Is Surgery for Hepatic Echinococcosis Appropriate in a Low-Volume Center?

Background: Cystic echinococcosis is a parasitic disease that develops in endemic areas due to the transmission of Echinococcus granulosus. The liver is the organ most affected. The most frequent symptoms include pain, palpable mass, jaundice, and fever. Diagnosis is based on epidemiologic history, examination, imaging, and serologic tests. Patients and Methods: We conducted a retrospective study of patients with hepatic echinococcosis diagnosed in our center. We collected data from our patients regarding personal history, cyst characteristics, surgery performed, and post-operative complications. Results: Sixteen patients were diagnosed with hepatic echinococcosis, 11 of whom underwent surgery. We found multiple cysts in six patients (37.5%) and a single cyst in 10 (62.5%). In 14 patients the cysts were found only in the right hepatic lobe (87.5%) and in two patients they were found in both lobes (12.5%). Segment 4 was affected in seven cases. The sizes ranged from 2.7 to 20 cm. Endoscopic retrograde cholangiopancreatography was prior to surgery in five patients. The interventions performed were partial cyst-pericystectomies in eight patients, a total cyst-pericystectomy in one case, and drains were placed in two cases of rupture. Post-operative fistulas were evident in five patients, four of which were closed. The fifth, which occurred after emergency surgery for rupture of the cyst, has maintained suppuration. The mean follow-up was 3.5 years. There was no post-operative mortality or recurrence to date. Conclusions: We can state that center without highly specialized hepato-biliary surgery units can assume the surgery of hydatid liver cysts excluding those with well-defined characteristics. The establishment of recommendations for the referral of patients with complex hydatid cysts may help in the optimal management of this pathology.

Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital.

BACKGROUND: Up to 25% of patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with a high death rate. To improve outcomes, patients may require interventional measures including surgical procedures. Multidisciplinary approach and best practice guidelines are important to decrease mortality. METHODS: We have conducted a retrospective analysis from a prospectively maintained database in a low-volume hospital. A total of 1075 patients were attended for acute pancreatitis over a ten-year period. We have analysed 44 patients meeting the criteria for severe acute pancreatitis and for intensive care unit (ICU) admittance. Demographics and clinical data were analysed. Patients were treated according to international guidelines and a multidisciplinary flowchart for acute pancreatitis and a step-up approach for pancreatic necrosis. RESULTS: Forty-four patients were admitted to the ICU due to severe acute pancreatitis. Twenty-five patients needed percutaneous drainage of peri-pancreatic or abdominal fluid collections or cholecystitis. Eight patients underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and biliary sepsis or pancreatic leakage, and one patient received endoscopic trans-gastric endoscopic prosthesis for pancreatic necrosis. Sixteen patients underwent surgery: six patients for septic abdomen, four patients for pancreatic necrosis and two patients due to abdominal compartment syndrome. Four patients had a combination of surgical procedures for pancreatic necrosis and for abdominal compartment syndrome. Overall mortality was 9.1%. CONCLUSION: Severe acute pancreatitis represents a complex pathology that requires a multidisciplinary approach. Establishing best practice treatments and evidence-based guidelines for severe acute pancreatitis may improve outcomes in low-volume hospitals.

Abdominal Wall Reconstruction Utilizing the Combination of Absorbable and Permanent Mesh in a Retromuscular Position: A Multicenter Prospective Study.

BACKGROUND: Optimal mesh reinforcement for abdominal wall reconstruction (AWR) in complex hernias remains questionable. Use of biologic, absorbable and synthetic meshes has been described. The idea of using an absorbable mesh (AM) under a permanent mesh (PM) in a retromuscular position may help in these challenging situations. METHODS: Between 2011 and 2016, consecutive patients undergoing open AWR utilizing an AM as posterior layer reinforcement and configuration of a large PM were identified in a multicenter prospectively maintained database in four hospitals. Main outcomes included demographics, ventral hernia classifications, perioperative data, complications and recurrences. RESULTS: A total of 169 complex incisional hernias were analyzed. Mean age was 60.9, with mean body mass index 30.7 (range: 20-46). Location of incisional hernias (IH) was: 80 midline, 59 lateral and 30 midline and lateral. 78% were grade I and II in Ventral Hernia Working Group classification. 52% of patients were discharged with no complication. There were 19% seromas, 13% hematomas, 12% surgical-site infection and 10% skin dehiscence. Only partial mesh removal was necessary in one patient. After a mean follow-up of 26 months (range 15-59), there were five (3.2%) recurrences. Reoperations on patients showed a band of fibrosis separating the peritoneum from the PM. CONCLUSION: The combination of AM with very large PM in the same retromuscular position in AWR seems to be safe. The efficacy with recurrence rates below 4% in complex midline and lateral IH may be explained by the use of larger PMs that are extended and configured with the support of AMs. Reoperations on patients have confirmed the previous experimental reports on the use of the AM.

