Índice de sustitución como indicador de calidad en cirugía mayor ambulatoria. Evolución anual en un servicio de cirugía / The substitution index as an indicators of quality of care in major ambulatory surgery: Annual evolution in a surgery department

Fundamento: El índice de sustitución (IS) es uno de los indicadores utilizados para monitorizar la calidad de los programas de cirugía mayor ambulatoria (CMA). El objetivo de nuestro trabajo es estudiar la evolución en los últimos años de dicho índice en nuestro servicio de cirugía. Métodos: En el período 1995-2000 fueron intervenidos 5.675 pacientes por patologías incluidas en los programas de CMA. El 37,8 por ciento de los pacientes fueron intervenidos sin ingreso. Se analiza el IS anual para cada enfermedad. Resultados: Observamos una evolución ascendente del IS para cada enfermedad, alcanzando en el año 2000 cifras del 93 por ciento para enfermedades como el sinus pilonidal. Conclusión: El IS como medida del impacto de la CMA en nuestro servicio ha presentado un incremento anual para la mayor parte de los procesos hasta equipararse con los estándares establecidos actualmente (AU)

Reparación laparoscópica de las hernias ventrales con Goretex® y Parietex® / Laparoscopic repair of ventral hernias with Goretex® and Parietex®

Introducción. La reparación laparoscópica de las hernias ventrales cubre el defecto dejando una prótesis intraabdominal. De la adecuada elección del material protésico pueden depender los resultados y complicaciones de esta técnica. Objetivo. Evaluar los resultados de la cirugía laparoscópica en las hernias ventrales con el uso de dos mallas diferentes en posición intraabdominal: Goretex® (politetrafluoroetileno) y Parietex® (poliéster y colágeno).Pacientes y métodos. Análisis retrospectivo de 46 pacientes intervenidos de hernia ventral mediante cirugía laparoscópica. Se estudian las características clínicas de los pacientes (antecedentes médicos y quirúrgicos), el tipo de eventración (clasificación SWR), las complicaciones intra y postoperatorias, la estancia hospitalaria y el seguimiento, en función del tipo de material implantado. Resultados. Todos los pacientes se completaron por cirugía laparoscópica. El análisis estadístico de la morbilidad ha demostrado la existencia de una relación significativa entre el íleo postoperatorio en los defectos múltiples y las mallas de Goretex (p < 0,05) y de los seromas con la malla de Goretex (p < 0,01). El 70 por ciento de las intervenciones realizadas con Parietex se completaron como cirugía mayor ambulatoria y las de Goretex tuvieron una estancia media de 6 días (rango: 2-16). La tasa de recidivas es del 4,3 por ciento (un caso en cada grupo).Conclusiones. La reparación laparoscópica en las hernias ventrales es una alternativa eficaz a la reparación abierta con una baja morbilidad que no se relaciona con el tipo de defecto. Tanto la malla bilaminar Parietex® como la de Goretex® son seguras para su uso intraabdominal (AU)

Invaginación intestinal en el adulto. Presentación de siete casos con énfasis en el diagnóstico preoperatorio / Intestinal invagination in the adult. Presentation of six cases with emphasis on preoperative diagnosis

Objetivo. La invaginación intestinal en el adulto es un proceso potencialmente grave que, por su infrecuencia fuera de la infancia, se diagnostica de forma habitual durante el acto quirúrgico indicado por un síndrome obstructivo mecánico. Presentamos una serie reciente de casos cuyo diagnóstico se obtuvo preoperatoriamente. Pacientes y métodos. Se han analizado los registros de todos los pacientes mayores de 18 años con el diagnóstico postoperatorio de invaginación intestinal tratados en nuestra institución entre 1996 y 2000.Resultados. En 4 años se intervinieron 7 pacientes, con una edad media de 40 años. Todos presentaron datos clínicos de obstrucción intestinal completa o parcial. El diagnóstico preoperatorio etiológico se efectuó en 6 casos, gracias a la realización frecuente de ecografía y tomografía computarizada. Todos los pacientes fueron intervenidos, 3 de forma urgente y 4 con carácter programado. Durante el acto quirúrgico se identificaron las lesiones causantes de la invaginación, 4 localizadas en el íleon terminal (divertículo de Meckel, seudotumor inflamatorio, pólipo fibroide, pólipo adenomatovelloso degenerado), dos en el ciego (ambos adenocarcinoma sobre pólipo) y, en el caso restante, un linfoma doble de yeyuno e íleon. Las intususcepciones fueron ileoileales en 3 casos, ileocólicas en 3 y doble yeyunoileal e ileocólica en el séptimo paciente. Se practicaron 3 hemicolectomías derechas, 2 resecciones ileales, una exéresis de divertículo de Meckel y, finalmente, una doble exéresis (yeyunal e ileocólica) en el caso del linfoma. No existió mortalidad. Conclusiones. La invaginación intestinal en el adulto es una entidad poco frecuente. Los síntomas son los de un cuadro obstructivo mecánico completo o parcial; en estos últimos, la evolución puede ser intermitente o crónica. La ecografía y la tomografía computarizada demuestran ser los métodos de diagnósticos preoperatorios más efectivos. En el adulto, aproximadamente la mitad de los casos se deben a una enfermedad maligna, por lo que la resección es el procedimiento de elección (AU)

