Estudio prospectivo, aleatorizado: cirugía laparoscópica con asistencia robótica versus cirugía laparoscópica convencional en la resección del cáncer colorrectal

Introduction

Robotic-assisted surgery is playing an increasingly important role in the last few years in the treatment of colorectal oncological disease. However, there are still no studies that objectively demonstrate the advantages of this type of surgery.We present a prospective randomised study in order to compare the short-term results between colorectal robotic surgery and laparoscopic surgery.

Material and method

A total of 56 patients diagnosed with colorectal cancer between January 2008 and January 2009, were randomised and assigned to the robotic or laparoscopic group. Age, body mass index, tumour location, conversions in each group, complications during and after surgery, and histological characteristics of the specimens obtained, were all compared.

Results

There were no significant differences between age (P=.055), body mass index (P=.12), or tumour location (P=.91). Only one patient in the robotic group required a transfusion and none in the laparoscopic group. The percentage of conversions was the same in both groups, however, the preparation times and operating times were significantly longer in patients intervened using the robotic device (P=.0001 and P=.017, respectively). There were no differences as regards the rate of complications or in the percentage of re-interventions (14.2% and 7.1%). The mean hospital stay of the patients was 9.3 (8.1) days in the robotic group and 9.2 (6.8) days in the laparoscopic (P=.79). The distal resection margin was greater in the specimen obtained using robotic surgery (P =.003) as well as the number of lymph nodes obtained in the specimen (P =.23).

Conclusion

Robotic colorectal was performed safely and effectively, and with similar clinical results.International Trial Number for this study is: ISRCTN60866560.     

Derivación biliopancreática laparoscópica: técnica quirúrgica en nuestra curva de aprendizaje

Background

We present our initial experience with the laparoscopic BPD technique for super-obese patients. Recommended tips on the technique are summarized.

Methods

A total of 35 super-obese patients were submitted to BPD by laparoscopy in November 2009 and June 2010 for the treatment of morbid obesity.

Results

All operations were performed by laparoscopy with no need to convert to laparotomy. No mayor complications and mortality related to surgery were observed.

Conclusion

The Scopinaro technique can be safely performed in super-obese patients by surgeons with special dedication for bariatric surgery and advanced skills in intracorporeal suturing and knot-tying.     

Estudio comparativo, prospectivo y no aleatorizado de la colecistectomía endoscópica transvaginal frente a la colecistectomía laparoscópica transparietal

Introduction

We present a non-randomised comparative study of two patients series followed up prospectively, in which convention laparoscopic cholecystectomy is compared with transvaginal cholecystectomy, a hybrid transluminal endoscopic procedure, with the objective of assessing the clinical safety of the procedures and its efficacy in the resolution of cholelithiasis.

Patients and method

A non-randomised prospective clinical series of 40 female patients, operated on for cholelithiasis using endoscopic surgery, 20 with a conventional laparoscopic approach and 20 using a transvaginal endoscopic approach. Surgical wound infection, urinary infection, evisceration, eventration, mortality and other complications.

Results

Scheduled operations were performed on the 40 patients as indicated. There were no complications during the operations. There was no mortality associated with the procedures and there was only one post-surgical complication, a urinary tract infection in one patient operated on by the transvaginal approach. The mean follow up was the same in both groups (9 months). The mean hospital stay was less than 0.8 days in both groups. The duration of the surgery was longer in the transvaginal approach group, with a mean of 69.5 min, compared to 46.2 min in the laparoscopy group.

Conclusions

Although the cosmetic benefit is obvious, no differences were found as regards parietal problems in this series. The duration of the transvaginal surgery is higher than that of the transparietal, but the times of both are acceptable. In this study, the non-inferiority in the safety and efficacy of the transvaginal approach is able to be assessed.     

25 años de cirugía laparoscópica en España

Introduction

The introduction of laparoscopic surgery (LS) can be considered the most important advancement in our specialty in the past 25 years. Despite its advantages, implementation and consolidation has not been homogenous, especially for advanced techniques. The aim of this study was to analyse the level of development and use of laparoscopic surgery in Spain at the present time and its evolution in recent years.

Material and methods

During the second half of 2012 a survey was developed to evaluate different aspects of the implementation and development of LS in our country. The survey was performed using an electronic questionnaire.

Results

The global response rate was 16% and 103 heads of Department answered the survey. A total of 92% worked in the public system. A total of 99% perform basic laparoscopic surgery and 85,2% advanced LS. Most of the responders (79%) consider that the instruments they have available for LS are adequate and 71% consider that LS is in the right stage of development in their environment.

