LAPAROSCOPIC CHOLECYSTECTOMY VERSUS MINILAPAROTOMY IN CHOLELITHIASIS: SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction

A introdução da técnica laparoscópica em 1985 foi um fator importante na colecistectomia por representar técnica menos invasiva, resultado estético melhor e menor risco cirúrgico comparado ao procedimento laparotômico.

Aim

To compare laparoscopic and minilaparotomy cholecystectomy in the treatment of cholelithiasis.

Methods

A systematic review of randomized clinical trials, which included studies from four databases (Medline, Embase, Cochrane and Lilacs) was performed. The keywords used were "Cholecystectomy", "Cholecystectomy, Laparoscopic" and "Laparotomy". The methodological quality of primary studies was assessed by the Grade system.

Results

Ten randomized controlled trials were included, totaling 2043 patients, 1020 in Laparoscopy group and 1023 in Minilaparotomy group. Laparoscopic cholecystectomy dispensed shorter length of hospital stay (p<0.00001) and return to work activities (p<0.00001) compared to minilaparotomy, and the minilaparotomy shorter operative time (p<0.00001) compared to laparoscopy. Laparoscopy decrease the risk of postoperative pain (NNT=7) and infectious complications (NNT=50). There was no statistical difference between the two groups regarding conversion (p=0,06) and surgical reinterventions (p=0,27), gall bladder''s perforation (p=0,98), incidence of common bile duct injury (p=1.00), surgical site infection (p=0,52) and paralytic ileus (p=0,22).

Conclusion

In cholelithiasis, laparoscopic cholecystectomy is associated with a lower incidence of postoperative pain and infectious complications, as well as shorter length of hospital stay and time to return to work activities compared to minilaparotomy cholecystectomy.     

HARTMANN PROCEDURE OR RESECTION WITH PRIMARY ANASTOMOSIS FOR TREATMENT OF PERFORATED DIVERTICULITIS? SYSTEMATIC REVIEW AND META-ANALYSIS

​ Open in a separate windowMortality after emergency surgery in randomized controlled trials     

STEP-BY-STEP ESOPHAGOJEJUNAL ANASTOMOSIS AFTER INTRA-CORPOREAL TOTAL GASTRECTOMY FOR LAPAROSCOPIC GASTRIC CANCER TREATMENT: TECHNIQUE OF "REVERSE ANVIL"

Background

The laparoscopic gastrectomy is a relatively new procedure due mainly to the difficulties related to lymphadenectomy and reconstruction. Until the moment, technique or device to perform the esophagojejunal anastomosis by laparoscopy is still a challenge. So, a safe, cheap and quickly performing technique is desirable to be developed.

Aim

To present technique proposed by the authors with its technical details on reconstruction with "reverse anvil".

Method

After total gastrectomy completed intra-corporeally, the reconstruction starts with the preparation of the intra-abdominal esophagus cross-section next to the esophagogastric transition of 50%. A graduated device is prepared using Levine gastric tubes (nº. 14 and 10), 3 cm length, connected to the anvil of the circular stapler (nº. 25) with a wire thread (2-0 or 3-0) of 10 cm, which is connected to end of this device. The whole device is introduced in reverse esophagus. The esophagus is amputated and the wire is pulled after previous transfixation in the distal esophagus and the anvil positioned. The jejunal loop is sectioned 20-30 cm from duodenojejunal angle, and the anvil put in the jejunal loop and connect previously in the esophagus. Linear stapler (blue 60 mm) is used to close the opening of the jejunal loop.

Conclusion

The "reverse anvil" technique used by the authors facilitated the transit reestablishment after total gastrectomy, contributing to obviate reconstruction problems after total gastrectomy.     

直肠癌低位吻合术后肛门功能评价

对95例直肠癌低位吻合术后肛门功能进行评定．结果显示肛门功能优良者76例(80%)肛门功能和吻合口平面有关。并讨论以肛门控耐力、便意、感觉，排便次数、排便时间等来评价肛门功能。     

