Results during the learning curve in the laparoscopic common bile duct exploration for choledocolithiasis.

OBJECTIVES: To analyze the results obtained in terms of efficacy and safety during the learning curve of a surgical team in the technique of laparoscopic common bile duct exploration with cholecystectomy (LCBDE+LC) using choledochoscopy for the treatment of patients with cholelithiasis and choledocolithiasis or common bile duct stones (CBDS) (CDL). METHODS: Single-center prospective analysis of patients treated with LCBDE+LC during the first 4 years of implementation of the technique. A descriptive and comparative analysis was carried out between groups according to the transcystic (TCi) or transcolecocal (TCo) approach, and also evolutionary by periods. The effectiveness of the technique was evaluated using the variable success rate and safety through the analysis of the overall complication rate and the bile leak rate as the most frequent adverse effect. RESULTS: A total of 78 patients were analyzed. The most frequent approach was TCo (62%). The overall success rate was 92%. The TCi group had a shorter operating time, a lower overall complications rate and a shorter hospital stay. The TCo approach was related to a higher rate of clinically relevant bile leak (8%). Complex cases increased significantly during the learning curve without effect on the overall results. CONCLUSIONS: LCBDE+LC is an effective and safe technique during the learning curve. Its results are comparable to those published by more experienced groups and do not present significant differences related to the evolution during learning period.

Treatment of Liver Trauma: Operative or Conservative Management.

BACKGROUND: The liver is one of the most frequently damaged organs when abdominal trauma occurs. Currently, a conservative management constitutes the treatment of choice in patients with hemodynamic stability. The aim of this study is to evaluate the results of an operative and conservative management of 143 patients with liver injury treated in a single institution. METHODS: A retrospective study of the patients admitted with the diagnosis of liver trauma was performed from 1992-2008. The patients were classified according to the intention to treatment: Group I, operative management; Group II, conservative management. Variables analyzed included demographic data, injury classification, associated lesions, surgical treatment, transfusions, morbi-mortality, and hospital stay. We established two periods (1992-1999; 2000-2008) in order to compare diagnosis and management. RESULTS: A total of 143 patients were analyzed. Thirty-one percent correspond to severe injuries. Conservative treatment was followed in 60.8 % with surgery undertaken in 14.9 % of patients from this group due to failure of conservative treatment. Immediate surgery was carried out in 38.2 %. Total mortality was 14 %. Morbidity (35.7-38.5 %) in the group of immediate surgery and failure of conservative management is similar, but not in mortality (28.6-15.4 %). In the second group (2000-2008) there are more patients with conservative treatment, with a low percentage of failure of this treatment and morbi-mortality. CONCLUSIONS: Conservative treatment is an adequate treatment in a great number of patients. Failure of conservative treatment did not show a higher incidence of complications or mortality but it should be performed in centers with experienced surgeons.

Risk of death after emergency repair of abdominal wall hernias. Still waiting for improvement.

PURPOSE: The precise importance of factors affecting morbidity and mortality in patients with complicated abdominal wall hernias undergoing emergency surgical repair has been not completely elucidated. PATIENTS AND METHODS: A retrospective multicentric study of all patients (n = 402) with abdominal wall hernia who underwent urgent operations over 1-year period was conducted in ten hospitals. Logistic regression analysis was used to evaluate variables that affect morbidity and mortality. RESULTS: Thirty-five percent of patients had inguinal hernia, 22% femoral hernia, 20% umbilical hernia, and 15% incisional hernia. Mesh repair was used in 92.5% of cases. Intestinal resection was required in 49 patients. Perioperative complications occurred in 130 patients, and 18 patients died (mortality rate 4.5%). Complications and mortality rate were significantly higher in the group of intestinal resection. Patients older than 70 years also showed more complications, required intestinal resection more frequently, and had a higher mortality rate than younger patients. In the logistic regression analysis, age over 70 years, intestinal resection, and American Society of Anesthesiologists (ASA) III/IV class emerged as independent predictors of a poor outcome. Based in our results, we propose a simple schema to calculate risk of death in these patients. CONCLUSION: Using multivariate logistic regression analysis, probabilities of death after complicated abdominal wall hernia surgery are increased in patients with: age over 70 years, high ASA class, and associated intestinal resection. Guidelines should be developed to improve prognosis in these patients.

Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry.