Conclusions

Basic laparoscopic surgery has developed in our country to be considered the standard performed by most surgeons, and forms part of the basic surgical training of residents. With regards to advanced LS, although it is frequently used, there are still remaining areas of deficit, and therefore, opportunities for improvement.     

Invaginación intestinal en el adulto: presentación de un caso y revisión de la literatura médica española

Introduction

Intestinal invagination in the adult is an uncommon condition, often manifested by non-specific chronic or sub-acute symptoms. In the majority of occasions there is an organic lesion. There are currently no large patient series published in the literature to help define the management of these patients.

Material and method

A review of case series published in the Spanish literature. A data base of patients over 15 years old was designed. Data was extracted from national clinical cases using Internet resources. Our own recent clinical case is added.

Results

A series of 30 adults with intestinal invagination was obtained (29 cases from the review and one own). The median age was 45 years (19–84 years) and 17/30 (57%) were males. A total of 27/30 patients had abdominal pain and 8/30 (28%) cases had established intestinal obstruction. The preoperative diagnosis of invagination was made in 25/30 (83%) of patients. The invaginations were; enteroenteric, 61%; colocolic, 12%; enterocolic, 21%; and gastrojejunal, 6%. A total of 85% of the invaginations were associated with a proliferative lesion and 43% of the latter were malignant.

Conclusions

The diagnosis of invagination in the adult is usually made preoperatively. There are no data to support intestinal resection without performing a reduction. Resection must be the norm and the presence of lymph nodes is no argument to perform large resections.     

Colecistectomía laparoscópica en pacientes mayores de 80 años

Introduction

The increasing aging of the population also increases the prevalence of symptomatic gallbladder diseases. It is important to analyse their surgical treatment in the elderly.

Methods

All the laparoscopic cholecystectomies performed in our surgery department on patients aged 80 years-old or over from 1992 to 2007 were included in this study.

Results

Laparoscopic cholecystectomy was performed on 133 patients 80 years-old and over, with 63% of them women, and an average age of 83.23 years. Biliary colic (29%) and acute pancreatitis (44%) were the main reasons for surgery. Associated diseases were found in 73% of them. Only 7.5% needed urgent surgery, even although 71% were admitted urgently. There were 13.5% conversions to open surgery, 17% morbidity and 2.3% mortality.

Conclusions

Laparoscopic cholecystectomy can be recommended in symptomatic gallbladder disease in the elderly.     

Anemia, hierro, transfusión y alternativas terapéuticas. Revisión desde una perspectiva quirúrgica

Anemia is very common entity or comorbidity in surgical patients. Its management involves a multidisciplinary approach with the aim of optimizing the available therapeutic resources with individualized care for each clinical situation. Rational use of blood transfusions, iron therapy (oral and intravenous), erythropoiesis stimulating agents and other therapeutic alternatives by physicians must achieve maximal benefit with minimal complications for our patients. This review article summarizes the main characteristics of anemia, iron metabolism, erythropoiesis and therapeutic alternatives from a surgical perspective in the light of present knowledge.     

Gastroplastia tubular plicada, una nueva técnica para el tratamiento de la obesidad mórbida

Introduction

Laparoscopic Gastric Plication is a new technique derived from sleeve gastrectomy. Plication of the greater curvature produces a restrictive mechanism that causes weight loss. The results of the first cases where this technique has been applied in this hospital are presented.

Methods

A review was made of patients operated on in our hospital between November 2009 and December 2010. Plication of the gastric greater curvature was performed under general anaesthetic and by laparoscopy using 3 lines of sutures and with an orogastric probe as a guide. The results of the morbidity, mortality and weight loss are presented.

Results

A total of 13 patients were operated on (7 women). The maximum body mass index (BMI) varied between 37.11 kg/m² and 51.22 kg/m² at the time of the operation. The most frequently found morbidity was nausea and vomiting. Two patients required further surgery due intractable vomiting and total dysphagia; in one the plication unfolded, and in the second it was converted into vertical gastrectomy.

Conclusions

Laparoscopic Gastric Plication is a new surgical technique which gives equivalent short-term results as vertical gastrectomy. It is a reproducible and reversible technique with results and indications still to be validated.     