神经干端侧吻合后侧支发芽能力的实验研究

为观测神经干在端侧吻合后的侧支发芽能力，分别在供体神经上作外膜开窗，检查其侧支发芽情况，并与端端吻合作比较。实验用１６只成年ＳＤ大白鼠，将其随机分为４个组。１组，腓神经切断后在胫神经外膜上开窗，然后将两者作端侧吻合。２组，手术步骤同１组，但不作胫神经外膜开窗。３组，胫神经不开窗，离断的腓神经与胫神经平行缝合。４组，腓神经切断后立即行端端吻合。术后３个月，所有动物分别测定腓神经功能指数（ＰＦＩ），乙酰胆碱转移酶（ＣｈＡＴ）活性，并作组织学检查。结果显示，第１组与第２组的ＰＦＩ，ＣｈＡＴ活性无明显差异（Ｐ＞０．０５）。组织学检查证实，侧支发芽纤维的存在，即使在第３组，也可见到大量的神经纤维，侧支发芽的纤维为小的有髓纤维。但１组的ＣｈＡＴ活性仅是第４组的２／３。结果提示，外膜鞘在远期对神经的侧支发芽能力几乎没有影响。神经侧支发芽能力比我们通常想象的要强，但在临床应用以前尚需作进一步研究。     

EFFECT OF OMEGA-3 FATTY ACID IN THE HEALING PROCESS OF COLONIC ANASTOMOSIS IN RATS

Background :

The use of long-chain polyunsaturated fatty acids has been studied in the context of healing and tissue regeneration mainly due to its anti-inflammatory, immunoregulatory and antioncogenic properties. Previous studies have demonstrated beneficial effects with the use of enteral immunonutrition containing various farmaconutrients such as L-arginine, omega-3, trace elements, but the individual action of each component in the healing of colonic anastomosis remains unclear.

Aim :

To evaluate the influence of preoperative supplementation with omega-3 fatty acids on the healing of colonic anastomoses of well-nourished rats.

Methods :

Forty Wistar adult male rats, weighing 234.4±22.3 g were used. The animals were divided into two groups: the control group received for seven days olive oil rich in omega-9 oil through an orogastric tube, while the study group received isocaloric and isovolumetric omega-3 emulsion at a dose of 100 mg/kg/day, also for seven days. Both groups were submitted to two colotomies followed by anastomosis, in the right and left colon, respectively. Parameters evaluated included changes in body weight, anastomotic complications and mortality, as well as maximum tensile strength by using a tensiometer and collagen densitometry at the anastomotic site.

Results :

There were no differences in body weight or mortality and morbidity between groups. The value of the maximum tensile strength of the control group was 1.9±0.3 N and the study group 1.7±0.2, p=0.357. There was, however, a larger amount of type I collagen deposition in the study group (p=0.0126). The collagen maturation índex was 1.74±0.71 in the control group and 1.67±0.5 in the study group; p=0,719).

Conclusions :

Preoperative supplementation of omega-3 fatty acid in rats is associated with increased collagen deposition of type I fibers in colonic anastomoses on the 5^th postoperative day. No differences were observed in the tensile strength or collagen maturation index.     

RESECTION AND ANASTOMOSIS OF OBSTRUCTED LEFT COLONIC CANCER: PRIMARY OR STAGED?

A retrospective analysis of the treatment of 70 patients with obstructed left colonic cancer was undertaken in order to assess whether staged or primary resection was more appropriate. Thirty-four patients had initial colostomy and staged resection (group 1) while 36 patients were treated by primary resection and immediate anastomosis following intra-operative bowel washout (group 2). There were seven deaths (10%), five in group 1 and two in group 2. The wound infection rate and average hospital stay were 44% and 36 days in group l and 19.4% and 16.5 days in group 2, respectively. Twenty per cent of patients in group 1 did not complete their staged procedures and had to live with their colostomies. The smoother postoperative recovery and shorter hospital stay was particularly significant in group 2 patients. As primary resection and anastomosis can now be performed with relative safety and reduced morbidity, we conclude that staged procedures can no longer be accepted as standard treatment for left colonic obstruction.     

小肝癌射频消融术与手术切除术疗效的Meta分析

目的 比较小肝癌射频消融术(radiofrequency ablation,RFA)与手术切除术的临床疗效.方法 通过计算机检索Pubmed数据库、万方数据库、中国全文期刊数据库和维普数据库,并结合文献追溯、网上查询(www.baidu.com;www.google.com)的方法,收集关于RFA与手术切除术治疗小肝癌...     

