Morbimortalidad de la resección pancreática

Aim

Assess the postoperative morbidity rates in pancreatic resection.

Material and method

Prospective observational study which includes 117 patients who underwent surgery consecutively due to pancreatic or periampullary tumours. In 61 of the patients, cephalic pancreatectomy was carried out; 15 underwent total pancreatectomy; one underwent enucleation and 40 underwent distal pancreatectomy.

Results

Overall morbidity was 48.7% (59% for cephalic pancreatectomy, 35% for distal pancreatectomy and 46.7% for total pancreatectomy). The most frequent complications were intra-abdominal abscesses and collections (15.38%) and medical complications (13.68%). The incidence of pancreatic fistula was 9.83% for cephalic pancreatectomy and 10% for distal pancreatectomy. The reintervention incidence was 14.53%. Overall mortality was 5.12% (6.56% for cephalic pancreatectomy, 2.5% for distal pancreatectomy and 6.67% for total pancreatectomy). The presence of postoperative complications, the need for reintervention and the fact of being over 70 years of age correlated significantly with mortality.

Discussion

Pancreatic resection has high morbidity rates. Mortality is low and is practically limited to patients older than 70 years.     

Morbilidad y mortalidad de la ileostomía derivativa temporal en la cirugía por cáncer de recto

Introduction

A temporary diverting ileostomy is frequently used to reduce the consequences of a distal anastomotic leakage after total mesorectal excision in rectal cancer surgery. This surgical technique is associated with high morbidity and a not negligible mortality. The aim of this study is to evaluate the morbidity and mortality rate associated with an ileostomy and its posterior closure.

Material and methods

Between 2001 and 2012, 96 patients with temporary diverting ileostomy were retrospectively analyzed. Morbidity and mortality were analyzed before and after the stoma closure. The studied variables included age, sex, comorbidities, time to bowel continuity restoration and adjuvant chemotherapy.

Results

In 5 patients the stoma was permanent and another 5 died. The morbidity and mortality rates associated with the stoma while it was present were 21 and 1% respectively. We performed a stoma closure in 86 patients, 57% of whom had previously received adjuvant therapy. There was no postoperative mortality after closure and the morbidity rate was 24%. The average time between initial surgery and restoration of intestinal continuity was 152.2 days. This interval was significantly higher in patients who had received adjuvant therapy. No statistically significant difference was found between the variables analyzed and complications.

Conclusions

Diverting ileostomy is associated with low mortality and high morbidity rates before and after closure. Adjuvant chemotherapy significantly delays bowel continuity restoration, although in this study did not influence in the rate of complications.     

Exploración laparoscópica de la vía biliar,lecciones aprendidas tras más de 200 casos

Introduction

Laparoscopic common bile duct exploration (LCBDE) is a reliable, reproducible and cost-effective treatment for common bile duct stones. Several techniques have been described for choledochotomy closure.

Aims

To present our experience and the lessons learned in more than 200 cases of LCBDE.

Patients and methods

Between January 1999 and July 2012, 206 patients with common bile duct stones underwent LCBDE. At the beginning of the series, we performed the closure of the CBD over a T-tube (36 patients), subsequently we favoured closure over an antegrade stent (133 patients) but due to a high incidence of acute pancreatitis in the last 16 patients we have performed primary closure.

Results

The 3 closure groups were matched for age and sex. Jaundice was the most frequent presentation. A total of 185 (88,5%) patients underwent choledochotomy whereas in 17 (8,7%) patients the transcystic route was used. The group that underwent choledochotomy had a larger size of stones compared to the transcystic group (9,7 vs 7,6 mm). In the stented group we found an 11,6% incidence of pancreatitis and 26,1% of hyperamylasemia. In the primary closure group we found a clear improvement of complications and hospital stay. The increased experience of the surgeon and age (younger than 75) had a positive impact on mortality and morbidity.

Conclusions

Primary closure of the common bile duct after LCBDE seems to be superior to closure over a T tube and stents. The learning curve seems to have a positive impact on the outcomes making it a safe and reproducible technique especially for patients aged under 75.     

