Laparoscopic appendectomy in complicated appendicitis with compromised appendix base: a retrospective cohort study.

BACKGROUND: Patients with compromised appendix base constitute a subgroup of patients with complicated appendicitis, and there is few available information. OBJECTIVE: To study the frequency of stump leaks and fistulae in patients with complicated appendicitis with compromised stump. METHOD: This is an observational, retrospective study of patients that underwent laparoscopic appendectomy with compromised appendix stump. RESULTS: From 2015 to 2019, 158 patients with complicated appendicitis were operated, of them 54 had compromised base or stump. There were 66.7% men, with a mean age of 38.7 years. For stump closure, a simple knot was employed in 57.4%, and in 42.6% an invaginated suture was employed. Regarding complications, 16.7% developed intraabdominal abscess, 7.4% ileus and 7.4% had wound infection. We found one stump leak and one stump fistula. The mean length of stay was 5.4 days (range: 1-20). There were 5 reoperations, 4 for abscess drainage and 1 for stump leak. CONCLUSIONS: Patients with acute complicated appendicitis with compromised appendicular base, laparoscopic surgery either with simple knot or with invaginated suture resulted in low frequency of stump leaks and fistula.

ANTECEDENTES: Los pacientes con base apendicular comprometida constituyen un subgrupo de pacientes con apendicitis complicada y existe poca información al respecto. OBJETIVO: Conocer la frecuencia de fístulas y fugas fecales en pacientes con apendicitis complicada con base apendicular comprometida. MÉTODO: Se trata de un estudio observacional, retrospectivo y transversal de pacientes operados de apendicectomía laparoscópica con base apendicular comprometida. RESULTADOS: De 2015 a 2019 se encontraron 158 casos de apendicitis complicada, de los cuales 54 tenían la base apendicular comprometida. Hubo predominio de varones (66.7%) y la edad media fue de 38.7 años. En el 57.4% de los casos se realizó un nudo simple y en el 42.6% un punto transfictivo con invaginación del muñón. En relación con las complicaciones, el 16.7% desarrollaron abscesos intraabdominales, el 7.4% íleo y el 7.4% infección de herida. Hubo un paciente con fuga del muñón y un paciente con fístula cecal. El tiempo medio de estancia hospitalaria fue de 5.4 días (rango: 1-20). Se realizaron cinco reintervenciones: cuatro para drenaje de absceso intraabdominal y una por fuga del muñón. CONCLUSIONES: En los pacientes con base apendicular comprometida, el manejo laparoscópico con ligadura simple o con punto transfictivo resulta en una baja frecuencia de fuga y fístula del muñón apendicular.

Peroral endoscopic myotomy as treatment for Zenker's diverticulum (Z-POEM): a multi-center international study.

BACKGROUND: Peroral endoscopic myotomy for the treatment of Zenker's diverticulum (Z-POEM) is a novel technique that has been described in several recent reports. This method utilizes the third space (submucosal layer) to create a tunnel to facilitate complete visualization of the septum and hence cutting it entirely. Conventional endoscopic septotomy carries the risk of recurrence due to incomplete visualization of the septum. While surgical correction is a risky and lengthy procedure in old comorbid patients with Zenker's diverticulum. The aim of this study is to assess the efficacy and safety of Z-POEM. METHODS: The study enrolled 24 patients diagnosed with Zenker's diverticulum (ZD) who underwent Z-POEM at seven independent endoscopy centers in five different countries. RESULTS: Mean patient age ± standard deviation (SD) was 74.3 ± 11 years. Most of the patients were males (n = 20, 83.3%); four (16.7%) were females. More than 50% of the patients (n = 14, 58.3%) had associated comorbidities. The mean size of the diverticula was 4 cm (range 2-7 cm). The Kothari-Haber Score was used to assess clinical symptoms; values ranged from 6 to 14 (median = 9). We achieved 100% technical success with a median procedure time of 61 min and no adverse events. Median hospital stay was 1 day (range 1-5 days). There is a significant reduction in the Kothari-Haber Score after Z-POEM (P < 0.0001). Technical success was achieved in 100% of the patients. Clinical success was achieved in 23/24 (95.8%) of the patients with a median follow-up of 10 months (range 6-24 months). CONCLUSION: Z-POEM is a safe and effective modality for managing ZD.

