Recomendaciones para el diagnóstico, la estadificación y el tratamiento del cáncer de páncreas (parte I) / Recommendations fordiagnosis, staging and treatment of pancreatic cancer(PartI)

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Recomendaciones para el diagnóstico, estadificación y tratamiento del cáncer de páncreas (parte ii) / Recommendations for diagnosis, staging and treatment of pancreatic cancer(PartII)

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Long-term results of laparoscopic repair of incisional hernias using an intraperitoneal composite mesh.

BACKGROUND: This study was designed to evaluate the long-term complications and recurrences of laparoscopic repair of incisional hernias. Very few studies evaluate objectively the long-term results of laparoscopic incisional hernia repair. METHODS: Data for 200 consecutive patients who underwent laparoscopic incisional hernia repair (LIHR) in a university teaching hospital using a standardized procedure between January 1994 and December 2006 were collected prospectively. The median follow-up was 6 (range, 1-12) years. RESULTS: The conversion rate from laparoscopic to open approach was 2.5% (205 initial patients). Mean operative time was 51 minutes; 63% of these patients were discharged the day of surgery. Mean hospital stay was 2.6 days. There was an overall postoperative complication rate of 15%. We had four small bowel injuries repaired laparoscopically, and one patient died as a result of a sepsis. Postoperative pain was limited, with a mean analgesics requirement of 6.8 (range, 0-30) days. During a mean follow-up of 60 (range, 12-144) months, the recurrence rate was 6.2%, which developed within 1 year of the operation and associated with body mass index >37, defect size >10 cm, and multiple Swiss-cheese defects (p < 0.01). CONCLUSIONS: 1) Intra-abdominal composite mesh is good tolerance. 2) The recurrence rate is low and within 1 year of the operation. 3) The long-term morbidity with LIHR is moderate. 4) The risk of intestinal injury is not predictable. 5) Reoperations can be performed with sufficient guarantee using laparoscopy.

[Controversies in the current management of traumatic abdominal wall hernias]. / Controversias en el manejo actual de las hernias traumáticas de pared abdominal.

The management of traumatic abdominal wall hernias is controversial. We performed a MEDLINE search and report a personal series of 10 patients. Cases were classified according to the cause of injury. Fifty-six percent were caused by car accidents and 14% by bicycle accidents. Diagnosis was clinical in 22% and surgical in 13% and intra-abdominal lesions were found in 67%. Treatment was delayed in 12%. In our series, 55% were lumbar hernias due to traffic accidents and all were associated with pelvic fracture. Treatment was delayed in 50%, including laparoscopic surgery with good results. In conclusion, traumatic hernias due to road traffic accidents are frequently associated with intra-abdominal lesions. The diagnostic technique of choice is computed tomography and delayed surgery (laparoscopy) is an effective option.

Controversias en el manejo actual de las hernias traumáticas de pared abdominal / Controversies in the current management of traumatic abdominal wall hernias

Las hernias traumáticas de pared abdominal presentan importantes controversias en cuanto a su manejo. Para intentar responder al problema se realizó una revisión en MEDLINE y se añadió una serie personal de 10 pacientes. Los casos se clasificaron según el agente lesional. El 56% fueron causados por accidentes de coche y el 14%, por bicicleta. En el 22% se hizo un diagnóstico clínico y en el 13%, quirúrgico, y se encontró lesiones intraabdominales en el 67%. El 12% fueron manejados de forma diferida. En nuestra serie, el 66% fueron hernias lumbares por accidentes de tráfico y todas asociaban fractura pélvica. El tratamiento fue diferido en el 50% de los casos, incluida la cirugía laparoscópica con buenos resultados. En conclusión, las hernias traumáticas por accidentes de tráfico se asocian con mucha frecuencia a lesiones intraabdominales; la Tomografía computarizada puede ser la mejor forma de diagnóstico y la cirugía diferida (laparoscopia) es una buena opción (AU)