Estudio comparativo prospectivo aleatorizado entre apendicectomía laparoscópica por puerto único y apendicectomía laparoscópica convencional

Introduction

Laparoscopic appendectomy is probably the technique of choice in acute appendicitis. Single port laparoscopic surgery (SILS) has been proposed as an alternative technique. The objective of this study is to compare the safety and efficacy of SILS against conventional laparoscopic appendectomy (LA).

Material and methods

From January 2011 to September 2012, 120 patients with acute appendicitis were prospectively randomized; 60 for SILS and 60 for LA. Patients between 15 to 65 years were selected, with onset of symptoms less than 48 h. We compared BMI, surgery time, start of oral intake, hospital stay, postoperative pain, pathology and costs.

Results

The median age, BMI, sex and time of onset of symptoms to diagnosis were similar. There were no statistically significant differences in the operative time, start of oral intake or hospital stay. There was a significant difference in postoperative pain being higher in SILS (4 ± 1.3) than in LA (3.3 ± 0.5) with a P=.004. Flemonous appendicitis predominated in both groups in a similar percentage. A total of 3 cases with intra-abdominal abscess (SILS 2, LA 1) required readmission and resolved spontaneously with intravenous antibiotic treatment. One case of SILS required assistance by a 5 mm trocar in the RLC for drainage placement. The cost was higher in SILS due the single port device.

Conclusion

SILS appendectomy is safe, effective and has similar results to LA in selected patients, and although the cost is greater, the long term results will determine the future of this technique.     

Neoplasia intraepitelial anal: resultados de la aplicación de un protocolo diagnóstico en pacientes de riesgo mediante el uso de citología anal

Introduction

Anal intraepithelial neoplasia is a precursor condition of squamous anal carcinoma. The groups at risk of this lesion are patients with anogenital condylomata, cervical dysplasia, human immunodeficiency virus infection and, in general, patients with HPV infection. The aim of this study was to analyse the results of a diagnostics protocol of Anal Intraepithelial Neoplasia in high risk population using anal cytology.

Patients and method

The protocol is based on a visit in the outpatient department, clinical interview, physical examination and anal cytology evaluated by Bethesda criteria. The cross-sectional observational study was designed to study the anal smear results and their relationship with risk factors.

Results

A total of 64 patients were included from January 2005 to December 2006. In the overall series, 25 patients have been diagnosed with abnormal anal cytology: 9 atypical squamous cells of undetermined significance (ASCUS), 15 low-grade and 1 high-grade squamous intraepithelial lesions. There were no significant associations between abnormal cytology results and the presence of anal condyloma (p=0.22). Neither were there statistical associations found with high risk-HPV infection (p=0.84), HIV infection (p=0.98) or tobacco use (p=0.14).

Conclusions

Our diagnostic protocol of anal intraepithelial neoplasia revealed 25% of patients with pre-invasive lesions of squamous anal cancer.     

El abordaje multidisciplinar es útil para la optimización de la hemoglobina preoperatoria en cirugía neoplásica colorrectal

Introduction

Optimising haemoglobin (Hb) levels less than 13 g/dl in the preoperative period can reduce the transfusion rate. With this aim, we developed a multidisciplinary protocol in our hospital for the treatment of patients proposed for colorectal cancer surgery.

Patients and method

A study was conducted on 437 patients who had surgery performed for colorectal cancer in the period 2005-2009. The data recorded were: demographic data, Hb and iron metabolism (Fe) at the time of diagnosis, Hb on the day of the surgery and on discharge, tumour location, preoperative adjuvant treatment (chemotherapy and/or radiotherapy), tumour stage (TNM), iron treatment, transfusion rate, and complications at 30 days. Patients were classified into Group A; Hb < 13 g/dl and/or abnormal Fe metabolism, and Group B; Hb > 13 g/dl and/or normal Fe metabolism.

Results

Of the total, 53.3% were in Group B and were treated with Fe; 73.6% intravenous (IV), and the rest oral. The mean dose of IV Fe was 867 mg. The mean intraindividual difference between the Hb on the day of surgery and at the initial value, increased by 0.6 g/dl in Group A, while it decreased by 0.8 g/dl in Group B. The mean intraindividual difference between the Hb at discharge and the diagnosis decreased by 0.4 g/dl in Group A compared to 2.5 g/dl in Group B. The overall transfusion rate was 8.6%. No statistically significant differences were observed in complications.

Conclusions

A multidisciplinary and early treatment of colorectal cancer enables patients with a low haemoglobin (Group A) to be optimised, as well as achieving a lower transfusion rate.     

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.     

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.