BACKGROUND: Reports on laparoscopic sleeve gastrectomy (LSG) communicate very good short-term results on very high-risk morbid obese patients. However, mid- and long-term results are still unknown. A National Registry has been created in Spain to achieve information on the outcomes of this bariatric procedure. METHODS: Data were obtained from 17 centers and collected in a database. Technical issues, preoperative comorbid conditions, hospital stay, early and late complications, and short- and mid-term weight loss were analyzed. RESULTS: Five hundred forty patients were included; 76% were women. Mean BMI was 48.1 +/- 10. Mean age was 44.1 +/- 11.8. Morbidity rate was 5.2% and mortality rate 0.36%. Complications presented more frequently in superobese patients (OR, 2.8 (1.18-6.65)), male (OR, 2.98 (1.26-7.0)), and patients >55 years old (OR, 2.8 (1.14-6.8)). Staple-line reinforcement was related to a lower complication rate (3.7 vs 8.8%; p = 0.039). Mean hospital stay was 4.8 +/- 8.2 days. Mean follow-up was 16.5 +/- 10.6 months (1-73). Mean percent excess BMI loss (EBL) at 3 months was 38.8 +/- 22, 55.6 +/- 8 at 6 months, 68.1 +/- 28 at 12 months, and 72.4 +/- 31 at 24 months. %EBL was superior in patients with lower initial BMI and lower age. Bougie caliber was an inverse predictive factor of %EBL at 12 and 24 months (RR, 23.3 (11.4-35.2)). DM is remitted in 81% of the patients and HTA improved in 63.2% of them. A second-stage surgery was performed in 18 patients (3.2%). CONCLUSIONS: LSG provides good short- and mid-term results with a low morbid-mortality rate. Better results are obtained in younger patients with lowest BMI. Staple-line reinforcement and a thinner bougie are recommended to improve outcome.

Hernioplastia inguinal electiva en pacientes con anticoagulación oral. ¿Son candidatos a cirugía ambulatoria? / Elective inguinal hernioplasty in patients on chronic anticoagulation therapy. Management and outcome

Introducción El tratamiento perioperatorio de los pacientes con anticoagulantes orales (ACO) incrementa la complejidad de la hernioplastia inguinal electiva. Objetivo Analizar la seguridad de nuestro protocolo de tratamiento en pacientes con ACO intervenidos de hernioplastia inguinal electiva y valorar el porcentaje de pacientes tratados mediante cirugía ambulatoria y cirugía de corta estancia. Material y métodos Se revisaron los datos administrativos de 1.184 pacientes intervenidos de hernioplastia inguinal en 2005 2007 y se identificó a 47 pacientes en tratamiento con ACO. Se utilizó, como tratamiento puente perioperatorio, un protocolo estandarizado con heparinas de bajo peso molecular (HBPM). Los resultados se analizaron hasta 30 días después del procedimiento e incluían las siguientes variables: hemorragia, episodios tromboembólicos o muerte y régimen hospitalario (cirugía mayor ambulatoria, corta estancia o ingreso convencional).Resultados La media de edad fue 74±10 años; 12 (25%) pacientes tenían un alto riesgo tromboembólico y 31 (67%) pacientes tenían la categoría ASA III. La técnica quirúrgica de elección fue la hernioplastia sin tensión con mallas de polipropileno. En 6 (13%) pacientes se diagnosticó hematoma de la herida quirúrgica y 1 (2,1%) paciente sufrió una hemorragia mayor que precisó de reintervención. Ningún paciente tuvo episodios tromboembólicos y no hubo fallecimientos. A 11 (23%) pacientes se trató de forma ambulatoria y a 16 (34%), en régimen de cirugía de corta estancia. La media de estancia hospitalaria fue 2,4±5,1 días. Conclusiones La hernioplastia inguinal electiva en pacientes con ACO, mediante una terapia puente con HBPM, es un procedimiento seguro. La anticoagulación oral no es una contraindicación absoluta para la cirugía ambulatoria (AU)

