Urgencias quirúrgicas no relacionadas con la pandemia COVID-19. Caso clínico: hernia interna yeyunal complicada con necrosis intestinal en el ligamento ancho útero-ovárico / Covid No-related Surgical Emergencies During COVID-19 Time. Case Report: Broad Ligament Internal Hernia With Associated Small Bowel Necrosis

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Fast-Track in Bariatric and Metabolic Surgery: Feasibility and Cost Analysis Through a Matched-Cohort Study in a Single Centre.

BACKGROUND: Due to the rise in severe obesity in Western countries and the increase in bariatric surgery, enhanced recovery (ER) pathways should be developed and promoted. METHODS: A monocentric prospective series of 103 bariatric surgery patients managed with the ER pathway (group ER) was compared with a retrospective and immediately previous series of 103 patients managed with standard care (group CS). The aim of the present study was to assess and compare the differences in terms of mean postoperative length of stay (LOS), costs for surgery and recovery, and the differences in terms of complications, readmission, and reoperation rate in the short term between the ER and CS groups. RESULTS: The mean LOS was 4.18 days in group CS and 1.79 days in group ER (p < 0.0001). The mean operative time (OT) per patient was 190.20 min in the group CS and 133.54 min in the group ER, resulting in an average cost of 7272.57€ per patient in group CS and 5424.09€ per patient in group ER. The average recovery cost was 1809.94€ for the group CS series and 775.07 for the group ER one. Overall complications (Clavien-Dindo up to II) occurred in 6 patients (5.8 %) in group CS and in 2 patients (1.9 %) in group ER (p = 0.149) and specific complications (Clavien-Dindo IIIb) occurred for 9 patients (8.7 %) in Group CS and for 14 patients (13.5 %) in group ER (p = 0.268) after hospital discharge within 1-month of follow-up. Twelve patients (11.5 %) in group CS and 13 (12.5 %) in group ER were readmitted after discharge (p = 0.831) within 1-month of follow-up; 8 patients (7.7 %) in group CS versus 9 patients (8.8 %) in group ER needed to be reoperated (p = 0.800) within 1-month follow-up. CONCLUSIONS: Enhanced recovery pathway reduces significantly LOS in bariatric surgical patients and shortens the mean OT of the procedure, with no significant differences in terms of surgical outcomes. Furthermore, recovery charges were lower and operative time was shorter allowing for procedural cost reduction.

Pure laparoscopic pancreatoduodenectomy with initial approach to the superior mesenteric artery.

INTRODUCTION: The "artery-first approach" (AFA) to the superior mesenteric artery allows an early assessment of resectability of pancreatic tumours and could improve the benefits of laparoscopy, reducing invasiveness, especially for unresectable tumours. AIM: To describe our technique of pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA, and to report the surgical outcomes of this procedure in a small series of 12 patients through a retrospective analysis of a prospectively collected database. MATERIAL AND METHODS: Twelve selected patients underwent elective full laparoscopic pancreatoduodenectomy with the AFA. The technical aspects of the procedure are described in detail and the included images facilitate the understanding of the procedure. RESULTS: The mean operative time was 300 min (range: 250-540 min). No intraoperative complications were observed. No conversion to laparotomy was necessary. The mean postoperative hospital stay was 18 days (range: 8-42). Mortality was null. There were 3 major complications at the 3rd post-operative month follow-up: 2 patients reporting a grade A pancreatic fistula and one biliary fistula. CONCLUSIONS: Our work shows that pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA is feasible, in selected patients. The AFA could improve on the advantages of laparoscopy in the identification of unresectable patients, and it also allows early control of vascular structures.

Totally laparoscopic 95% gastrectomy for cancer: technical considerations.

INTRODUCTION: Total gastrectomy is the standard treatment for tumours arising in the proximal stomach and for diffuse cancer according to the Lauren classification. Laparoscopic approach is progressively accepted and provides encouraging results. In order to reduce complications associated to the esophago-jejunal anastomosis, the concept of the 95 % open gastrectomy was developed in Japan, in the early 1980s. This procedure provides the spearing of a small remnant gastric stump of 2 cm and allows performing a gastro-jejunal anastomosis. Unlike the 7/8 gastrectomy, the 95 % gastrectomy allows the complete resection of the gastric fundus and an optimized pericardial lymph node dissection (group 1 and 2). We herein describe, step-by-step, our technique of full laparoscopic 95 % gastrectomy (G95 %), with D2 lymphadenectomy, including complete lymphadenectomy of the cardial nodes. DISCUSSION: When it is possible to respect the oncologic criteria regarding proximal resection margin, 95 % gastrectomy would offer best short-term results, such as lower anastomotic leak rate and a better quality of life, limiting the effect of disruption of the eso-gastric junction. CONCLUSION: In selected patients, laparoscopic G95 % is feasible and safe; it could be performed without any additional technical difficulties. Controlled clinical trials are necessary to confirm the encouraging results of the cases series, recently reported in literature.

Minimally invasive management of postoperative esophagojejunal anastomotic leak.

PURPOSE: Postoperative esophagojejunal fistula induces morbidity and mortality after total gastrectomy and affects the long-term survival rate. METHODS: Between 2003 and 2011, 38 patients underwent laparoscopic total gastrectomy and 2 developed an esophagojejunal fistula. RESULTS: The diagnosis was established by a computed tomography scan with contrast ingestion. The absence of complete dehiscence and the vitality of the alimentary loop were checked during laparoscopic exploration, associated with effective drainage. During the endoscopy, dehiscence was assessed and a covered stent and nasojejunal tube were inserted for enteral feeding. The leaks healed progressively, oral feeding was resumed and the drains removed within 3 weeks. The stent was removed 6 weeks. Three months later, the patients were able to eat without dysphagia. CONCLUSIONS: Early diagnosis allows successful conservative management. The objectives are effective drainage, covering by an endoscopic stent and renutrition. Management by a multidisciplinary team is essential.

Barbed versus usual suture for closure of the gastrojejunal anastomosis in laparoscopic gastric bypass: a comparative trial.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is one of the main bariatric procedures that require safe and reproducible anastomosis. The objective of this study is to compare the risk of leaks and stenosis of a mechanical gastric pouch jejunal anastomosis between the usual interrupted sutures and a continuous barbed suture for gastrojejunotomy, in order to reduce procedure time and costs. METHODS: A comparative trial of 100 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass was performed between October 2010 and July 2011. The population was divided into two groups of 50 consecutive patients. In the first group, gastrojejunotomy was sutured with resorbable interrupted sutures and the second with continuous barbed suture. Diabetes, body mass index and the American Society of Anaesthesiology score were compared. The time required for suturing and the incidence of anastomotic leaks and stricture were also compared after 6 months. RESULTS: No fistulas or anastomotic stenoses had occurred at post-operative month 6 in either group. Gastrojejunotomy suture time was significantly shorter in the barbed suture group (11 versus 8.22 min; p < 0.01). Total costs of material to complete the reconstruction were significantly lower in the barbed suture group (€26.69 versus €18.33; p < 0.001). CONCLUSIONS: The use of barbed suture is as safe as usual sutures and allows easier and faster suture in the closure of gastrojejunotomy. This suture could be incorporated in the standard laparoscopic Roux-en-Y gastric bypass technique.