Long-term results of a prospective randomized trial of midline laparotomy closure with onlay mesh.

PURPOSE: Incisional hernia (IH) continues to be one of the most common complications of laparotomy. The short-term protective effect of the use of mesh has been demonstrated in several studies. At present, there is little evidence on the long-term results of the prophylactic use of mesh. The aim of the present study is to analyze the long-term prevention of IH 5 years after a midline laparotomy during elective surgery. METHODS: A prospective study was performed including all of the 160 patients that had been previously included in the prospective, randomized, controlled trial performed between May 2009 and November 2012. The protocol and results at 1 year have been previously published in 2014. The patients in group A (mesh) were fitted with a polypropylene mesh to reinforce the standard abdominal wall closure. The patients in group B (non-mesh) underwent a standard abdominal wall closure and were not fitted with the mesh. All patients were followed for 5 years or until the diagnosis of incisional hernia was made, further surgery was performed, or the patient died. Cases lost to follow-up were also registered. RESULTS: Five years after surgery, in group A (mesh) we have found 4/80 (5.1%) incisional hernias, while in group B (no mesh) 37/80 patients were diagnosed with an incisional hernia (46.8%). The Kaplan-Meier survival curves for these results show statistically significant differences (p > 0.001). CONCLUSION: The protective effect of the use of an onlay mesh in abdominal wall closure is significantly maintained in the long-term, up to 5 years after surgery. International Standard Randomized Controlled Trial number: ISRCTN98336745.

A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis.

BACKGROUND: The use of prophylactic antibiotics in acute severe necrotizing pancreatitis is controversial. METHODS: Prospective, randomized, placebo-controlled, double-blind study was carried out at Bellvitge Hospital, in Barcelona, Spain. Among 229 diagnosed with severe acute pancreatitis, 80 had evidence of necrotizing pancreatitis (34/80 patients were excluded of the protocol). Forty-six patients without previous antibiotic treatment with pancreatic necrosis in a contrast-enhanced CT scan were randomly assigned to receive either intravenous ciprofloxacin or placebo. Five patients were secondarily excluded, and the remaining 41 patients were finally included in the study (22 patients received intravenous ciprofloxacin and 19 patients placebo). RESULTS: Comparing the 22 with intravenous ciprofloxacin and 19 with placebo, infected pancreatic necrosis was detected in 36% and 42% respectively (p = 0.7). The mortality rate was 18% and 11%, respectively (p = 0.6). No significant differences between both treatment groups were observed with respect to variables such as: non-pancreatic infections, surgical treatment, timing and the re-operation rate, organ failure, length of hospital and ICU stays. CONCLUSION: The prophylactic use of ciprofloxacin in patients with severe necrotizing pancreatitis did not significantly reduce the risk of developing pancreatic infection or decrease the mortality rate. The small number of patients included in this study should be considered.

Tumor sólido pseudopapilar de páncreas: diagnóstico y tratamiento curativo / Solid pseudopapillary tumors of the pancreas: diagnosis andcurative treatment

Objetivos: dar a conocer a través de una serie de casos clínicosuna entidad poco frecuente, con una presentación clínica yunos hallazgos radiológicos concretos, que permiten establecer undiagnóstico y un tratamiento que será en la mayoría de los casoscurativo.Pacientes y métodos: se realizó un estudio descriptivo y retrospectivode los casos diagnosticados y tratados quirúrgicamenteen una Unidad Pancreático-Biliar de un hospital universitario, duranteel periodo comprendo entre marzo de 1999 y septiembrede 2005.Resultados: la incidencia fue de 6 pacientes mujeres, con unaedad media de 33,5 años (rango 11-72). La clínica más comúnfue la de dolor y masa abdominal palpable. La tomografía computerizadafue diagnóstica en tres de las pacientes, en las tres restantesse estableció el diagnóstico diferencial con el tumor neuroendocrino.El tratamiento quirúrgico fue individualizado a cadapaciente según los hallazgos y las imágenes visualizadas en la tomografíacomputerizada. El estudio anatomopatológico confirmóel diagnóstico de presunción, informándose de un caso de carcinomasólido-pseudopapilar de páncreas. La estancia hospitalariafue de 18,16 días (rango 8-30). Mortalidad de 0%. En el seguimientocon una media de 46,3 meses (rango 12-76), no existenrecidivas.Conclusiones: la presencia en una mujer joven de una lesiónvoluminosa en el páncreas, debe hacernos pensar en el tumor sólidopseudopapilar. Debido a su bajo potencial de malignidad y ala existencia de unos patrones radiológicos concretos, su diagnósticodebe ser preciso, ya que el tratamiento quirúrgico radical escurativo

