Outpatient laparoscopic cholecystectomy: a new gold standard for cholecystectomy.

OBJECTIVE: To contribute our experience for five years in the implemetation of outpatient laparoscopic cholecystectomy (LC). PATIENTS: Between January 1999 and March 2004 we performed 504 outpatient LCs. We applied both exclusion and inclusion criteria, an anesthetic and surgical protocol, and discharge-specific criteria. Postoperative management in "fast track" regime. Postoperative period controlled by protocol, including phone calls after cholecystectomy. RESULTS: The ambulatory percentage in the global series was 88.8%, and mean hospital stay was 6.1 hours. Fifty-one patients required overnight stays (10.1%), most of them for "social" causes. Five patients required admission (between 24 and 48 hours) for different causes (conversion to laparotomy, intraoperative neumothorax, and postoperative medical complications). Six patients (1.1%) were readmitted, and we observed 11.6% postoperative complications in the global series, with abdominal parietal pain being most frequent. Phone localization by 22.00 p.m. in the same day of surgery was 100% complete for outpatient cases. Postoperative surveillance within the first month after surgery was completed in 93.9%, and within th first year in 86.7% of patients. CONCLUSIONS: Outpatient LC is safe and feasible, and probably represents a new "gold standard" in the treatment of symptomatic cholelithiasis.

Colecistectomía laparoscópica ambulatoria. ¿El nuevo “gold standard” de la colecistectomía? / Outpatient laparoscopic cholecystectomy. A new gold standard for cholecystectomy?

Objetivo: aportar nuestra experiencia durante cinco años enla implantación de la colecistectomía laparoscópica (CL) en unprograma de cirugía mayor ambulatoria (CMA).Pacientes: entre enero de 1999 y marzo de 2004, se realizaron504 CL consecutivas en régimen ambulatorio. Se aplicaroncriterios de exclusión e inclusión, un procedimiento anestésico-quirurgicoprotocolizado, y criterios específicos al alta hospitalaria. Elmanejo postoperatorio se realizó en régimen de “fast track” o derecuperación rápida. Seguimiento postoperatorio estricto medianteprotocolo de revisiones, incluido localización telefónica el día dela colecistectomía.Resultados: el índice de sustitución de la serie global fue88,8%, siendo la estancia hospitalaria media de este grupo de 6,1horas. Cincuenta y un pacientes requirieron estancia nocturna enel hospital (10,1%), la mayoría por causas de índole “social”. Cincopacientes requirieron ingreso (entre 24 y 48 horas) por diferentescausas (conversión a cirugía abierta, neumotórax intraoperatorio,y complicaciones médicas postoperatorias). Seis pacientes(1,1%) fueron reingresados en nuestra clínica y se observó un11,6% de complicaciones postoperatorias en la serie global, dondeel dolor abdominal de tipo parietal fue la más frecuente. El contactoobligatorio telefónico a las 22,00 horas del mismo día de lacirugía se cumplió en el 100% de los casos ambulatorios. El seguimientopostoperatorio al mes de la intervención fue del 93,9% yal año, del 86,7% de los pacientes.Conclusiones: la CL en régimen ambulatorio se puede realizarde manera segura y fiable, y probablemente representa el nuevo“gold standard” del tratamiento de la colelitiasis sintomática

Objective: to contribute our experience for five years in theimplemetation of outpatient laparoscopic cholecystectomy (LC).Patients: between January 1999 and March 2004 we performed504 outpatient LCs. We applied both exclusion and inclusioncriteria, an anesthetic and surgical protocol, and discharge-specificcriteria. Postoperative management in “fast track” regime. Postoperativeperiod controlled by protocol, including phone calls aftercholecystectomy.Results: the ambulatory percentage in the global series was88.8%, and mean hospital stay was 6.1 hours. Fifty-one patientsrequired overnight stays (10.1%), most of them for “social” causes.Five patients required admission (between 24 and 48 hours)for different causes (conversion to laparotomy, intraoperative neumothorax,and postoperative medical complications). Six patients(1.1%) were readmitted, and we observed 11.6% postoperativecomplications in the global series, with abdominal parietal painbeing most frequent. Phone localization by 22.00 p.m. in thesame day of surgery was 100% complete for outpatient cases.Postoperative surveillance within the first month after surgery wascompleted in 93.9%, and within th first year in 86.7% of patients.Conclusions: outpatient LC is safe and feasible, and probablyrepresents a new “gold standard” in the treatment of symptomaticcholelithiasis

Impact of surgeon organization and specialization in rectal cancer outcome.

PURPOSE: The present study was designed to assess the differences in the outcome of patients with rectal cancer treated by a group of surgeons before and after being organized as a Coloproctology Unit at the same University Department of Surgery. METHODS: Comparison of two periods of rectal cancer surgery: I (1986-91) and II (1992-95). Period I: 94 patients were operated on by 14 general surgeons. Period II: 108 patients were operated on by only 4 surgeons of the same group organized as a Colorectal Surgery Unit after visiting referral centres abroad, adopting techniques such as total mesorectal excision (TME) for middle and low rectal cancer and washout of rectal stump. Mean follow-up during periods I and II was 69.1 and 42.0 months, respectively. A prospective data base analysis was used. Survival and local recurrence rates were calculated by the actuarial method. For comparison between groups the log rank method was used. RESULTS: The two groups were comparable with respect to mean age, gender, TNM and rectal tumour location. A significant increase in radical resectability and a decrease of the Abdominoperineal resection (APR)/Low anterior resection (LAR) ratio were observed in the second period. The overall pelvic recurrence rate was 25% in the first period and 11 in the second (P < 0.01). Significant differences were also found when the patients with LAR were compared between both periods, 30% vs 9% (P < 0.01) and specially when the 10 cm anal verge distance was considered to divide the LAR groups. No differences were found regarding the APR procedures in both periods. There was improved cancer-specific survival for the LAR group in the second period (P=0.03). CONCLUSION: Specialization and centralization influence the quality of rectal cancer surgery, mainly local recurrence rates and survival after low anterior resection.

Esplenosis gástrica: causa infrecuente de hemorragia digestiva alta / Gastric splenosis: an uncommon cause of upper gastrointestinal hemorrhage

La esplenosis representa el resultado del autotrasplante de tejido esplénico que generalmente sigue a un traumatismo o cirugía esplénica, cuando células esplénicas viables y pulpa se diseminan e implantan en la cavidad peritoneal. Presentamos un caso de esplenosis gástrica que simulaba una tumoración submucosa gástrica y causó una anemia ferropénica debida a hemorragia digestiva alta crónica (AU)

[Acquired enterovesical fistulas]. / Fístulas enterovesicales adquiridas.

We report on 23 patients with acquired vesicoenteric fistula treated during the past 12 years: 48% of these were of inflammatory etiology (11 cases), 35% were caused by neoplasms (8 cases) and 17% were iatrogenic (4 cases). The most frequent symptoms were pneumaturia and fecaluria (78% of cases). Cystoscopy was the most useful diagnostic procedure in detecting fistula (13 of 18 cases). Other imaging techniques, though less effective for diagnosis, were useful in assessing the status of the GI tract and, at times, in determining the etiology of the fistulae. Treatment depends on the etiology, localization and patient general condition. The technique most frequently applied in our series was resection of the fistulous tract, together with the compromised intestinal segment, and bladder suture.