Background Perioperative management of patients on anticoagulant therapy increases the complexity of elective inguinal hernia repair. We assessed the safety of our standardised anticoagulation protocol and investigated the outpatient and one day surgery rates. Material and methods The records of 1184 patients undergoing elective inguinal hernioplasty between 2005 and 2007 were reviewed; 14 patients on chronic anticoagulation therapy were identified. We used a standard bridging therapy protocol with low-molecular-weight heparins. Outcomes were assessed at 30 days post-procedure and included bleeding, thromboembolic events or death and type of hospital admission. Results Mean age was 74±10 years; 12 (25%) patients were high risk for thromboembolism and 31 (67%) patients were ASA III. Almost all inguinal repairs were performed using a polypropylene mesh; 6 (13%) patients had a surgical site haematoma and there was 1 (2.7%) major bleeding, that was re-operated on. No thromboembolic events or deaths occurred; 11 (23%) patients were treated on an outpatient basis and 16 (34%) on a one day surgery regimen. Mean hospital stay was 2.4±5.1 days. Conclusions Elective inguinal hernioplasty in patients on chronic oral anticoagulation therapy using a standard bridging protocol is a safe procedure. Chronic anticoagulation therapy is not a contraindication for ambulatory surgery (AU)

[Elective inguinal hernioplasty in patients on chronic anticoagulation therapy. Management and outcome]. / Hernioplastia inguinal electiva en pacientes con anticoagulación oral. ¿Son candidatos a cirugía ambulatoria?

BACKGROUND: Perioperative management of patients on anticoagulant therapy increases the complexity of elective inguinal hernia repair. We assessed the safety of our standardised anticoagulation protocol and investigated the outpatient and one day surgery rates. MATERIAL AND METHODS: The records of 1184 patients undergoing elective inguinal hernioplasty between 2005 and 2007 were reviewed; 14 patients on chronic anticoagulation therapy were identified. We used a standard bridging therapy protocol with low-molecular-weight heparins. Outcomes were assessed at 30 days post-procedure and included bleeding, thromboembolic events or death and type of hospital admission. RESULTS: Mean age was 74+/-10 years; 12 (25%) patients were high risk for thromboembolism and 31 (67%) patients were ASA III. Almost all inguinal repairs were performed using a polypropylene mesh; 6 (13%) patients had a surgical site haematoma and there was 1 (2.7%) major bleeding, that was re-operated on. No thromboembolic events or deaths occurred; 11 (23%) patients were treated on an outpatient basis and 16 (34%) on a one day surgery regimen. Mean hospital stay was 2.4+/-5.1 days. CONCLUSIONS: Elective inguinal hernioplasty in patients on chronic oral anticoagulation therapy using a standard bridging protocol is a safe procedure. Chronic anticoagulation therapy is not a contraindication for ambulatory surgery.

[Controlled, open, parallel-group study of the clinical and microbiological efficacy of piperacillin-tazobactam versus metronidazole + gentamicin in urgent colorectal surgery]. / Estudio controlado con grupos paralelos y abierto de la eficacia clínica y microbiológica de piperacilina-tazobactam frente a metronidazol más gentamicina en cirugía colorrectal urgente.

INTRODUCTION: Antibiotic treatment is an important element in infection control after urgent abdominal surgery. The aim of this study was to determine the therapeutic efficacy of piperacillin-tazobactam versus a combination of 2 antibiotics (metronidazole and gentamicin) in patients undergoing urgent appendicular and/or colorectal surgery. PATIENTS AND METHOD: The study period comprised December 1998 to December 2002. A total of 183 patients who required urgent surgery for colon disease and/or severe acute appendicitis were prospectively and randomly included. Patients were randomly distributed in 2 groups. Group A received piperacillin-tazobactam (4/0.5/8 h/i.v.) and group B received metronidazole (500 mg/i.v./8 h) plus gentamicin (5 mg/kg/i.v./24 h). Treatment was started between 30 and 60 minutes prior to surgery and was continued for at least 3 days. RESULTS: The incidence of wound infection in patients who underwent surgery for colon disease and acute appendicitis was lower when they were treated with piperacillin-tazobactam (P< .05). The incidence of intraperitoneal abscess in the group of patients who underwent surgery for severe acute appendicitis was lower when they were treated with piperacillin-tazobactam. Microbiological analyses revealed that there was a predominance of infection due to Escherichia coli. CONCLUSIONS: The association of piperacillin-tazobactam was more effective than that of metronidazole and gentamicin in the prevention and treatment of local infection in the treated groups. Therapeutic failure was mainly related to the presence of gram-negative bacteria.