The management of traumatic abdominal wall hernias is controversial. We performed a MEDLINE search and report a personal series of 10 patients. Cases were classified according to the cause of injury. Fifty-six percent were caused by car accidents and 14% by bicycle accidents. Diagnosis was clinical in 22% and surgical in 13% and intra-abdominal lesions were found in 67%. Treatment was delayed in 12%. In our series, 55% were lumbar hernias due to traffic accidents and all were associated with pelvic fracture. Treatment was delayed in 50%, including laparoscopic surgery with good results. In conclusion, traumatic hernias due to road traffic accidents are frequently associated with intra-abdominal lesions. The diagnostic technique of choice is computed tomography and delayed surgery (laparoscopy) is an effective option (AU)

Endometriosis extragenital como causa de dolor inguinal agudo en mujer fértil / Extragenital endometriosis as a cause of acute inguinal pain in a woman of reproductive age

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Laparoscopic hernioplasty in secondary lumbar hernias.

BACKGROUND: Lumbar hernia is an uncommon defect of the posterior abdominal wall, and surgical treatment is still controversial. The aim of this study was to analyze the utility of the laparoscopic approach in the repair of these hernias. MATERIALS AND METHODS: We undertook a descriptive analysis of 15 patients diagnosed with lumbar hernia who underwent surgery with transabdominal laparoscopy between 1997 and 2004. The following variables were analyzed: clinical data, intraoperative and postoperative complications, operative time, length of hospital stay, analgesic consumption, and recurrences. The technique was evaluated aesthetically by measuring the abdominal perimeter using a tape measure. The mean follow-up was 32 months (range, 12-55 months). RESULTS: Intraoperative morbidity consisted of two cases of bleeding caused by the mechanical suture. Postoperative morbidity consisted of 3 cases of hematomas, 2 of seromas, and 2 of transitory pain. Seven patients (47%) were treated as day cases, and only one required admission due to pain. At 12-month follow-up we found one recurrence and a significant reduction in abdominal perimeter (P < 0.05). CONCLUSION: The transabdominal laparoscopic approach offers good clinical and aesthetic results both for the patient and the hospital, as almost half of the cases can be treated as day cases. We believe it should be considered the technique of choice for incisional lumbar hernia repair.

Anatomical and surgical study of totally extraperitoneal laparoscopic hernioplasty.

BACKGROUND: Laparoscopic surgery provides direct access to the extraperitoneal inguinal space for a clear, amplified view of the anatomical structures. However, the variety of terms used to describe the fascial elements has partly prevented the promulgation of this approach. MATERIAL/METHODS: Two hundred patients received surgery for inguinal hernia at an outpatient surgery unit by means of totally extraperitoneal laparoscopy. Regional anatomical dissection was performed during the operation, which was filmed for later analysis. DISCUSSION: The totally extraperitoneal laparoscopic technique is described anatomically, including management of the internal spermatic fascia to create an opening for the use of fenestrated meshes. The technical maneuvers are discussed, with comparison of other possible methods of approach. CONCLUSIONS: From our experience we would recommend: 1) a consensus on terminology is necessary for dissemination of the TEP approach; 2) the ISF must be dissected to avoid ruptures of the sac and ensure parietalization; 3) the "sling of the TF" must be preserved, and 4) the TEP approach does not require dissection medial or inferior to the Cooper ligaments.

Reparación laparoscópica de las hernias lumbares secundarias: cirugía abierta frente a laparoscópica. Estudio prospectivo no aleatorizado / Laparoscopic repair of secondary lumbar hernias: open vs. laparoscopic surgery. A prospective, non randomized study

Introducción. La hernia lumbar es un defecto de la pared abdominal posterior poco frecuente y su tratamiento quirúrgico es todavía controvertido. El objetivo del estudio es valorar la utilidad de la vía laparoscópica frente a la cirugía abierta. Pacientes y método. Estudio prospectivo no aleatorizado con 16 pacientes intervenidos por hernia lumbar secundaria entre enero de 1997 y enero de 2003: 9 mediante vía laparoscópica y 7 por vía abierta. Las variables analizadas fueron: datos clínicos y hospitalarios (tiempo quirúrgico y estancia), bienestar del paciente (consumo de analgésicos y retorno a su actividad habitual) y recurrencias. Se realiza un análisis del coste hospitalario del proceso. Resultados. No encontramos diferencias entre ambos grupos en cuanto a la edad y los antecedentes, aunque el tamaño de los defectos operados por laparoscopia fue menor. El tiempo quirúrgico medio, la morbilidad postoperatoria, la estancia hospitalaria media, el consumo de analgésicos y el retorno a la actividad habitual fueron significativamente menores en el grupo laparoscópico (p < 0,01). El coste hospitalario del proceso no presentó diferencias estadísticas en función del abordaje quirúrgico, pero sí el coste final tras incluir los gastos por reingreso y recidiva (p < 0,01). Conclusiones. En nuestra serie, la vía laparoscópica puede ser empleada en la reparación de las hernias lumbares secundarias con una mayor eficacia y rentabilidad que la vía abierta tradicional y con el mismo coste (AU)