NAUSEA AND VOMITING AFTER GYNAECOLOGICAL SURGERY: A META-ANALYSIS OF FACTORS AFFECTING THEIR INCIDENCE

A total of 1442 patients who had major gynaecological surgerywere recruited into three multi-centre studies using a standardgeneral anaesthetic technique in order to assess the efficacyof various doses of orally administered ondansetron in the preventionof postoperative nausea and vomiting. A total of 1257 patientswere included in this analysis: 420 received oral formulationsof placebo and 212, 296 and 329 received ondansetron 1, 8 and16 mg, respectively. The following factors were measured inthese studies and were considered to have a possible influenceon the proportion of patients experiencing postoperative nauseaand vomiting: age of patient; volatile anaesthetic; intraoperativedose of fentanyl; postoperative dose of morphine; country; anaesthesiaduration; neuromuscular blocker; neuromuscular block antagonist;pre-medicant; recovery time , type of surgery; antiemetic treatment;body weight. Using a process of elimination based on logisticregression techniques, the factors found to be the most importantinfluences on the frequencies of nausea and vomiting were antiemetictreatment, type of surgery, neuromuscular blocker, country,volatile anaesthetic and age. A statistically significant interactionbetween type of surgery and age was observed. Adjusted probabilitiesof nausea and vomiting were obtained from the model, includingall the above factors, together with the type of surgery byage interaction. Ondansetron 8 mg showed the smallest adjustedprobability of nausea (0.54) and vomiting (0.34) and placebothe greatest (nausea 0.75, vomiting 0.61). A similar patternof adjusted probabilities over neuromuscular blocking agentswas seen for nausea and vomiting, with the greatest occurringin patients receiving pancuronium (nausea 0.74, vomiting 0.57)and the least in patients receiving alcuronium (nausea 0.59,vomiting 0.38). For country effects, the United Kingdom exhibitedthe greatest adjusted probability of nausea (0.75) and vomiting(0.54) and Germany the smallest (nausea 0.49, vomiting 0.34).Adjusted probabilities of nausea and vomiting were similar forenflurane and isoflurane. With increasing age, the adjustedprobabilities of postoperative nausea and vomiting appearedto increase for patients having abdominal hysterectomy and laparotomy.This pattern was not repeated in patients having vaginal hysterectomy.(Br. J. Anaesth. 1993; 71: 517–522)      

肠切除并Ⅰ期肠吻合术治疗急性左半结肠完全性梗阻48例临床分析

本文对1990年1月至1997年7月收治的急性左半结肠完全性梗阻患者48例施行肠切除并Ⅰ期肠吻合术。手术效果较好，仅3例发生肠瘘、4例伤口感染、2例死亡，平均住院天数为13.5天，比传统的分期手术缩短7-10天，Ⅰ期愈合率为81.25%。作者认为，肠切除并Ⅰ期肠吻合术值得临床应用和推广。     

MORBIDITY AND MORTALITY AFTER SINGLE- AND DOUBLE-STAPLED COLORECTAL ANASTOMOSES IN PATIENTS WITH CARCINOMA OF THE RECTUM

Background : The optimal method of restoring intestinal continuity after rectal resection has been controversial. This study aims to compare the morbidity, mortality and survival of patients having either single-stapled (SS) or double-stapled (DS) colorectal anastomoses following resection of the rectum for cancer. Methods : Peri-operative and long-term follow-up data were prospectively documented in all patients undergoing rectal resection for carcinoma with a stapled anastomosis at our institution over a 14-year period. Patients were stratified by anastomotic technique (SS or DS). Peri-operative mortality, complications potentially related to anastomotic technique and cancer-related outcome were compared. Results : Two hundred and thirty-five patients had SS and 65 patients had DS anastomoses. The groups were well matched for age, sex, and tumour stage. Double-stapled anastomoses were used more frequently in the distal third of the rectum (P < 0.001). The distal margin of resection was not influenced by anastomotic technique. Major anastomotic leakage in 2.9% of SS cases was not significantly different from 6.1% of DS cases, and leakage was not influenced by anastomotic technique at any given level of the rectum. Two-year local recurrence rates were not significantly different between groups (SS 3.5%: DS 5.9%). Conclusions : These results suggest that the double-stapling technique is as safe as the single-stapling technique for constructing an anastomosis after excision of the rectum for cancer, in terms of the risk of leakage, the development of an anastomotic stricture. or local recurrence.     

LIVER TRANSPLANTATION AFTER SEVERE HEPATIC TRAUMA: CURRENT INDICATIONS AND RESULTS

Background :

The liver is the most injured organ in abdominal trauma. Currently, the treatment in most cases is non-operative, but surgery may be necessary in severe abdominal trauma with blunt liver damage, especially those that cause uncontrollable bleeding. Despite the damage control approaches in order to achieve hemodynamic stability, many patients develop hypovolemic shock, acute liver failure, multiple organ failure and death. In this context, liver transplantation appears as the lifesaving last resource

Aim :

Analyze the use of liver transplantation as a treatment option for severe liver trauma.