Síndrome de Mallory-Weiss. Reporte de caso y breve revisión de la literatura / Mallory-Weiss syndrome. Case report and brief review of the literature

Resumen Introducción El síndrome de Mallory-Weiss se caracteriza por el desgarro longitudinal de la mucosa de la unión gastroesofágica. En el presente trabajo hemos realizado una breve revisión de la literatura de utilidad para el estudiante de medicina y la hemos acompañado de un caso clínico para ilustrar el contenido aquí desarrollado. Caso Paciente del sexo masculino, de 40 años de edad, que acudió al servicio de urgencias de nuestra institución por presentar hematemesis, melena, datos de hipovolemia, e hipo de 2 días de evolución. Como antecedentes de importancia refirió consumo de alcohol a razón de 15 copas cada tercer día. Durante la endoscopía diagnóstica se identificó en la unión esofagogástrica, un coágulo adherente a la mucosa de 5 mm, con lo que se diagnosticó un desgarro de Mallory-Weiss. El tratamiento se realizó mediante endoscopía. Se optó por una inyección local de adrenalina con colocación posterior de liga. El paciente fue dado de alta sin complicaciones. Conclusión Los estudios realizados sobre el síndrome de Mallory-Weiss han permitido actualizar la información que se tiene al respecto. El avance tecnológico y científico ha incrementado las tasas de éxito del manejo de esta identidad.

Abstract Introduction Mallory-Weiss syndrome is characterized by the longitudinal tear of the mucosa of the gastroesophageal junction. In the present work we have made a brief review of the literature useful for the medical student and we have accompanied a clinical case to illustrate the content developed here. Case A 40-year-old male attended the emergency department of our institution due to hematemesis, melena, hypovolemia, and 2-day history of hiccups. The patient referred alcohol consumption at a rate of 15 drinks every third day. During diagnostic endoscopy, a mucosal adherent clot of 5 mm was identified in the gastric esophageal junction, and a Mallory-Weiss tear was diagnosed. The treatment was performed by endoscopy. We opted for a local injection of Adrenaline with subsequent endoscopic ligation. The patient was discharged without complications. Conclusion The studies carried out on the Mallory-Weiss Syndrome have made it possible to update the information available. The technological and scientific advance has increased the success rates of the management of this identity.

Oclusión intestinal por íleo biliar, tratamiento quirúrgico / Bowel obstruction for gall stone ileus, surgical management

Resumen Antecedentes: El íleo biliar es una rara complicación de la colecistitis crónica litiásica que representa del 1 al 3% de los casos de oclusión intestinal. Primera vez descrito por Bartolin en 1654, el íleo biliar ocurre por obstrucción crónica del conducto cístico y necrosis de la vesícula biliar, lo que puede desarrollar una fistula colecisto-entérica. Rigler en 1941 describió la tríada clásica del íleo biliar. Caso clínico: Mujer de 56 años de edad con diagnóstico de insuficiencia hepática que súbitamente presentó distención abdominal con ausencia de evacuaciones y canalización de gases. La tomografía abdominal mostró datos que sugieren el diagnóstico de oclusión intestinal, por lo que se realizó laparotomía exploradora con presencia de distención de asas. Se retiraron 2 litos por medio de enterolitotomía; evolución posquirúrgica adecuada hasta lograr estabilización hemodinámica y alta hospitalaria. Conclusiones: La presencia de íleo biliar es una rara causa de colusión intestinal que requiere de tratamiento quirúrgico para su resolución. Ee necesita un alto nivel de sospecha para su diagnóstico y manejo.

Abstract Background: Gall-stone ileus is a weird complication of the lithiasic cholecyst since it represents only 1 to 3% of the bowel obstuccion cases. It was described for the first time by Bartoin in 1654, the gall-stone ileus happens due to a cronic obstruccion in the cistic duct than causes gallbladder necrosis and a bile enteric fistula. In 1941, Rigler described the classic triad for the gall-stone ileus. Clinical case: A 56-year-old woman that had a diagnosis of hepatic failure, suddenly presented abdominal distension, constipation and obstipation. The abdominal tomography showed data that suggested a bowel occlusion, therefore, we performed an exploratory laparotomy and found distension of the bowel loops and the presence of three gall stones, that were removed with enterolitotomy. The pacient had a good posquirurgic evolution and was discharged from hospital. Conclusions: The gall-stone ileus is a rare cause for bowel occlusion that requires surgical treatment; it needs a high level of suspicion for its diagnoses and management.

Laparoscopic cholecystectomy after endoscopic treatment of choledocholithiasis: a retrospective comparative study.