Introduction. Lumbar hernia is an uncommon defect of the posterior abdominal wall and its surgical treatment remains controversial. The aim of the present study was to evaluate the utility of laparoscopy versus open surgery. Patients and method. We performed a prospective, nonrandomized study of 16 patients with secondary lumbar hernias who underwent surgery between January1997 and January 2003. Nine patients underwent laparoscopy and 7 underwent open surgery. The variables analyzed were clinical features, hospital data (operating time and length of hospital stay), patient comfort (analgesic consumption and return to normal daily activity) and recurrences. Hospital costs were also analyzed. Results. No differences were found between the two groups in age or history, although the size of laparoscopically-repaired defects was smaller. Mean operating time, postoperative morbidity, mean length of hospital stay, analgesic consumption, and return to daily activities were significantly lower in the laparoscopic group (P<.01). No statistically significant differences in the cost of the process were found according to surgical approach but significant differences were found in final cost after including the cost of readmissions and recurrences (P<.01). Conclusions. In our series, the laparoscopic approach was more effective than traditional open surgery in the repair of secondary lumbar hernias while the cost of the two procedures was the same (AU)

[Laparoscopic repair of secondary lumbar hernias: open vs. laparoscopic surgery. A prospective, nonrandomized study]. / Reparación laparoscópica de las hernias lumbares secundarias: cirugía abierta frente a laparoscópica. Estudio prospectivo no aleatorizado.

INTRODUCTION: Lumbar hernia is an uncommon defect of the posterior abdominal wall and its surgical treatment remains controversial. The aim of the present study was to evaluate the utility of laparoscopy versus open surgery. PATIENTS AND METHOD: We performed a prospective, nonrandomized study of 16 patients with secondary lumbar hernias who underwent surgery between January 1997 and January 2003. Nine patients underwent laparoscopy and 7 underwent open surgery. The variables analyzed were clinical features, hospital data (operating time and length of hospital stay), patient comfort (analgesic consumption and return to normal daily activity) and recurrences. Hospital costs were also analyzed. RESULTS: No differences were found between the two groups in age or history, although the size of laparoscopically-repaired defects was smaller. Mean operating time, postoperative morbidity, mean length of hospital stay, analgesic consumption, and return to daily activities were significantly lower in the laparoscopic group (P<.01). No statistically significant differences in the cost of the process were found according to surgical approach but significant differences were found in final cost after including the cost of readmissions and recurrences (P<.01). CONCLUSIONS: In our series, the laparoscopic approach was more effective than traditional open surgery in the repair of secondary lumbar hernias while the cost of the two procedures was the same.

Immediate, early, and late morbidity with laparoscopic ventral hernia repair and tolerance to composite mesh.

The laparoscopic repair of ventral hernias is still a controversial therapeutic option, and little is known of its medium- and long-term morbidity. The purpose of the study is to evaluate the postoperative morbidity of laparoscopic ventral hernia repair and analyze the clinical factors that might be related to it. 86 consecutive patients who had ventral hernia and underwent endoscopic surgery in a Universitary teaching hospital. Epidemiological, clinical, postoperative complications, tolerance, aesthetic evaluation of the wall and recurrence rate are analyzed. The mean follow-up (100%) was 42 months (range: 1-5 years) and included clinical and ultrasonographic evaluation. The overall postoperative morbidity rate was 23.2%, with one case of mortality following a sepsis due to intestinal perforation; the rate of re-admissions and recurrences was 3.5%. Statistically significant relationships were shown between the complications and infra-umbilical location (P < 0.001), age over 60 years and female sex (P < 0.05). The dynamic ultrasound study showed 91% and 94% of the patients to be adhesion-free at 1 and 3 years respectively. Aesthetic assessment of the wall at 3 years showed persistent asymmetries in 5% of the patients and a 92% degree of personal satisfaction. The morbidity with laparoscopic ventral hernia repair is not negligible. The surgeon must know these complications and be able to treat them appropriately.