Laparoscopic repair of ventral and incisional hernias using a new composite mesh (Parietex): initial experience.

Ventral hernia repair is still a difficult problem for surgeons because of the high recurrence rate and possible postoperative complications. Repairs with a prosthesis have reduced the recurrence rate, but the anterior approach still involves high morbidity and a long hospital stay. The purpose of this article was to evaluate the results of laparoscopic surgery on ventral hernias using a new double-layer mesh in an intra-abdominal position. A retrospective analysis was performed of the first 20 patients undergoing laparoscopic surgery for ventral hernia (75% incisional and 25% umbilical) with intra-abdominal prosthetic repair using a double-layer mesh consisting of three-dimensional multifiber polyester on one side and a hydrophilic resorbable nonstick collagen membrane on the other (Parietex composite, Sofradim, Villefranche sur Saone, France). The procedure was done on an outpatient basis in 85% of the cases. There was no morbidity or mortality. During a mean follow-up period of 10 months we found no infections, rejections, fistulas, recurrences, or alterations in bowel function. Laparoscopic repair of ventral hernias is an efficient alternative to open repair, with a low morbidity rate and short hospital stay. The double-layer mesh is safe for intra-abdominal use.

Reparación laparoscópica de las hernias incisionales mediante malla bilaminar de Parietex: resultados con un año de seguimiento / Laparoscopic repair of incisional hernias with bilaminar Parietex® mesh. Result after 1 year of follow-up

Introducción. La reparación de las hernias ventrales todavía supone un difícil problema para el cirujano general por su alto índice de recidivas y de complicaciones postoperatorias. Las reparaciones con prótesis han disminuido la tasa de recidivas, pero la vía anterior todavía supone una considerable morbilidad y una elevada estancia hospitalaria. Objetivo. Evaluar los resultados de la cirugía laparoscópica en las hernias ventrales y la tolerancia de una nueva malla en posición intraabdominal. Pacientes y métodos. Análisis retrospectivo de los primeros 20 pacientes que se han intervenido por hernia ventral (75 por ciento incisionales y 25 por cientoumbilicales) mediante cirugía laparoscópica con reparación protésica intraabdominal con una malla bilaminar: por un lado, poliéster multifibra tridimensional y, por otro lado, una membrana antiadherente hidrofílica y reabsorbible de colágeno. Resultados. Todos los pacientes fueron intervenidos sin morbimortalidad. El 85 por ciento de las intervenciones se realizaron como cirugía sin ingreso. Durante el seguimiento medio de 10 meses no se han encontrado infecciones, rechazos, fístulas, recidivas ni alteraciones del tránsito intestinal. Conclusiones. La reparación laparoscópica en las hernias ventrales es una alternativa eficaz a la reparación abierta y la malla bilaminar Parietex® es segura para su uso intraabdominal (AU)

Fistulectomía radial y cierre primario en el tratamiento de la fístula periareolar recidivante / Radial fistulectomy and primary closure in the treatment of recurrent periareolar fistula

Objetivo. La fístula periareolar recidivante es un proceso inflamatorio crónico cuya patogenia y tratamiento siguen siendo controvertidos. El objetivo del estudio fue evaluar la efectividad de la fistulectomía radial con cierre primario, bajo anestesia local y en régimen ambulatorio, en esta enfermedad. Material y métodos. Realizamos un estudio sobre 12 pacientes (nueve mujeres y tres hombres) evaluados consecutivamente desde 1996. Cuando la enfermedad se detectó en fase de absceso se realizó drenaje simple. Establecida la fístula, la cirugía definitiva consistió en la escisión radial de todo el trayecto con cierre primario bajo anestesia local en régimen ambulatorio. El período de seguimiento medio fue de 1,8 años (rango: 0,5-3 años).Resultados. Todas las pacientes fueron dadas de alta el día de la intervención y no se produjeron consultas distintas de las programadas al alta. Como complicación destaca una infección de la herida quirúrgica que remitió con drenaje y tratamiento antibiótico. No se han detectado recidivas en el período estudiado. Conclusiones. El procedimiento es realizable bajo anestesia local y en régimen de cirugía ambulatoria; la tasa de infección de herida es muy baja; la técnica resulta sencilla y fácilmente reproducible por cualquier cirujano, y la tasa de recidiva resultaría muy baja en comparación con otras técnicas publicadas (AU)

Treatment of the abdominal wall defects in an ambulatory surgical setting: our experience.