Esophagectomy outcomes at a mid-volume cancer center utilizing prospective multidisciplinary care and a 2-surgeon team approach

Background

Esophagectomy is associated with high morbidity and mortality, leading to calls for restricted performance at high-volume centers.

Methods

Patients with esophageal cancer were evaluated prospectively in a multidisciplinary tumor board from January 2012 - December 2012. A 2-surgeon team was utilized and detailed outcomes were assessed prospectively.

Results

Thirty-one patients underwent esophagectomy, 20 patients underwent laparoscopic transhiatal (65%) approach, and 11 patients underwent laparoscopically assisted Ivor-Lewis (35%) approach. Eighty-one percent of the patients were male, with a median age of 64 years (range: 35 to 83 years) and 73% of the patients had adenocarcinoma. Neoadjuvant chemoradiation was performed in 79% of the patients. R0 resection was achieved in 29 (94%) patients, median nodes identified were 15. Major complications (grade III to V) occurred in 13 (42%) patients and did not correlate with surgical techniques, anastomotic leak occurred in 5 (16%) patients, and significant pulmonary complications occurred in 11 (35%) patients. The length of stay at the hospital was 10 days, readmission rate 23%, and 30-day mortality rate 6%.

Conclusions

High-quality esophagectomy can be performed safely at a mid-volume cancer center. Our outcomes question the reliance on volume alone as an indicator of cancer surgical quality.     

Evolución del cierre de ileostomía en una unidad de cirugía colorrectal. Análisis comparativo según la técnica

Introduction

The objective of this study is to assess whether the results of loop ileostomy closure in terms of morbidity and hospital stay are influenced by the type of anastomosis and suture used.

Method

All patients who underwent loop ileostomy closure were reviewed. A retrospective cohort study comparing morbidity and hospital stay according to the type of anastomosis (TT/LL) and the type of suture (hand sewn/mechanical) was performed.

Results

From January 2003 to November 2011 a total of 167 loop ileostomy closures were analized. The groups were: type of anastomosis (TT 95/LL 72) and type of suture (manual 105/stapled 62). In 76% of the observed population the underlying disease was cancer. Mortality occurred in one case. The stratified morbidity analysis by type of complications showed no significant differences between the groups in terms of local (7.4% TT, LL 8.3%, 6.7% hand sewn, stapled 9.7%), general (TT 9.5%, 16.7% LL, hand sewn 6.7%, 6.5% stapled) and surgical (TT 15.8%, 19.4% LL, hand sewn 17.1%, 17.7% stapled) complications, nor in the rate of reoperations (TT 6.3%, 6.9% LL, hand sewn 6.7%, 6.5% stapled) and hospital stay in days (TT 7.8, 8 LL, hand sewn 8.6, stapled 6.7)

Conclusions

Closure of loop ileostomy can be performed regardless of the type of suture or anastomosis used, with the same rate of morbidity and hospital stay.     

Amélioration de la perfusion des organes vitaux par la valve d’impédance inspiratoire et le concept de pompe respiratoire : rationnel physiologique et application clinique

Objective

In this article, we review the effects of the respiratory pump to improve vital organ perfusion by the use of an inspiratory threshold device.

Data sources

Medline and MeSH database.

Study selection

All papers with a level of proof of I to III have been used.

Data extraction

The analysis of the papers has focused on the physiological modifications induced by intrathoracic pressure regulation.

Data synthesis

Primary function of breathing is to provide gas exchange. Studies of the mechanisms involved in animals and humans provide the physiological underpinnings for “the other side of breathing”: to increase circulation to the heart and brain. We describe studies that focus on the fundamental relationship between the generation of negative intrathoracic pressure during inspiration through a low-level of resistance created by an impedance threshold device and the physiologic effects of a respiratory pump. A decrease in intrathoracic pressure during inspiration through a fixed resistance resulting in an intrathoracic pressure of −7 cmH₂O has multiple physiological benefits including: enhanced venous return, cardiac stroke volume and aortic blood pressure; lower intracranial pressure; resetting of the cardiac baroreflex; elevated cerebral blood flow oscillations and increased tissue blood flow/pressure gradient.

Conclusion

The clinical and animal studies support the use of the intrathoracic pump to treat different clinical conditions: hemorrhagic shock, orthostatic hypotension, septic shock, and cardiac arrest.     