Objectives: to highlight an infrequent occurrence using a seriesof clinical cases with symptoms and signs, and specific radiologicalfindings allowing its diagnosis and treatment, which is inmost cases successful.Patients and methods: a descriptive and retrospective studyof patients diagnosed by computed tomography scanning andthen treated with surgery in the Pancreas and Biliary Unit of aUniversity Hospital from March 1999 to September 2005.Results: there were 6 female patients with a mean age of33.5 years (range 11-72). Most common signs included pain anda palpable mass in the abdomen. Three patients were diagnosedby computed tomography scanning, and a differential diagnosiswith a neuroendocrine tumor was performed for the remainingthree subjects. Surgical treatment was adapted to each patient accordingto the findings and images seen in their computed tomographyscans. Biopsy results confirmed the presumed diagnoses,and showed one case of solid pseudopapillary carcinoma of thepancreas. Average hospital stay was of 18.16 days (range 8-30).Mortality rate was 0%. No recurrences occurred during follow-upfor 46.3 months on average (range 12-76).Conclusions: the presence of a huge mass in the pancreas ofa young female should prompt suspicion for a solid pseudopapillarytumor. Given its low malignant potential, and the presence ofspecific radiographic patterns, its diagnosis should be accurate, asradical surgical treatment is effective

Solid pseudopapillary tumors of the pancreas: diagnosis and curative treatment.

OBJECTIVES: To highlight an infrequent occurrence using a series of clinical cases with symptoms and signs, and specific radiological findings allowing its diagnosis and treatment, which is in most cases successful. PATIENTS AND METHODS: A descriptive and retrospective study of patients diagnosed by computed tomography scanning and then treated with surgery in the Pancreas and Biliary Unit of a University Hospital from March 1999 to September 2005. RESULTS: There were 6 female patients with a mean age of 33.5 years (range 11-72). Most common signs included pain and a palpable mass in the abdomen. Three patients were diagnosed by computed tomography scanning, and a differential diagnosis with a neuroendocrine tumor was performed for the remaining three subjects. Surgical treatment was adapted to each patient according to the findings and images seen in their computed tomography scans. Biopsy results confirmed the presumed diagnoses, and showed one case of solid pseudopapillary carcinoma of the pancreas. Average hospital stay was of 18.16 days (range 8-30). Mortality rate was 0%. No recurrences occurred during follow-up for 46.3 months on average (range 12-76). CONCLUSIONS: The presence of a huge mass in the pancreas of a young female should prompt suspicion for a solid pseudopapillary tumor. Given its low malignant potential, and the presence of specific radiographic patterns, its diagnosis should be accurate, as radical surgical treatment is effective.

Results of the management of upper gastrointestinal bleeding from gastroesophageal varices.

INTRODUCTION: The management of upper gastrointestinal bleeding caused by rupture of gastric and/or esophageal varices in patients with liver cirrhosis must focus on the initial control of the haemorrhage avoiding further worsening of an already poor liver function and the prevention of early relapsing bleeding. Therapeutic options include endoscopic, pharmacological and surgical methods. MATERIAL AND METHODS: Prospective study of the results obtained after the follow-up of 90 bleeding episodes in a total of 54 patients, 35 men and 19 women, with a mean age of 58 years (range 32-77), to which a therapeutic protocol for acute bleeding secondary to portal hypertension was applied over a 22-months period. Patient classification according to Child-Pugh upon admission was 57% Child A, 34% Child B and 9% Child C. RESULTS: Mean hospital length of stay was 9 days (2-50). Of the 90 bleeding episodes, 15 were early relapsing bleeding episodes (16.7%). Twelve patients died (mortality rate of 22.2% by patients and 13.4% by bleeding episodes). Twelve emergency surgical procedures were performed because of the persistence of haemorrhage. Forty one per cent of patients were readmitted because of relapsing bleeding at least once during the follow-up period. CONCLUSIONS: Management of upper gastrointestinal bleeding due to gastroesophageal varices in patients with liver cirrhosis requires a combined therapy in order to attain maximum effectiveness in acute haemorrhagic episodes and to address all potential later consequences. Such therapy should be provided in a hospital fully equipped and with specialists in this pathology. Based on our experience, emergency surgery as rescue treatment for persistent or short-term relapsing bleeding should be restricted to patients with good hepatic function because of its high morbidity and mortality.