Estudio controlado con grupos paralelos y abierto de la eficacia clínica y microbiológica de piperacilina-tazobactam frente a metronidazol más gentamicina en cirugía colorrectal urgente / Controlled, open, parallel-group study of the clinical and microbiological efficacy of piperacillin-tazobactam versus metronidazole + gentamicin in urgent colorectal surgery

Introducción. El tratamiento antibiótico es un elemento importante para el control de la infección postoperatoria en la cirugía abdominal de urgencias. El objetivo de este estudio consiste en determinar la eficacia terapéutica del tratamiento con piperacilina-tazobactam frente a la combinación de dos antibióticos (metronidazol más gentamicina) en pacientes intervenidos de cirugía colorrectal y apendicular urgente. Pacientes y método. El período de estudio comprendió de diciembre de 1998 a diciembre de 2002. Se incluyó de forma prospectiva y aleatorizada a un total de 183 pacientes que requirieron cirugía de urgencia por presentar afecciones en el colon y/o apendicitis aguda grave. Los pacientes se han distribuido en dos grupos de forma aleatoria. Grupo A: piperacilina-tazobactam (4/0,5 g/8 h por vía intravenosa [i.v.]), y grupo B: metronidazol (500 mg/8 h/i.v.) más gentamicina (5 mg/kg/24 h/i.v.). El tratamiento se inició entre 30 y 60 min antes de la intervención quirúrgica y se administró durante un mínimo de 3 días. Resultados. Los pacientes intervenidos de cirugía del colon y de apendicitis aguda presentaron una menor incidencia de infección de la herida quirúrgi-ca cuando se los trató con piperacilina-tazobactam (p < 0,05). En el grupo de pacientes intervenidos de afección apendicular se objetivó una menor incidencia de abscesos intraabdominales cuando fueron tratados con piperacilina-tazobactam. Tras el análisis microbiológico de los cultivos, se observa que existe un predominio de infección por Escherichia coli. Conclusiones. La asociación de piperacilina-tazobactam se ha mostrado más eficaz que la asociación metronidazol-gentamicina en la prevención y el tratamiento de infecciones locales en los grupos tratados. El fracaso terapéutico se asocia principalmente a gérmenes gramnegativo (AU)

Introduction. Antibiotic treatment is an important element in infection control after urgent abdominal surgery. The aim of this study was to determine the therapeutic efficacy of piperacillin-tazobactam versus a combination of 2 antibiotics (metronidazole and gentamicin) in patients undergoing urgent appendicular and/or colorectal surgery. Patients and method. The study period comprised December 1998 to December 2002. A total of 183 patients who required urgent surgery for colon disease and/or severe acute appendicitis were prospectively and randomly included. Patients were randomly distributed in 2 groups. Group A received piperacillin-tazobactam (4/0.5/8 h/iv) and group B received metronidazole (500 mg/iv/ 8 h) plus gentamicin (5 mg /kg/iv/24 h). Treatment was started between 30 and 60 minutes prior to surgery and was continued for at least 3 days. Results. The incidence of wound infection in patients who underwent surgery for colon disease and acute appendicitis was lower when they were treated with piperacillin-tazobactam (P<.05). The incidence of intraperitoneal abscess in the group of patients who underwent surgery for severe acute appendicitis was lower when they were treated with piperacillin-tazobactam. Microbiological analyses revealed that there was a predominance of infection due to Escherichia coli. Conclusions. The association of piperacillin-tazobactam was more effective than that of metronidazole and gentamicin in the prevention and treatment of local infection in the treated groups. Therapeutic failure was mainly related to the presence of Gram-negative bacteria (AU)

Real-time direct measurement of human liver allograft temperature from recovery to transplantation.

Temperature is a key parameter in organ preservation that has been consistently linked to primary nonfunction (PNF). In this communication, and for the first time anywhere, continued and direct measurements of human liver intraparenchymal temperatures are reported in six clinical cases of orthotopic liver transplantations (OLT). These measurements cover the entire transplantation procedure and include the full transport phase. In contrast with long-held beliefs, these data demonstrate that liver allograft temperatures reach and stabilize at near 0 degrees C, instead of 4 degrees C, during transport using standard protocols. Furthermore, these low temperatures do not appear to contribute to graft failure when negative factors such as long preservation, the presence of hepatic steatosis, or advanced donor age are present. The clinical and experimental implications of these findings, together with other relevant elements derived from the direct and continuous monitoring of human liver allograft intraparenchymal temperatures, are discussed.

Preoperative evaluation of biliary anatomy in adult live liver donors with volumetric mangafodipir trisodium enhanced magnetic resonance cholangiography.