The role of diabetes and other co-morbidities on survival after esophageal cancer surgery in a population-based study

Background

There is limited knowledge on how diabetes and other comorbidities influence the survival of patients undergoing curative esophageal cancer surgery.

Methods

A population-based and prospective cohort study included patients who underwent surgical resection for esophageal or cardia cancer in Sweden from 2001 to 2005, with follow-up until 2011. Associations between diabetes and other comorbidities in relation to postoperative mortality were analyzed using Cox proportional-hazards regression with adjustment for potential confounding factors.

Results

Among 609 patients, 67 (11%) with diabetes had no increased risk for mortality compared with those without diabetes (hazard ratio, .81; 95% confidence interval, .60 to 1.09). Compared with patients without any predefined comorbidities, those with 1 (hazard ratio, 1.15; 95% confidence interval, .93 to 1.43) or ≥2 comorbidities (hazard ratio, 1.05; 95% confidence interval, .83 to 1.33) had no statistically significantly increased risk for mortality.

Conclusions

This study revealed no strongly increased risk for mortality in patients with diabetes or other comorbidities selected for esophageal cancer surgery.     

Impact de la mise en place d’un réseau de soins en traumatologie sur la mortalité des patients traumatisés graves du bassin

Aim

To evaluate the impact of a regional trauma network on intra-hospital mortality rates of patients admitted with severe pelvic trauma.

Study

Retrospective observational study.

Patients

Sixty-five trauma patients with serious pelvic fracture (pelvic abbreviated injury scale [AIS] score of 3 or more).

Methods

Demographic, physiologic and biological parameters were recorded. Observed mortality rates were compared to predicted mortality according to the Trauma Revised Injury Severity Score methodology adjusted by a case mix variation model.

Results

Twenty-nine patients were admitted in a level I trauma centre (reference centre) and 36 in level II trauma centres (centres with interventional radiology facility and/or neurosurgery). Patients from the level I trauma centre were more severely injured than those who were admitted at the level II trauma centres (Injury Severity Score [ISS]: 30 [13–75] vs 22 [9–59]; P < 0.01). Time from trauma to hospital admission was also longer in level I trauma centre (115 [50–290] min vs 90 [28–240] min, P < 0.01). Observed mortality rates (14%; 95% confidence interval, 95% CI, [1–26%]) were lower than the predicted mortality (29%; 95% CI [13–44%]) in the level I trauma centre. No difference in mortality rates was found in the level II trauma centres.

Conclusion

The regional trauma network could screen the most severely injured patients with pelvic trauma to admit them at a level I trauma centre. The observed mortality of these patients was lower than the predicted mortality despite increased time from trauma to admission.     

The Hybrid Intrathoracic Oesophago-gastric Anastomosis in Oesophageal Cancer—Morbidity and Mortality

Background

The technique of the side-to-side, hybrid stapled/hand-sewn, intrathoracic, oesophago-gastric anastomosis was first described in 1996 (Bird et al. Aust N.Z J Surg 66:77–763, 1996). However despite some clinical and theoretical advantages, it has never been as popular as either hand-sewn or circular-stapled anastomosis. The aim of this study was to review the experience of a single surgeon (RC) who has used this type of anastomosis since 1993 as the routine means of reconstruction following oesophagectomy.

Methods

A retrospective review of prospectively collected data was performed. The study included 195 consecutive oesophageal resections performed by a single surgeon (RC) from 1993 to 2011.

Results

Of 195 patients undergoing oesophagectomy, 180 patients had an intrathoracic anastomosis for oesophageal cancer. Of the 180 patients, 177 had an anastomosis formed using the hybrid technique. The clinical anastomotic leak rate in this group was found to the 2.7 % with an in hospital mortality of 0.5 %. The total number of patients requiring post-operative dilatation was 17/180 or approximately 9 % of patients.

Conclusions

The hybrid oesophageal anastomosis is associated with a low mortality and anastomotic leak rate and a modest incidence of stricturing.     