Methods :

Were reviewed 14 articles in the PubMed, Medline and Lilacs databases, selected between 2008-2014 and 10 for this study.

Results :

Were identified 46 cases undergoing liver transplant after liver trauma; the main trauma mechanism was closed/blunt abdominal trauma in 83%, and severe trauma (>grade IV) in 81 %. The transplant can be done, in this context, performing one-stage procedure (damaged organ removed with immediate transplantation), used in 72% of cases. When the two-stage approach is performed, end-to-side temporary portacaval shunt is provided, until new organ becomes available to be transplanted. If two different periods are considered - from 1980 to 2000 and from 2000 to 2014 - the survival rate increased significantly, from 48% to 76%, while the mortality decreased from 52% to 24%.

Conclusion :

Despite with quite restricted indications, liver transplantation in hepatic injury is a therapeutic modality viable and feasible today, and can be used in cases when other therapeutic modalities in short and long term, do not provide the patient survival chances.     

IN‐HOSPITAL MORTALITY AND ASSOCIATED COMPLICATIONS AFTER BOWEL SURGERY IN VICTORIAN PUBLIC HOSPITALS

Background : The purpose of the present paper was to determine the mortality rate and associated complications after large bowel resection and anastomosis in Victorian public hospitals. Methods : A retrospective analysis of data from the Victorian Inpatient Minimum Database (VIMD) was undertaken. The data were collected from all Victorian public hospitals performing hemicolectomy and anterior resection (resection of the rectum with anastomosis) from 1987/88 to 1995/96. Results : A total of 11 036 patients underwent hemicolectomy or anterior resection in the time period studied, there being a 7% increase in the rate of operations performed over the 9 years. Two‐thirds of these operations were for carcinoma of the large bowel. The anastomotic leak rate of 4.5% fell slightly but the in‐hospital mortality rate of 6.5% did not change over the study period. The total morbidity recorded (mainly major complications) was 24.6%. The patients most at risk of death were the elderly with pre‐existing cardiac or respiratory disease undergoing an emergency operation. Conclusions : Notwithstanding some inaccuracies of coding and reporting, the morbidity and mortality for surgery of the large intestine remains high, largely due to the comorbidities of the patients, although certain technical complications such as leakage of an anastomosis after anterior resection are still associated with a significantly increased risk of death. Consideration should be given to the routine use of high‐dependency nursing units for these high‐risk patients after major colorectal surgery, and support from physicians to reduce morbidity and mortality from associated medical conditions worsened by surgery.     

RESTORATIVE PROCTOCOLECTOMY WITH ILEAL POUCH–ANAL ANASTOMOSIS IN 203 PATIENTS: THE AUCKLAND EXPERIENCE

Background : Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become an established operation for patients with ulcerative colitis and familial adenomatous polyposis (FAP). The results of a 15-year experience with IPAA are reported. Methods : Between September 1982 and June 1997, 203 patients had IPAA surgery. From a review of the charts, data were collected on the surgical procedure, the diagnosis and early and late complications. Pouch function was assessed by means of a postal questionnaire. Results : Of the 201 patients (median age of 32 years; 89 women) with complete records, 122 had J pouches, 65 had W pouches and 14 S pouches were constructed. The pre-operative diagnosis in 88% was ulcerative colitis and in 10% it was FAP. During a median follow-up time of 6.1 years the diagnoses were changed for 8% of the patients; in 4% the diagnosis was changed to Crohn’s disease. The overall mortality was 1.5% (early = 2, late = 1) The overall morbidity was 62% (early = 17%, late = 52%). The pouch was removed or was non-functional in 9%. All patients with a final diagnosis of Crohn’s disease have had their pouch excised. The median stool frequency was 4.0 (range 1.3–8.7) during the day, and 0.7 (range 0–2.1) during the night. The fewer night-time stools (J = 1.0 ± 0.6; W = 0.4 ± 0.5 P < 0.0001) and the reduced requirement of the W-pouch patients for anti-diarrhoeals (P = 0.004) were offset by the need for two W-pouch patients to pass a catheter to empty their pouches. Conclusions : The type of patients who present for IPAA surgery and the outcomes observed in this series of Auckland patients are similar to those reported from major centres elsewhere.     