Resultados del tratamiento de la hemorragia digestiva alta por varices esofagogástricas / Results of the management of upper gastrointestinal bleeding from gastroesophageal varices

Introducción: el tratamiento de la hemorragia digestiva alta por rotura de varices esofágicas y/o gástricas en pacientes con cirrosis hepática debe estar dirigido al control inicial de la hemorragia --sin alterar más una función hepática ya deteriorada--, y a la prevención de la recidiva hemorrágica precoz. Métodos endoscópicos, farmacológicos y quirúrgicos forman el conjunto de alternativas terapéuticas. Material y métodos: estudio prospectivo de los resultados obtenidos tras el seguimiento de 90 episodios hemorrágicos de un total de 54 pacientes, 35 hombres y 19 mujeres, con una edad media de 58 años (32-77), sobre los que se aplicó un protocolo terapéutico de la hemorragia aguda secundaria a la hipertensión portal, durante un periodo de 22 meses. La clasificación según Child-Pugh al ingreso fue 57 por ciento Child A, 34 por ciento Child B y 9 por ciento Child C.Resultados: la estancia media hospitalaria fue de 9 días (250). De los 90 episodios hemorrágicos, se registraron 15 recidivas hemorrágicas precoces (16,7 por ciento). Murieron 12 pacientes (mortalidad del 22,2 por ciento por pacientes y del 13,4 por ciento por episodios hemorrágicos). Se realizaron 12 intervenciones de urgencias por persistencia de la hemorragia. El 41 por ciento de los pacientes reingresaron por recidiva de la hemorragia al menos una vez durante el periodo de seguimiento. Conclusiones: el tratamiento de la hemorragia digestiva alta por varices esófago-gástricas con cirrosis hepática, requiere un conjunto de diferentes tratamientos para obtener la máxima eficacia en el episodio hemorrágico agudo y poder abarcar todas las posibles repercusiones a posteriori; dicho tratamiento debería ser realizado en un centro hospitalario que disponga de material y personal especializado en esta patología. En nuestra experiencia, la cirugía de urgencias, como tratamiento de rescate de la hemorragia persistente o recidivante a corto plazo, sólo tendría lugar en algunos pacientes con una buena función hepática dada su alta morbi/mortalidad (AU)

Cirugía radical del carcinoma de vesícula biliar / Radical surgery for gallbladder carcinoma

Introducción. El objetivo de este trabajo es analizar los resultados del tratamiento quirúrgico radical del carcinoma de vesícula biliar. Pacientes y métodos. Desde 1996 a 1999 han sido intervenidos con intención curativa 12 pacientes afectados de carcinoma de vesícula biliar. En 10 casos se trataba de un hallazgo incidental después de una colecistectomía simple. La intervención quirúrgica propuesta fue linfadenectomía del hilio hepático con segmentectomía IVb y V. La resección de la vía biliar se incluyó en función de los hallazgos intraoperatorios. Resultados. La estadificación pTNM definitiva fue: estadio I en 2 casos, estadio II en 2 casos, estadio III en 5 casos y estadio IV en 3 casos. No hubo mortalidad postoperatoria. En 5 pacientes no se produjo ninguna complicación. La estan cia mediana fue de 10,5 días. La supervivencia actuarial a los 32 meses es del 61 por ciento. La supervivencia según el grado de invasión ganglionar fue significativa (p = 0,005), estando vivos todos los pacientes pN0. Conclusiones. En los tumores incidentales la reintervención es obligatoria en los tumores pT2-3 y pN1. No obstante, si no se puede garantizar un margen de resección de vesícula no invadido, o bien el tumor se extiende hasta la capa muscular (pT1b), es mejor reintervenir a estos enfermos. La actitud terapéutica en los pT4 y pN2 debe ser paliativa. La reintervención de estos pacientes debería llevarse a cabo en centros con especial dedicación a cirugía hepatobiliopancreática para disminuir la morbimortalidad (AU)

Resultados en el tratamiento de la pancreatitis aguda grave / Results of treatment in severe acute pancreatitis