Survival after oesophagectomy for cancer of the oesophagus

Background Formerly an inevitably fatal disease, oesophageal cancer today has predictable chances for cure.Methods The recent literature and authors own experiences in the surgical management of oesophageal cancer was reviewed to identify factors associated with improved survival after oesophagectomy.Results Currently reported overall 5-year-survival rates are reaching 40% and more in patients who have had an oesophagectomy performed with curative intention. The reasons for improved survival after surgical resection are multifactorial in nature: decreased postoperative mortality and morbidity (due to improved patient selection, surgical technique and perioperative management), the use of tailored surgical strategies (adopted to the histological tumour type, tumour location, stage of disease and the individual patients risk profile), and multimodality treatment in patients with locally advanced disease.Conclusion The prognosis of patients who have had oesophagectomy for oesophageal cancer has markedly improved during the past decades. With improved long-term survival after oesophagectomy, postoperative quality of life gains importance as an additional parameter of outcome after oesophageal cancer surgery.     

Utilidad de la escala Obesity surgery mortality risk score en la predicción de complicaciones tras cirugía bariátrica por vía laparoscópica

Introduction

Morbimortality after bariatric surgery varies according to patient characteristics and associated comorbidities. The aim of this study was to evaluate the usefulness of the Obesity sugery mortality risk score scale (OS-MRS) to predict the risk of postoperative complications after bariatric surgery.

Methods

A retrospective study was performed of a prospective series of patients undergoing bariatric surgery in which the OS-MRS scale was applied preoperatively. Postoperative complications were classified as proposed by Dindo-Clavien. We analyzed the relationship between the categories of OS-MRS scale: A) low risk, B) intermediate risk, and C) high risk and the presence of complications.

Results

Between May 2008 and June 2012, 198 patients were included (85 [42.9%] after gastric bypass and 113 [57.1%] after sleeve gastrectomy). Using the OS-MRS scale, 124 patients were classified as class A (62.6%), 70 as class B (35.4%) and 4 as class C (2%). The overall morbidity rate was 12.6% (25 patients). A significant association between OS-MRS scale and rate of complications (7.3, 20 and 50%, respectively, P=.004) was demonstrated. The gastric bypass was associated with a higher complication rate than sleeve gastrectomy (P=.007). In multivariate analysis, OS-MRS scale and surgical technique were the only significant predictive factors.

Conclusions

The OS-MRS scale is a useful tool to predict the risk of complications and can be used as a guide when choosing the type of bariatric surgery.     

Circumferential margin plays an independent impact on the outcome of rectal cancer patients receiving curative total mesorectal excision

Background

The aim of this study was to determine the impact of the circumferential resection margin on the outcomes of patients with rectal cancer undergoing total mesorectal excision.

Methods

Medical records from July 2004 to June 2008 were prospectively reviewed, and 348 patients who underwent potentially curative surgery for rectal cancer were identified. The influence of the circumferential resection margin on local recurrence, distant metastasis, and 5-year cancer-specific survival was assessed.

Results

Of 348 patients, 13 (3.7%) had positive circumferential resection margins. During a median follow-up period of 58.0 months, 8 patients (2.3%) had local recurrence and 53 (15.2%) developed distant metastases. Local recurrence rates and distant metastasis rates in patients with positive circumferential resection margins were 15.4% and 61.5%, respectively, significantly higher than in those with negative circumferential resection margins (1.8% and 13.4%, respectively) (P < .001). The 5-year cancer-specific survival rates were 75.8% and 0% for patients with tumors having negative and positive circumferential resection margins, respectively (P < .001).

Conclusions

A circumferential resection margin of ≤1 mm adversely affects cancer-specific survival, local recurrence, and distant metastasis.     

Estudio de coste-beneficio comparando la reparación de la hernia ventral abierta y laparoscópica

Objective

Laparoscopic surgery is a successful treatment option offering significant advantages to patients compared with open ventral hernia repair. A cost-benefit analysis was performed to compare the clinical results and economic costs of the open and laparoscopic techniques for anterior abdominal wall hernia repair, in order to determine the more efficient procedure.

Material and methods

We performed a prospective study of 140 patients with primary and incisional hernia, and analyzed clinical data, morbidity, costs of surgery and hospital stay costs.

