes (15%) han presentado clínica postoperatoria de RGE. Diecinueve pacientes (95%) refirieron estar satisfechos con el resultado de la intervención. Conclusiones El tratamiento laparoscópico de la acalasia es una técnica segura, reproducible y efectiva, que consigue un control de los síntomas de la acalasia muy satisfactorio con una mínima morbilidad (AU)

Introduction Heller myotomy using the laparoscopic approach is the best treatment that we can offer to patients with achalasia. On not acting on the cause of the disease, we can only alleviate the persistence of the symptoms, but not make them disappear. Objective To analyse the results of our group in the treatment of achalasia by laparoscopy. Material and methods The pre- and post-operative results are analysed of a series of 20 patients intervened prospectively by laparoscopy of achalasia during a period from May 2003 to April 2010. For this we used a modification of the grading scale of pre- and post-operative symptoms described by Velanovich for GER (a scale from 0-5). Data on the complications and the hospital stay were also collected. Results A wide Heller myotomy was performed using a Dor type antireflux mechanism. There were no oesophageal perforations or complications during the surgery. Two (10%) patients had postoperative complications. The mean hospital stay was 3.11±2.13 days. After a mean follow up of 55.8±14.1 months, the symptoms studied had significantly decreased after the surgery. Only 3 (15%) patients had clinical symptoms of GER after surgery. Nineteen patients (95%) said they were satisfied with the operation. Conclusions The laparoscopic treatment of achalasia is a safe technique, reproducible and effective technique, which achieves very satisfactory control of the achalasia symptoms with a minimum of morbidity (AU)

[Laparoscopic treatment of achalasia: analysis of results and reflections on the technique]. / Tratamiento laparoscópico de la acalasia. Análisis de resultados y reflexiones sobre la técnica.

INTRODUCTION: Heller myotomy using the laparoscopic approach is the best treatment that we can offer to patients with achalasia. On not acting on the cause of the disease, we can only alleviate the persistence of the symptoms, but not make them disappear. OBJECTIVE: To analyse the results of our group in the treatment of achalasia by laparoscopy. MATERIAL AND METHODS: The pre- and post-operative results are analysed of a series of 20 patients intervened prospectively by laparoscopy of achalasia during a period from May 2003 to April 2010. For this we used a modification of the grading scale of pre- and post-operative symptoms described by Velanovich for GER (a scale from 0-5). Data on the complications and the hospital stay were also collected. RESULTS: A wide Heller myotomy was performed using a Dor type antireflux mechanism. There were no oesophageal perforations or complications during the surgery. Two (10%) patients had postoperative complications. The mean hospital stay was 3.11 ± 2.13 days. After a mean follow up of 55.8 ± 14.1 months, the symptoms studied had significantly decreased after the surgery. Only 3 (15%) patients had clinical symptoms of GER after surgery. Nineteen patients (95%) said they were satisfied with the operation. CONCLUSIONS: The laparoscopic treatment of achalasia is a safe technique, reproducible and effective technique, which achieves very satisfactory control of the achalasia symptoms with a minimum of morbidity.

Laparoscopic treatment of gastric tumors.

PURPOSE: To assess the use of different laparoscopic approaches in the management of gastric tumors based on tumor type and location. MATERIALS AND METHODS: Between March 2002 and June 2005, 23 consecutive patients with gastric lesions were treated with laparoscopy procedures. Six patients presented with stromal tumors, 5 with benign lesions, and 12 with resectable gastric cancers. RESULTS: The patients were 13 men and 10 women, mean age 66.2 +/- 11.1 years (range, 29-84 years). Five laparoscopic gastric wedge resections, 6 intragastric submucosal resections, and 12 gastrectomies (10 subtotal and 2 total) were performed. Mean operative time was 49.1 +/- 18.8 minutes (range, 30-85 minutes) in the gastrointestinal stromal tumors and 64.1 +/- 19.2 minutes (range, 45-90 minutes) in benign tumors. Gastrectomy required an average of 197.6 +/- 36.9 minutes (range, 130-260 minutes). The mean times were 142.5 +/- 9.6 minutes in the subtotal gastrectomy group with extracorporeal anastomosis and 190.8 +/- 20.1 minutes when the anastomosis was totally laparoscopic (P < 0.002). All procedures were completed laparoscopically and there were no intraoperative complications. There were four postoperative complications: one wall hematoma secondary to the introduction of a trocar, one prolonged ileus, one intra-abdominal abscess, and one esophagojejunal leakage. Gastrointestinal stromal tumor patients were discharged after a mean 5.8 +/- 1.3 days; patients with benign pathology after 5.2 +/- 0.9 days, and gastric cancer patients after 10.7 +/- 7.3 days (range, 6-28 days). The mean number of dissected lymph nodes in gastric cancer was 21.3 (range, 16-31). CONCLUSION: Laparoscopic treatment of gastric lesions is technically feasible and safe. Compared to conventional surgery, it offers the advantages of low invasiveness and improved quality of life.