Patients with combined choledocholithiasis and cholecystitis require treatment of both diseases. The aim of our study was to analyze perioperative results of next-day (< 24 h) vs. early (> 24 h) laparoscopic cholecystectomy (LC) after endoscopic clearance of common bile duct stones. We conducted a retrospective study of patients that underwent LC after endoscopic treatment of choledocholithiasis, with combined diagnoses of common bile duct stones (with or without acute cholangitis) and gallbladder stones (with acute or chronic cholecystitis). From January 2014 to May 2017, 87 patients underwent LC after endoscopic sphincterotomy: 40 patients within 24 h (NDLC) and 47 after 24 h (ELC). Regarding pre-ERCP diagnosis, 29 (72.5%) of patients in the NDLC group and 33 (70.2%) of patients in the ELC group had high-risk of choledocholithiasis (p = 0.814), acute cholecystitis (32.5 vs. 25.5%, p = 0.474) and acute cholangitis (17.5 vs. 17%, p = 0.953). The median time from ERCP to LC was 23 h (IQR 22-23) in the NDLC group and 72 h (IQR 48-80) in the ELC group (p < 0.001). No statistically significant differences were found in regard to operative time, estimated blood loss, overall morbidity and rate of conversion to open surgery. Patients in the NDLC group had a shorter total length of stay (2 vs. 4 days, p < 0.001). Laparoscopic cholecystectomy performed within the first 24 h after endoscopic treatment of choledocholithiasis is safe and feasible, without increased postoperative morbidity and associated with reduction of the hospital length of stay.

Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial.

BACKGROUND: Previous observational studies have demonstrated the safety of discharging patients after laparoscopic appendectomy within the same day without hospitalization. The application of Enhanced Recovery After Surgery (ERAS) guidelines has resulted in shorter length of stay, fewer complications, and reduction in medical costs. The aim of this study was to investigate if ERAS protocol implementation in patients with acute uncomplicated appendicitis decreases the length of stay enough to allow for ambulatory laparoscopic appendectomy. METHODS: In this prospective, randomized controlled clinical trial, 108 patients were randomized into two groups: laparoscopic appendectomy with ERAS (LA-E) or laparoscopic appendectomy with conventional care (LA-C). The primary endpoint was postoperative length of stay. The secondary end points were time to resume diet, postoperative pain, postoperative complications, re-admission rate, and reoperation rate. RESULTS: From January 2016 through May 2017, 50 patients in the LA-E group and 58 in the LA-C were analyzed. There were no significant differences in preoperative data. Regarding the primary end point of the study, the ERAS protocol significantly reduced the postoperative length of stay with a mean of 9.7 h (SD: 3.1) versus 23.2 h (SD: 6.8) in the conventional group (p < 0.001). The ERAS protocol allowed ambulatory management in 90% of the patients included in this group. There was a significant reduction in time to resume diet (110 vs. 360 min, p < 0.001) and less moderate-severe postoperative pain (28 vs. 62.1%, p < 0.001) in the LA-E versus LA-C group. The rate of complications, readmissions, and reoperations were comparable in both groups (p = 0.772). CONCLUSIONS: ERAS implementation was associated with a significantly shorter length of stay, allowing for the ambulatory management of this group of patients. Ambulatory laparoscopic appendectomy is safe and feasible with similar rates of morbidity and readmissions compared with conventional care.

Intraoperative endoscopy prevents technical defect related leaks in laparoscopic Roux-en-Y gastric bypass: A randomized control trial.

BACKGROUND: Postoperative anastomotic leaks, bleeding and stenosis are major causes of morbidity after laparoscopic Roux-en-Y gastric bypass (LRYGB). Retrospective studies suggest that intraoperative endoscopy reduces the incidence of these complications. METHODS: We conducted a prospective randomized controlled trial in a single institution between March 2013 and January 2016. Patients were assigned to one of two groups: LRYGB with Intraoperative Endoscopy (IOE) or LRYGB without IOE. Patient selection criteria were morbidly obese patients, 18 years or older who were candidates to LRYGB. The primary outcome was the frequency of technical defect related anastomotic leaks. Secondary outcomes were operative time, length of hospital stay, anastomotic related complications, reoperations and 30-day mortality. RESULTS: 50 patients were randomly assigned in the IOE group and 50 in the control group. The IOE group had statistically significant lower rate of anastomotic leak (0 vs. 8%, p = .0412), and lower need for reoperation (0 vs. 8%, p = .0412). The IOE group had longer operative time (194.10 vs. 159 min, p < .001), and shorter mean length of hospital stay (2.44 vs. 3.46 days, p = .025). No differences were found in the rate of bleeding of the anastomosis, narrow anastomosis and 30-day mortality. CONCLUSION: This study specifically provides evidence that air leak test performed by intraoperative endoscopy is superior to simple visual inspection in preventing technical defect related leaks after laparoscopic Roux-en-Y gastric bypass.