How we do it: down to up posterior components separation.

BACKGROUND: Posterior component separation with transversus abdominis release technique is increasingly being used for abdominal wall reconstruction in complex abdominal wall repair. The main purpose of this study is to present a modification of the surgical technique originally described that facilitates the surgical procedure and offers additional advantages. METHODS: Based on the knowledge of the anatomy of the retromuscular space and the preperitoneal aerolar tissue distribution, we start the incision on the posterior rectus sheath from the arcuate line in a down to up direction. The posterior rectus sheath is incised 0,5-1 cm medial to the linea semilunaris and cut longitudinally as far as the fibers of transversus abdominis muscle that are divided in the superior part of the abdomen. It is also possible to avoid cutting the fibers of this muscle if we incise the posterior rectus sheath in an oblique direction to the midline from the umbilical area. Since 2012 to 2016, 69 consecutive patients with down to up TAR have been prospectively followed. Main outcome measures included demographics, perioperative details, wound complications, and recurrences. RESULTS: Between 2012 and 2016, we have operated 69 patients with down to up TAR technique. Mean operative time was 251 (range 65-566) minutes. Mean hospital stay was 9,8 (2-98) days. 10 patients presented surgical site events (14,5%): 6 patients had superficial site infection, 3 deep and 1 organ space. During follow-up, 3 patients (4,3%) presented incisional hernia recurrence. CONCLUSIONS: This novel modification allows a simpler dissection of the preperitoneal retromuscular space and makes the TAR technique easier to perform. It also enables to incise only the insertion of the transversalis fascia cranially.

¿Puede ser una apendicitis aguda la primera manifestación de endometriosis? / Can acute appendicitis be the first manifestation of endometrial disease?

Objetivo. Demostrar la relación entre la afectación endometriósica del apéndice cecal y el desarrollo de una apendicitis aguda. Pacientes y métodos. Presentamos una serie institucional de 8 pacientes con endometriosis apendicular diagnosticadas tras apendicectomía entre junio de 2009 y marzo de 2014. Resultados. La media de edad fue 40,6 años, 6 en edad fértil. En 5 (62,5%) la afectación endometriósica apendicular resultó única y en 3 (37,5%) múltiple, fundamentalmente en el ovario. Siete (87,5%) iniciaron los síntomas como una apendicitis aguda. Los implantes endometriósicos afectaban la capa serosa en 6 pacientes, la capa muscular en una y la grasa periapendicular en otra. Conclusión. El diagnóstico de endometriosis apendicular en mujeres con apendicitis aguda solo se puede realizar tras el examen de las piezas de apendicectomía, aunque puede ser sospechado en el contexto clínico. La laparoscopia permite un diagnóstico adecuado con exploración completa de la pelvis, la apendicectomía y el tratamiento de otras lesiones (AU)

Aim. To determine the relationship between endometriotic involvement of the appendix and the development of acute appendicitis. Patients and methods. We report a series of 8 patients with appendiceal endometriosis diagnosed after appendicectomy from June 2009 to March 2014. Results. The mean age was 40.6 years. Six patients were of reproductive age. Endometriotic appendiceal involvement alone was found in 5 patients (62.5%) and multiorgan involvement, mainly affecting the ovary, in 3 patients (37.5%). Clinical presentation was acute appendicitis in 7 patients (87.5%). Endometriotic implants involved the serous layer in 6 patients, the muscle layer in one patient, and periappendiceal fat in another patient. Conclusion. Diagnosis of appendiceal endometriosis in women with acute appendicitis can only be performed after specimen study, although it may be suspected in the clinical context. Laparoscopy allows pelvic and abdominal cavity examination, appendectomy, and the treatment of other lesions (AU)

Invaginación yeyuno-gástrica tras gastrectomía tipo Billroth II / Jejuno-gastric invagination after Billroth II gastrectomy

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