Morbilidad precoz, temprana y tardía de laeventroplastia laparoscópica y tolerancia de la malla bilaminar (Parietex®) intraabdominal / Early, medium- and long-term morbidity of laparoscopic ventral hernioplasty and tolerance to the double-layer intra-abdominal mesh (parietex®)

Introducción. La reparación de las hernias incisionales mediante laparoscopia es una opción terapéutica todavía controvertida y cuya morbilidad es poco conocida, principalmente a medio y largo plazo. Objetivo. Evaluar la morbilidad postoperatoria de la eventroplastia laparoscópica, y analizar qué factores clínicos podrían relacionarse con ella. Pacientes y métodos. Estudio prospectivo de 86 pacientes operados de eventración mediante cirugía endoscópica. Se evalúan parámetros clínicos (edad, sexo, enfermedades asociadas, cirugía abdominal previa, localización y tipo de defecto), complicaciones postoperatorias (hematomas, seromas, obstrucción intestinal, fístulas, infecciones, etc.), tolerancia y valoración estética parietal y tasa de recidivas. El seguimiento medio (100 por ciento) ha sido de 42 meses (rango, 1-5 años) y ha incluido evaluación clínica y ecográfica. Resultados. La morbilidad postoperatoria global fue del 23,2 por ciento, con un caso de mortalidad tras sepsis por perforación intestinal, y una tasa de reingresos y de recidivas del 3,5 por ciento. Se han demostrado relaciones estadísticamente significativas entre las complicaciones y la localización infraumbilical (p < 0,001), la edad mayor de 60 años y el sexo femenino (p < 0,05).El estudio ultrasónico dinámico ha demostrado un 91 y un 94 por ciento de pacientes libres de adherencias al año y 3 años, respectivamente. La valoración estética de la pared a los 3 años ha demostrado asimetrías persistentes en el 5 por ciento de los pacientes y un grado de satisfacción personal del 92 por ciento. Conclusiones. La morbilidad de la eventroplastia laparoscópica no es despreciable. El cirujano debe de conocer estas complicaciones y estar en condiciones de poder tratarlas de forma adecuada. Aconsejamos durante el período de aprendizaje seleccionar hernias incisionales de pacientes varones, menores de 65 años, con defectos inferiores a 12 cm y de localización no infraumbilical (AU)

Open vs laparoscopic repair of spigelian hernia: a prospective randomized trial.

HYPOTHESIS: The elective treatment of a spigelian hernia is still under discussion, fundamentally owing to its rarity. The purpose of the study is to analyze the elective surgical treatment of spigelian hernia. DESIGN: A prospective, randomized controlled trial. SETTING: University teaching hospital. PATIENTS AND INTERVENTIONS: Two surgeons performed 11 conventional and 11 laparoscopic repairs for a spigelian hernia, alternating roles as primary surgeon and assistant. Each time the type of technique was randomly chosen using a computerized program. MAIN OUTCOME MEASURES: Epidemiological, clinical, and surgical factors are analyzed according to treatment, ie, the open or laparoscopic approach. RESULTS: The statistical study shows no significant differences for epidemiological or diagnostic factors, but it does show significant advantages for laparoscopy in terms of morbidity (P<.05) and hospital stay (P<.001). CONCLUSION: The approach using extraperitoneal laparoscopy is the technique that offers best results in the elective treatment of spigelian hernia.

Outpatient laparoscopic incisional/ventral hernioplasty: our experience in 55 cases.