Results

The cost of disposable surgical supplies was higher with laparoscopic repair but reduced the average length of stay (P < .001) and patient morbidity (P < .001). The total cost of the laparoscopic procedure was, therefore, less than initially estimated, yielding a savings of 1,260 € per patient (2,865 € vs. 4,125 €).

Conclusions

Laparoscopic ventral hernia repair is associated with a reduced complication rate, a lower average length of stay and with lower total costs. Laparoscopic repair can save 1.260 € for each patient, and so this procedure should be considered a cost-effective approach.     

Pancreatitis aguda durante la gestación,experiencia de 7 años en un centro de tercer nivel

Introduction

Acute pancreatitis is a common cause of acute abdomen in pregnant women. The purpose of this study was to determine the frequency at our institution and its management and outcomes.

Methods

A retrospective analysis of a database of cases presented in 7 consecutive years at a tertiary center was performed.

Results

Between December 2002 and August 2009, there were 19 cases of acute pancreatitis in pregnant women, 85% with a biliary etiology. The highest frequency was in the third trimester of pregnancy (62.5% cases). In cases of gallstone pancreatitis, 43.6% of pregnant women had had previous episodes before pregnancy. A total of 52.6% of the patients were readmitted for a recurrent episode of pancreatitis during their pregnancy. Overall, 26.3% of the patients received antibiotic treatment and 26.3% parenteral nutrition. Laparoscopic cholecystectomy was performed during the 2nd trimester in two patients (10.5%). There was no significant maternal morbidity.

Conclusion

Acute pancreatitis in pregnant women usually has a benign course with proper treatment. In cases of biliary origin, it appears that a surgical approach is suitable during the second trimester of pregnancy.     

Tratamiento quirúrgico de la mediastinitis necrosante descendente

Introduction

Descending necrotizing mediastinitis (DNM) is a serious infection which occurs as a complication of oropharyngeal infection. Its surgical management and the routine transthoracic approach remain controversial. In this article we report our experience in the management of this disease, and review the different surgical approaches that have been reported in the medical literature.

Material and methods

A retrospective review was made of the clinical records of 29 patients treated between 1988 and 2009. Several demographic variables were analyzed, origin of the initial infection, stage of the disease according to Endo's classification, surgical technique and outcome.

Results

Surgical treatment consisted of both cervical and mediastinal drainage and radical debridement. The mediastinal drainage was made through a transcervical approach in 10 cases and transthoracic in 19, depending on the extent of the mediastinitis. The outcome was satisfactory in 24 patients and 5 died (mortality 17.2%).

Conclusions

According to our results and the conclusions of the main authors, we recommend a prompt and aggressive surgery with a transthoracic approach in cases of widespread DNM.     

Aprendizaje de la cirugía del cáncer de recto por laparoscopia sin aumento de la morbimortalidad

Introduction

The treatment of rectal cancer via laparoscopy is controversial due to its technical complexity. Several randomized prospective studies have demonstrated clear advantages for the patient with similar oncological results to those of open surgery, although during the learning of this surgical technique there may be an increase in complications and a worse prognosis.

Objective

Our aim is to analyze how the learning curve for rectal cancer via laparoscopy influences intra- and postoperative results and oncological markers. A retrospective review was conducted of the first 120 patients undergoing laparoscopic surgery for rectal neoplasia. The operations were performed by the same surgical team with a wide experience in the treatment of open colorectal cancer and qualified to perform advanced laparoscopic surgery. We analyzed sex, ASA, tumour location, neoadjuvant treatment, surgical technique, operating time, conversion, postoperative complications, length of hospital stay, number of lymph nodes, stage and involvement of margins.

Results

Significant differences were observed with regard to surgical time (224 min in the first group, 204 min in the second group), with a higher rate of conversion in the first group (22.5%) than in the second (11.3%). No significant differences were noted for rate of conservative sphincter surgery, length of hospital stay, post-surgical complications, number of affected/isolated lymph nodes or affected circumferential and distal margins.

Conclusions

It is possible to learn this complex surgical technique without compromising the patient's safety and oncological outcome.     