Impacto de la cirugía laparoscópica en el manejo del dolor abdominal agudo en la mujer joven. ¿Indicación de apendicectomía selectiva? / Impact of laparoscopic surgery in the management of acute abdominal pain in young women. Indication for selective appendicectomy?

Introducción. El objetivo de este estudio es analizar la utilidad de la laparoscopia en las mujeres en edad fértil con dolor agudo en la fosa ilíaca derecha (FID), a fin de mejorar su diagnóstico y proceder a su tratamiento adecuado.Pacientes y método. Estudio prospectivo realizado entre enero de 1999 y octubre de 2003 en mujeres de edad fértil con sospecha clínica de apendicitis aguda. En los casos en que el diagnóstico era claro clínicamente se procedía a la intervención quirúrgica por vía convencional (grupo abierto). Cuando el diagnóstico clínico era dudoso y la clínica era susceptible de exploración quirúrgica, se indicaba una laparoscopia diagnóstica; no se practicaba una apendicectomía sistemática si la paciente no presentaba una apendicitis aguda (grupo laparoscópico).Resultados. Durante este período se intervino a un total de 159 mujeres en edad fértil con sospecha clínica de apendicitis aguda, 89 en el grupo laparoscópico y 70 en el grupo abierto. En el primer grupo, 68 casos (76,4 por ciento) presentaron una apendicitis aguda, mientras en los 21 restantes la causa fue diferente de esta entidad clínica; el motivo más frecuente fue la enfermedad ginecológica en 16 casos (18 por ciento). En estas 21 pacientes que no presentaban una apendicitis aguda no se practicó apendicectomía y ninguna de ellas precisó reintervención por apendicitis aguda en un seguimiento medio de 3 meses (ningún falso negativo).En el grupo abierto se halló una apendicitis aguda en 60 casos (85,7 por ciento) y el índice de apendicectomías blancas fue del 12,8 por ciento. En el grupo laparoscópico no hubo ningún caso de apendicectomía blanca (p < 0,02).Conclusiones. En mujeres de edad fértil con sospecha de apendicitis aguda, la laparoscopia aumenta la precisión diagnóstica y puede disminuir el índice de apendicectomías innecesarias. Cuando la laparoscopia descarta el diagnóstico de apendicitis aguda, resulta seguro dejar el apéndice en la cavidad abdominal, una vez evaluado como normal (AU)

Recurrent inguinal hernia: a ten-year review.

BACKGROUND: This study evaluates the results obtained in recurrent inguinal hernia repair over the past ten years in a general hospital using laparoscopic (LAP) and open tension-free mesh (Lichtenstein) procedures. METHODS: A prospective controlled study with 258 recurrent inguinal hernias in 235 patients over a ten-year period. The main outcome measurements were recurrence rate, operating time, hospital stay, postoperative complications, and cost. RESULTS: There were 10 recurrences (4.3%): 7 in the Lichtenstein group (5.7%) and 3 (2.2%) in the LAP group (P = nonsignificant [NS]). There were 15 (12.2%) postoperative complications in the Lichtenstein group and 6 (4.4%) in the LAP group (P =0.04). The operating room costs were higher in the LAP group, but this difference was offset by a significantly shorter hospital stay, shorter operating time, and earlier return to work. CONCLUSION: Laparoscopic repair is an effective option for the treatment of recurrent inguinal hernia. The TEP approach combines the advantages of minimal invasive surgery and those of tension-free mesh repair, reducing operating time, postoperative morbidity, and recurrence rate.