Laparoscopic repair of ventral and incisional hernias is still a controversial therapeutic option. The purpose of this article is to evaluate the results of laparoscopic surgery on ventral hernias in an outpatient surgery unit of a university hospital. Fifty-five patients consecutively underwent laparoscopic surgery for ventral/incisional hernias in the outpatient unit. The patients' clinical features, hernia type, intraoperative, and postoperative complications and reasons for hospital admission are studied. Forty-two patients (76%) were discharged on the day of the surgery. Thirteen (24%) required hospital admission; 9 admissions were predictable (5 for intraoperative occurrences and 4 for associated surgery) and 4 were unpredictable (all for uncontrolled pain; 31%). We found no case of hospital admission for vomiting, urinary retention, or dizziness. Statistical analysis of the patients requiring admission showed no significant correlation with their clinical features or with the site, size, or recurrence of the abdominal wall defect (P > 0.05). Laparoscopic repair of ventral and incisional hernias can be done as a highly efficient ambulatory procedure, and morbidity and hospital admission with this technique do not depend on the type of hernia.

Tratamiento laparoscópico ambulatorio de la hernia de Spiegel: presentación de 10 casos / Ambulatory laparoscopic treatment of Spigelian hernia: presentation of 10 cases

Introducción. La hernia de Spiegel es una variedad de defecto de la pared abdominal anterior infrecuente. Su reparación puede ser difícil en función de su variable localización a lo largo de la fascia de Spiegel y por la debilidad de los tejidos circundantes. Pacientes y método. Se analiza una serie de 10 pacientes diagnosticados en una consulta especializada "de pared abdominal" y tratados de forma electiva mediante laparoscopia en un hospital de día. Resultados. La hernia de Spiegel se presentó con más frecuencia en mujeres (60 por ciento) y en el lado izquierdo (70 por ciento), con una edad media de 62,6 años (rango, 39-92 años). En 7 pacientes se realizó cirugía extraperitoneal y en tres se indicó la vía intraabdominal por múltiples cirugías previas y colecistectomía asociada (2 y 1, respectivamente). Un total de 9 pacientes fueron dados de alta sin ingreso hospitalario y sólo precisó un ingreso 48 h el paciente con colecistectomía asociada. No se han detectado complicaciones, reingresos ni recidivas durante un seguimiento medio de 16 meses (rango, 1-4 años).Conclusiones. La técnica laparoscópica es eficaz para reparar las hernias de Spiegel, ofreciendo como ventajas una excelente visión, la corrección de otros procesos asociados, una mínima morbilidad y que no precisa ingreso hospitalario. El abordaje totalmente extraperitoneal debe ser aconsejado en principio como la técnica de elección (AU)

El interpolador de alto orden: un medio para incrementar la resolución de las imágenes pulmonares obtenidas mediante tomografía computarizada espiral / The high-grade interpolator: a means for enhancing the resolution of helical computed tomography images of the lung

Objetivos: Nuestro trabajo pretende demostrar que la aplicación de un interpolador de alto orden en la reconstrucción de las imágenes torácicas aumenta la resolución, independientemente del filtro de alta resolución. Material y métodos: Ocho observadores separados en dos grupos (de expertos y de inexpertos) valoraron (en dos lecturas separadas en el tiempo) la misma sección torácica reconstruida cuatro veces (st-st, st-xs, b-st, b-xs), combinando los filtros (estándar-st y alta resoluciónb) y los interpoladores (estándar-st y alto orden-xs). Clasificaron las imágenes de más a menos según la resolución percibida. Los resultados se utilizaron para comparar tanto el grado de resolución introducido por el interpolador y el filtro, como la existencia o no de variabilidad entre observadores y entre sus propias observaciones, influida o no por la experiencia. Resultados: Seis de los ocho observadores clasificaron la imagen b-xs como la de mayor resolución en la mayoría de las ocasiones. En segundo lugar se clasificó la imagen b-st. En tercero la imagen st-xs. En último lugar la imagen st-st. Los otros dos observadores (uno entre los expertos y otro en los inexpertos) difirieron sólo en el orden de las imágenes st-xs y b-st, que fueron clasificadas en segundo y tercer lugar respectivamente. El grupo de expertos no mostró variabilidad intraobservador aunque sí dos de los inexpertos. Conclusiones: El interpolador de alto orden aumenta la resolución de las imágenes torácicas, independientemente de quien las evalúe, sin un aumento importante del ruido. Este hecho hace aconsejable su uso en las exploraciones torácicas con TC espiral (TCE). (AU)

Fiebre prolongada y dolor en hipocondrio derecho en paciente anciana / Prolonged fever and pain in the right upper quadrant in an elderly woman

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