Cirugía radical en el cáncer de vesícula incidental: valor del hallazgo de enfermedad residual en el estudio histopatológico diferido

Background

Surgical treatment of gallbladder cancer is still controversial. The extent of the radical surgery and its therapeutic efficacy continue to be debated.

Objective

Analyze the efficacy of radical resection in patients with incidental gallbladder cancer evaluating the presence of residual disease in the resection specimen and analyzing the associated factors of survival.

Methods

A retrospective analysis of patients with incidental GC between June 1999 and June 2010 was performed. Incidental (I) tumors were included. Data covering demographic features, clinical characteristics, local pathological stage, histological features and factors for long term survival were analyzed. p< 0.05 were considered significant.

Results

A total of 28 patients: 78,6% females. Median age 56 years. All treated by resection of segments 4b/5 and lymphadenectomy. Histological examination revealed residual disease in 42% (37% liver), residual disease was related to tumoral (T) stage (p 0,001). Patients with residual disease presented a DSS and DFS of 10 and 6.5 months respectively vs 56 months in those without residual disease (p 0,001). Variables associated with survival were T stage (P .006), TNM stage (P<.001), and residual disease in the resected specimen (P<.001).

Conclusions

Aggressive re-resection of incidental GC offers the only chance for cure but its efficacy depends on the extent of the disease found at the time of repeated surgery and in the deferred pathological study.     

Seguridad de la colecistectomía laparoscópica temprana (<48 h) para pacientes con pancreatitis aguda biliar leve: revisión sistemática de la literatura y metaanálisis

Background

In mild gallstone pancreatitis, cholecystectomy decreases the risk of recurrence. This should be performed during the initial hospitalization, but even when this is performed, the hospital stay can be prolonged, with an increase in costs and morbidity.The aim of this study is to compare the complication rate between patients who underwent an early cholecystectomy (<48 hours) vs. a late one (>48 hours).

Materials and methods

A systematic search was performed in the following data bases: PubMed, EMBASE, LILACS and Scielo. Articles on patients with acute, mild gallstone pancreatitis who required a cholecystectomy during their initial hospitalization were included and compared with those undergoing a late cholecystectomy, in order to evaluate the complications, number of days of hospitalization and need for readmission. The quality of the studies and the risks of bias were evaluated.

Results

A total of 580 articles and summaries were identified which included 3 observational studies and a randomized clinical trial. A total of 636 patients who underwent a cholecystectomy during the initial hospitalization were included,. Ten of 207 (4.83%) in the early cholecystectomy group showed some type of complication, and 19 of 429 (4.42%) in the late cholecystectomy group, with a risk difference of -0.0016 IC 95% ([-0.04]-0.04).Three of the included studies should be considered of low quality and one of high quality. No publication bias was evidenced.

Conclusion

No differences in complication rate were found between patients who underwent an early cholecystectomy versus a late cholecystectomy; nevertheless, further studies should be carried out in order to confirm these findings.     

Implicaciones pronósticas del estudio estandarizado de los márgenes de resección en el cáncer de páncreas

Introduction

Involvement of surgical resection margins is a fundamental prognostic factor in pancreatic oncological surgery. However, there is a lack of standardized histopathology definition. The aims of this study are to investigate the real rate of R1 resections when surgical specimens are evaluated according to a standardized protocol and to study its survival implications.

Patients y methods

One hundred consecutive surgically resected patients with pancreatic ductal adenocarcinoma were included in the study. They were further divided in 2 groups: pre-protocol, evaluated before the introduction of the standardized protocol and post-protocol, analyzed with the standardized protocol.

Results

R0 resection rate in the pre-protocol group was 78%, falling to 47% after the introduction of the standardized protocol (p = 0,003). The posterior retroperitoneal margin was the most frequently involved margin. In cases with tumors located at the pancreatic head and analyzed according to the standardized protocol R1 involvement negatively affected survival. Median survival in the R0 group was 22 months versus 16 in those with the margin involved (HR: 2.044; IC 95% 1,00-4,16; P=.043).

Conclusions

Standardized evaluation of the retroperitoneal margins in pancreatic cancer increases the rate of R1 patients. In cases with pancreatic cancer located at the pancreatic head involvement of posterior retroperitoneal margin significantly decreases survival.