OBJETIVO: analizar los resultados obtenidos en el tratamiento médico y quirúrgico de la pancreatitis aguda grave (PAG). PACIENTES Y MÉTODOS: se estudiaron, retrospectivamente, 90 pacientes ingresados desde enero de 1992 hasta enero de 1998, con PAG según criterios clínicos y radiológicos. Se realizó una tomografía computarizada con contraste e.v. (TC) en todos. La técnica quirúrgica de elección fue la necrosectomía y lavados continuos del lecho pancreático. RESULTADOS: el 70 por ciento (63/90) de los pacientes presentaron necrosis pancreática. La tomografía computarizada (TC) tuvo una sensibilidad del 73 por ciento para diagnosticar necrosis. Se operaron el 54 por ciento de los pacientes (49/90): 31 presentaban PAG infectada y 18 estéril. La mortalidad global fue del 25,6 por ciento (23/90), siendo del 43,8 por ciento (14/32) en la infectada y del 15,5 por ciento (9/58) en la estéril (p < 0,05). Esta aumentó a un 44,4 por ciento (8/18) en la estéril que precisó tratamiento quirúrgico. La mortalidad fue mayor en la PAG infectada operada en la primera semana del ingreso (81 por ciento) respecto a la que se intervino posteriormente (20 por ciento) (p < 0,05). CONCLUSIONES: la necrosis pancreática y la infección de la misma son los factores pronósticos más importantes en la evolución de la PAG. La mortalidad es significativamente mayor en los pacientes con necrosis infectada que fueron intervenidos durante la primera semana. Nuestros esfuerzos deben ir dirigidos no sólo a evitar la infección de la necrosis y el fracaso orgánico, sino a retrasar en lo posible el momento de la intervención quirúrgica si ésta es necesaria (AU)

Duodenopancreatectomía cefálica de urgencia tras una ingesta masiva de cáusticos / Emergency cephalic pancreatoduodenectomy after caustic ingestion

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Perforated colonic cancer. Evolution and prognosis.

OBJECTIVE: The purpose of this study was to determine whether patients with perforating colonic cancer, among patients who need emergency surgery, should be considered to comprise a group with a worse prognosis. METHODS: We retrospectively revised the clinical records for 91 cases of emergency primary resection for carcinoma of the colon, of which 22 were perforating (4 Dukes A, 10 Dukes B and 8 Dukes C) and 69 were obstructive (3 Dukes A, 30 Dukes B and 36 Dukes C). For purposes of comparison we also analyzed a synchronous series of 112 patients who underwent elective surgery. RESULTS: There were no recurrences or deaths among the 7 patients with Dukes A disease (follow-up from 6 to 90 months), so these patients were excluded. In the 84 remaining emergency patients, 38 showed progression of the disease (13 local recurrence, 17 liver metastases, 4 lung, 3 peritoneal and 1 bone metastases). There were 26 deaths (6 patients with perforating and 20 with obstructive disease). There was no significant difference in survival or disease progression between patients with perforating and obstructive disease. CONCLUSIONS: These results do not support the classical view of considering perforating cancer as a type with an especially ominous prognosis among patients who require emergency surgery.

Cáncer de colon perforado. Evolución y pronóstico / Perforated colonic cancer. Evolution and prognosis

OBJETIVO: analizar si el cáncer de colon perforado debe ser considerado como de peor pronóstico entre los casos que requieren cirugía urgente. Estudio retrospectivo. PACIENTES: se revisan 91 resecciones primarias por cáncer de colon en urgencias, de las que 22 fueron por perforación (cuatro Dukes A, 10 Dukes B y ocho Dukes C) y 69 por oclusión (tres Dukes A, 30 Dukes B y 44 Dukes C). Como comparación orientativa se incluyen 112 resecciones programadas (68 Dukes B y 44 Dukes C) practicadas durante el mismo período de tiempo. RESULTADOS: excluidos los siete casos Dukes A en los que no se han observado fallecimientos ni recidivas durante el período de seguimiento (mínimo de seis meses y máximo de 90), en los 84 pacientes urgentes restantes, 38 han presentado progresión de la enfermedad (13 recidiva local, 17 metástasis hepáticas, cuatro pulmonares, tres peritoneales y una metástasis ósea). Han fallecido 26 (seis perforados y 20 ocluidos). No se han observado diferencias estadísticamente significativas en la frecuencia de recidivas locales y metástasis hepáticas ni en la probabilidad de supervivencia entre los casos ocluidos y los perforados. CONCLUSIONES: estos resultados no dan soporte a la opinión clásica de que el cáncer de colon perforado constituye un grupo de peor pronóstico entre los cánceres que requieren tratamiento quirúrgico urgente (AU)

Results of treatment in severe acute pancreatitis.