Introduction: The creation of Outpatient Surgery (OPS) units has allowed to reduce the costs and the waiting lists in an efficient fashion. We describe our series of patients operated on for abdominal wall defects, a pathology suitable for ambulatory surgery. Patients and methods: Between May 1994 and March 1998, 206 inguinal hernias, 23 femoral hernias, 47 umbilical-epigastric hernias and nine incisional hernias were operated on in an ambulatory surgical setting. The patients were selected following the selection criteria previously established (related to the patient, the environment and the surgical procedure). The average age was 45 years, and the distribution by sex, 210 men and 75 women. Spinal anesthesia was preferently performed. The surgical techniques employed were Lichtenstein's hernioplasty and Shouldice and Bassini procedures for inguinal hernias; Lichtenstein's plug technique for femoral hernias and simple closure or preperitoneal mesh for the middle line defects. Results: 44 patients needed readmitttance to hospital (failure of OPS), the most important causes being excessive pain, urinary retention and nausea/vomiting. There was no severe morbidity nor mortality. Conclusion: Surgery for abdominal wall defects constitutes a group of procedures suitable for efficient and low risk OPS programs.

Subtotal colectomy vs. intraoperative colonic irrigation in the management of obstructed left colon carcinoma.

PURPOSE: Whether primary anastomosis should be performed after segmental resection with intraoperative colonic irrigation or subtotal colectomy is not yet established in the surgical treatment of obstructive left colon carcinoma. In this prospective, nonrandomized study, we present the results of 66 patients undergoing one-stage surgery for obstructed left colon carcinoma. PATIENTS AND METHODS: We compared two techniques, subtotal colectomy (35 patients) and intraoperative colonic irrigation with segmental resection and immediate anastomosis (31 patients). RESULTS: The mortality rate was similar in both groups, 8.5 percent in the subtotal colectomy group and 3.2 percent in the intraoperative colonic irrigation group. The surgical complication rate was significantly higher in the intraoperative colonic irrigation group (41.9 percent) than in the subtotal colectomy group (14.2 percent; P < 0.05). Mean operating time was significantly lower in the subtotal colectomy group than in the intraoperative colonic irrigation group (P < 0.05). Both groups had a similar mean duration of hospital stay. Ten patients who underwent subtotal colectomy (31.2 percent) presented with diarrhea in the immediate postoperative period, which disappeared spontaneously or with antidiarrheal medication; a disabling diarrhea persisted in two patients only (6.2 percent). CONCLUSION: We believe that subtotal colectomy is the treatment of choice for obstructed left-sided colonic carcinoma. Segmental resection with intraoperative colonic irrigation is more appropriate than subtotal colectomy only in patients with carcinomas of the rectosigmoid junction or with previous anal incontinence to avoid the appearance of postoperative diarrhea.

Gastric surgery does not increase the risk of developing Barrett's esophagus.

OBJECTIVE: Barrett's esophagus is currently believed to be related to severe and prolonged pathological acid gastroesophageal reflux. However, other factors have been discussed, especially pancreatic biliary reflux. To determine the importance of pancreatic-biliary reflux in the genesis of Barrett's esophagus, we assessed the prevalence of Barrett's esophagus in patients with an intact stomach and in those with previous gastric surgery. METHODS: This is a retrospective study in which 22,236 upper digestive endoscopy reports were reviewed and classified into two groups: intact stomach (n = 21,023) and operated stomach (n = 1,213). In turn, these two groups were divided into five subgroups according to surgical techniques. In each of the groups and subgroups, we calculated the percentage of patients with esophagitis, the percentage of esophagitis patients with Barrett's esophagus, and the percentage of Barrett's esophagus patients with complications. Results were compared by chi2 test. RESULTS: With regard to the prevalence of Barrett's esophagus, we found no significant differences between the study groups. CONCLUSIONS: We conclude that previous gastric surgery does not increase the risk that esophagitis patients will develop Barrett's esophagus.

Quantification of duodenogastric reflux in Barrett's esophagus.