Impact of minimally invasive surgery in the treatment of esophageal cancer

Background

Surgical treatment of esophageal cancer is associated to a high morbidity and mortality rate. The open transthoracic or transhiatal esophagectomy are considerably invasive procedures and have been associated to high rates of complications and operative mortality. In this way, minimally invasive esophageal surgery has been suggested as an alternative to the classic procedures because would produce improvement in clinical longterm postoperative outcomes.

Aim

To assess survival, mortality and morbidity results of esophagectomy due to esophageal cancer submitted to minimally invasive techniques and compare them to results published in international literature.

Method

An observational, prospective study. Between 2003 and 2012, 69 patients were submitted to a minimally invasive esophagectomy due to cancer. It was recorded postoperative morbidity and mortality according to the Clavien-Dindo classification. The survival rate was analyzed with the Kaplan-Meier method. The number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique, was analysed.

Results

63.7% of patients had minor complications (type I-II Clavien Dindo), while nine (13%) required surgical re-exploration. The most common postoperative complication corresponded to leak of the cervical anastomosis seen in 44 (63.7%) patients but without clinical repercusion, only two of them required reoperation. The mortality rate was 4.34%, and reoperation was necessary in nine (13%) cases. The average survival time was 22.59±25.38 months, with the probability of a 3-year survival rate estimated at 30%. The number of resected lymph nodes was 17.17±9.62.

Conclusion

Minimally invasive techniques have lower morbidity and mortality rate, very satisfactory lymphnodes resection and similar long term outcomes in term of quality of life and survival compared to results observed after open surgery.     

HERNIOPLASTY WITH AND WITHOUT MESH: ANALYSIS OF THE IMMEDIATE COMPLICATIONS IN A RANDOMIZED CONTROLLED CLINICAL TRIAL

Background:

Inguinal hernia repair is the most common procedure in general surgery and 80,000 operations are performed annually in Great Britain, 100,000 in France and 700,000 in the US. Given its high frequency has a major impact, both in the medical and economic aspects.

Aim:

Analyze the immediate postoperative complications comparing mesh versus non mesh hernioplasty.

Method:

Randomized control trial, with the enrollment of 263 patients underwent surgery for inguinal hernia randomized by randomization table. Treatment (mesh, Lichtenstein or without mesh, Bassini technique) was assigned using sequentially numbered opaque envelopes having fulfilled the inclusion criteria. The variables analyzed were: postoperative pain, seroma, hematoma, infection, return to normal activities and recurrence.

Results:

The mean age was 55.5 years, 88% patients were male and 12% female. The pain was higher in patients operated with mesh.

Conclusions:

The inguinal hernia repair mesh group had less immediate postoperative complications and significantly earlier return to work than hernioplasty without mesh, this being one of the most important conclusions.     

Sternal wound tuberculosis following cardiac operations: a review

Objective

The diagnosis and treatment of sternal wound infections with mycobacteria are challenging. Such an infection is often associated with a delayed diagnosis and improper treatment that may lead to a worsened clinical outcome. The present study is designed to highlight its clinical features so as to facilitate a prompt diagnosis and timely treatment.

Methods

MEDLINE, Highwire Press, and Google search engine were searched for publications in the English language, with no time limit, reporting on sternal wound infection caused by tuberculosis after cardiac surgery.

Results

A total of 12 articles reporting on 14 patients were included in this study. Coronary artery bypass grafting was the underlying surgical procedure in more than half of the cases. Purulent discharge and cold abscess were the two main presenting symptoms. Diagnosis of sternal wound infection was evidenced in all 14 patients by different investigations, with culture of samples being the most sensitive method of identifying the pathogen. Good response to first-line anti-tuberculous agents was noted. Almost all patients required surgical debridement/resection and, sometimes, sternal reconstruction. A delayed diagnosis of sternal wound infection may lead to repeated recurrences. A comparison between patients with sternal wound infection due to tuberculosis and non-tuberculous mycobacterial infections showed that the former infections took an even longer period of time. Comparisons also revealed patients with sternal tuberculosis infection had a significantly higher mortality than patients with sternal non-tuberculous infection (29.2% vs. 0%, P=0.051).

Conclusion

Sternal infection caused by tuberculosis after cardiac surgery has a longer latency, better response to first-line drugs, and better outcomes in comparison with non-tuberculous sternal infection. Early diagnosis and early anti-tuberculous treatment can surely improve the patients'' prognosis.