Accurate preoperative depiction of biliary anatomy is not always adequately accomplished by imaging techniques in living donor liver transplantation (LDLT). We present the results of a prospective study designed to evaluate the ability of mangafodipir trisodium (Mn-DPDP)-enhanced magnetic resonance (MR) cholangiography (MRC) for this purpose in a series of 25 adult living liver donors (LLDs). We also analyze if a simple or a more complex surgical procedure can be preoperatively suggested for biliary reconstruction in the recipients. Findings on MRC were compared with operative cholangiography (OC). A conventional distribution with a right hepatic duct (RHD) longer than 1 cm anticipated a simple procedure (duct-to-duct anastomosis or hepaticojejunostomy [HJ]). A shorter RHD or any variant were predictors of a more complex surgery (bench ductoplasty or multiple anastomoses). Agreement between MRC and OC in assessing the biliary anatomy was measured using the kappa statistic, and differences between the kind of surgery predicted at MRC and the biliary anastomosis performed were evaluated with Fisher's exact test. Normal variants were present in 16 / 25 donors (64%). MRC was accurate in depicting the pattern of bile duct distribution observed at OC in 22 / 25 (88%) donors (kappa = .831), and correctly predicted the complexity of biliary anastomosis in the recipient in 22 / 25 (88%) donors. No significant differences were observed between complexity of biliary surgery proposed at MRC and the final surgery performed (P = .002). In conclusion, Mn-DPDP-enhanced MRC is highly accurate in depicting the biliary duct anatomy and can be used preoperatively for surgical planning in LDLT.

Trasplante hepático de donante vivo en adultos.¿Pueden influir los cambios del flujo portal en lafunción hepática postoperatoria? / Living donor liver transplantation in adults. Can changes in portal flow influence postoperative liver function?

Introducción. En el trasplante hepático de donante vivo en adultos, utilizar injertos de pequeño tamaño en pacientes cirróticos con hipertensión portal grave puede tener consecuencias impredecibles. El objetivo de este artículo es evaluar, de forma prospectiva, la influencia de los cambios hemodinámicos sobre la función hepática postoperatoria y sobre el incremento del volumen hepático en el marco del trasplante hepático de donante vivo. Material y método. En los 3 últimos años se realizaron 30 trasplantes hepáticos de donante vivo. Se determinó el flujo portal derecho y el de la arteria hepática derecha en el donante y, una hora después de la reperfusión, en el receptor. La función hepática postoperatoria se controló con la determinación diaria de los parámetros bioquímicos. El incremento del volumen hepático se evaluó mediante volumetría por resonancia magnética realizada a los 2 meses del trasplante. Se correlacionaron los flujos vasculares con la función hepática postoperatoria y el incremento de volumen del injerto hepático. Resultados. Existió en todos los casos un aumento importante del flujo portal en los receptores, comparado con el de los donantes (hasta el quíntuplo en casos seleccionados). Los mayores incrementos del flujo portal se correlacionaron significativamente con una precoz normalización de la actividad de la protrombina. Conclusión. El incremento en el flujo sanguíneo del injerto es tolerado correctamente por la masa hepática sin afectar a la función hepática postoperatoria, siempre que se mantenga una adecuada relación entre el peso del injerto y el del receptor (> 0,8) y se consiga un adecuado drenaje venoso (AU)

Changes in portal vein flow after adult living-donor liver transplantation: does it influence postoperative liver function?

In adult living donor liver transplantation, using small grafts in cirrhotic patients with severe portal hypertension may have unpredictable consequences. The so-called small-for-size syndrome is present in most series worldwide. The goal of this study was to prospectively evaluate the influence of hemodynamic changes on postoperative liver function and on the percentage of liver volume increase, in the setting of living donor liver transplantation. Twenty-two consecutive adult living donor liver transplantations were performed at our institution in a 2-year period. We measured right portal flow and right hepatic arterial flow with an ultrasonic flow meter in the donor, and then in the recipient 1 hour after reperfusion. Postoperative liver function was measured by daily laboratory work. We also performed duplex ultrasounds on postoperative days 1, 2, and 7. Liver volume increase was estimated by magnetic resonance imaging graft volumetry at 2 months posttransplantation. We compared the blood flow results with the immediate liver function and its liver volume increase rate at 2 months. There was a significant increase in portal flow in the recipients compared with the donors (up to fourfold in some cases). Higher portal flow increase rates significantly correlated with faster prothrombin time normalization and faster liver volume increases. Median graft volume increase at 2 months was 44.9%. The increase in blood flow to the graft is well tolerated by the liver mass not affecting hepatocellular function as long as the graft-to body weight ratio is maintained (>0.8) and adequate outflow is provided.