OBJECTIVES: Our objective was to assess the role of reflux of duodenal contents in the genesis of Barrett's esophagus. Therefore, we performed a study to quantify duodenogastric reflux, using 99mTc-HIDA quantification in gastric juice after continuous intravenous infusion of the same. METHODS: The study contained 20 patients with Barrett's esophagus (10 uncomplicated and 10 complicated by ulcers and/or stenosis), 10 patients with peptic esophagitis without Barrett's esophagus (two grade I, four grade II, and four grade III, according to Savary-Miller), and 10 healthy volunteers who made up the control group. Comparisons were made between the groups. RESULTS: When we considered the groups overall, we observed that the 20 patients with Barrett's esophagus had higher reflux rates (p < 0.01) than either the 10 patients with peptic esophagitis without Barrett's esophagus, or the 10 controls. Complicated Barrett's esophagus presented higher reflux rates than uncomplicated Barrett's esophagus, although the differences were not statistically significant. However, on analyzing the results after considering the groups case by case, we see that the mean reflux rate in the Barrett's esophagus groups is due to five patients presenting much higher rates than the rest. CONCLUSIONS: Our results suggest that duodenogastric reflux might be involved in the appearance of Barrett's esophagus and its related complications, although only in certain cases. The pathogenesis of Barrett's esophagus is probably multifactorial, and other factors must be involved.

Conservative treatment versus antireflux surgery in Barrett's oesophagus: long-term results of a prospective study.

The results obtained for the treatment of 59 patients diagnosed with Barrett's oesophagus, randomized to receive medical treatment (n = 27) or antireflux surgery (n = 32) were assessed prospectively. Median follow-up for the patients undergoing medical treatment was 4 (range 1-11) years and for patients undergoing surgical treatment 5 (range 1-11) years. Satisfactory symptomatic control (excellent to good results) was achieved in 24 patients after medical therapy and in 29 after antireflux surgery. The proportion of patients with persistent inflammatory lesions (54 per cent) and persistent or recurrent stenosis (47 per cent) was significantly higher after conservative treatment than after surgery (5 and 15 per cent, respectively). A decrease in the length of the segment of columnar mucosa was observed in eight of the patients who underwent antireflux surgery, and in only two of those given medical therapy. Conversely, an upward progression of the columnar lining was more frequent in the latter group (11 versus three). Mild dysplasia was observed in five patients, all from the group undergoing medical treatment. Severe dysplasia was detected in two patients, one undergoing medical treatment and the other following surgical therapy, in whom an antireflux procedure had failed previously. Both patients underwent oesophageal resection, with confirmation of a carcinoma in situ. The patients in whom antireflux surgery proved effective showed no dysplastic change or progression to adenocarcinoma. These results, despite the small number of patients and methodological limitations, question the systematic conservative approach in the initial management of patients with Barrett's oesophagus.

Laparoscopic cholecystectomy in the treatment of acute cholecystitis.

BACKGROUND: Laparoscopic cholecystectomy has several advantages over traditional cholecystectomy, which make it the treatment of choice for patients with uncomplicated biliary lithiasis. However, in patients with acute cholecystitis, the role of this technique remains controversial and some clinicians regard this condition as a contraindication to laparoscopic cholecystectomy. STUDY DESIGN: Between June, 1991 and July, 1993, a total of 259 patients with cholelithiasis underwent laparoscopic cholecystectomy at the "Virgen de la Arrixaca" University Hospital. Of these patients, 60 underwent laparoscopic cholecystectomy for acute cholecystitis. RESULTS: Conversion to laparotomy was necessary in eight patients (13 percent). Mean operating time was 83 minutes (range, 45 to 180 minutes). Overall mean hospital stay (laparoscopy and conversions) was 3.1 days (range, one to nine days). There was no mortality or injury to the common bile duct in our series. CONCLUSIONS: We believe that laparoscopic cholecystectomy in patients with acute cholecystitis is a safe and effective procedure, in which the patient can benefit from the advantages of laparoscopic surgery without an increase in mortality and morbidity rates.

Gastrointestinal bezoars.

Of 99 patients with 117 gastrointestinal bezoars, 69 had undergone previous surgery, the most common operation being bilateral truncal vagotomy with pyloroplasty (55 patients). An excessive intake of vegetable fibre was found in 38 patients and poor mastication in 27. Thirty bezoars presented with gastric symptoms and patients had endoscopy as the diagnostic technique; 87 caused symptoms of intestinal obstruction with the diagnosis made by plain abdominal radiography. Medical treatment by enzymic or endoscopic fragmentation was used for 17 of 30 gastric bezoars; surgery was required in the remainder. Intestinal bezoars causing obstruction can be fragmented and 'milked' to the caecum. The stomach should be explored for associated gastric bezoars.