AIM: To analyze our results in the management of severe acute pancreatitis (SAP), especially in patients who required surgery. METHODS: In a retrospective study, 90 patients admitted between January 1992 and January 1998 were diagnosed as having SAP on the basis of clinical and radiological criteria. Contrast-enhanced tomography (CT) was done in all patients. The surgical technique of choice was necrosectomy and postoperative local lavage. RESULTS: Seventy percent of the patients (63/90) had pancreatic necrosis. Tomography had a sensitivity of 73% in detecting necrosis. Forty-nine patients (54%) needed surgery: 31 had infected SAP and 18 had sterile pancreatitis. Overall mortality rate was 25.6% (23/90); mortality was 43.8% (14/32) in patients with infected pancreatitis and 15.5% (9/58) in those with sterile SAP (p < 0.05). The mortality rate was 44.4% higher (8/18) in patients with sterile SAP who were operated on. Patients with infected SAP who were operated on during the first week of admission had a higher mortality rate (81%) than those operated on after the first week (20%) (p < 0.05). CONCLUSIONS: Pancreatic necrosis and infection are the most important prognostic factors in the course of SAP. The sooner the patients are operated on, the worse the prognosis, especially if there is infection. Efforts should be aimed at avoiding the onset of infection and organ failure, and at delaying surgery.

Efficacy and safety of an early discharge protocol in low-risk patients with upper gastrointestinal bleeding.

PURPOSE: The outcome of patients with upper gastrointestinal hemorrhage is greatly influenced by recurrence of bleeding, but it may be possible to identify patients who have a low risk for rebleeding, and can be discharged after a short hospitalization. To examine the effect of an early discharge protocol (length of hospital stay < or =3 days), we conducted a 2-year prospective study in patients with upper gastrointestinal bleeding at low risk for rebleeding, as selected by clinical and endoscopic criteria. METHODS: During the first year of the study, patients were managed according to the standard criteria by any of six surgical teams (control period). During the second year, patients were managed by only one surgical team under the early discharge protocol guidelines (study period). RESULTS: Overall, 488 of 942 (52%) patients were considered as low risk. Early discharge was achieved in 26 of 230 (11%) patients in the control period and in 191 of 258 (74%) in the study period (P <0.001). Age and number of compensated comorbidities did not affect the rate of early discharge. Length of hospital stay was reduced from (mean +/- SD) 6 +/- 2.7 days (control period) to 3 +/- 2.3 days (study period, P <0.001). No differences were observed in rates of rebleeding, need for surgery, readmission or mortality. By contrast, no differences in lengths of stay were observed during that time period among patients admitted with coronary artery disease, colorectal cancer, or acute pancreatitis. CONCLUSION: Most patients with upper gastrointestinal bleeding who are at low risk for rebleeding can be discharged early, leading to important cost savings.

Intraoperative colonic lavage and primary anastomosis in peritonitis and obstruction.

BACKGROUND: The surgical management of left colonic emergencies has evolved in the past few decades. Recently, there has been increasing interest in resection with primary anastomosis in selected cases. The aim of this study was to evaluate the differences in outcome in patients with peritonitis or obstruction treated by resection, on-table lavage and primary anastomosis of the left colon. METHODS: Between January 1992 and August 1995, 212 patients underwent emergency operation for a distal colonic lesion: 97 presented with peritonitis, 113 with obstruction and two with other indications. Intraoperative colonic lavage was performed in 37 patients with obstruction and in 24 with an acute intra-abdominal inflammatory process. RESULTS: The postoperative mortality rate was 5 per cent. The incidence of clinical anastomotic leakage was 5 per cent. Wound infection was observed in ten patients (16 per cent), more often in those with peritonitis (P = 0.03). The overall mean(s.d.) hospital stay was 15(9) days. CONCLUSION: Resection, on-table lavage and primary anastomosis constitute the operation of choice for selected patients with left colonic emergency.

[Surgical treatment of emergency pathology of the left colon]. / Tratamiento quirúrgico de la patología urgente del colon izquierdo.

The aim of this study was to evaluate the postoperative morbidity and mortality of patients with left colon disease that underwent emergency surgery. Intra-operative colonic irrigation (ICI) with primary anastomosis was used for unresectable lesions, faecal peritonitis, colon remnant associated lesions and poor performance status. The options included colostomy, Hartmann procedure or subtotal colectomy; 127 resections of left-sided large bowel were performed. In 56 cases the procedure was a Hartmann operation, in 38 cases subtotal colectomy and in 33 ICI. The most frequent complication was abdominal sepsis (29%). The overall mortality was 24%; 39% for the Hartmann procedure; 16% for subtotal colectomy and 6% for ICI. Our results suggest that ICI should be the first choice in patients with good performance status who undergo emergency surgery for left colon disease without faecal peritonitis or associated right colon lesions.