Factores predictivos de infección de herida en cirugía colorrectal. Estudio observacional multicéntrico de casos y controles

Introduction

The aim of this study is to evaluate the usefulness of Vicryl Plus^® suture in reducing the rate of postoperative wound infection in elective colorectal surgery.

Methods

A prospective case-control multicenter study with 480 patients undergoing elective colorectal surgery was performed between 2006 and 2007. Patients were divided in 2 groups of equal sample size: group 1, closure of the abdominal wall using Vicryl Plus^® and group 2 where PDS II^® was used. The study involved 5 hospitals in the Spanish State. Wound infection was classified into superficial and deep. All patients diagnosed of wound infection during the hospital stay and up to 30 days after discharge were studied. For the statistical analysis Chi-square test and Fisher exact were used for bivariate analysis and logistic regression model for multivariate analysis.

Results

Wound infection rates were significantly lower in group 1: 14.6 vs. 29.2. Multivariate analysis showed that risk of wound infection was higher in patients with cancer, lung disease, anemia, operative time greater than 2 h, lack of second dose intra-operative prophylactic antibiotic and laparotomy closure with PDS suture II^®.

Conclusions

The use of suture coated with triclosan can be an effective prophylactic tool in reducing wound infection rate in patients undergoing elective colorectal surgery.     

Hepatocarcinoma in noncirrhotic liver

Hepatocellular carcinoma (HCC) usually develops in patients with liver cirrhosis or chronic liver disease. These tumors are highly infrequent in patients without precipitating factors. We present a series of four patients with nonfibrolamellar HCC arising in healthy liver. None of the patients had viral infection, or showed alcohol abuse and/or hemochromatosis. Three patients underwent surgery. The clinical characteristics, therapeutic options, and survival and recurrence rates in this type of tumor are discussed.     

Benign solid liver tumors

Benign solid liver tumors are a heterogeneous group of lesions (adenoma, focal nodular hyperplasia, hemangioma, etc.) with highly varied epidemiological characteristics. Advances in diagnostic methods have improved preoperative diagnosis. Magnetic resonance imaging has become the key test, but there is still a percentage of cases in which definitive preoperative diagnosis is not feasible. The most frequent symptom is abdominal pain, although patients are frequently asymptomatic. Surgery is indicated when diagnosis is uncertain or there are complications (rupture, hemorrhage, etc.). Because of the risk of malignant transformation, adenomas should always be resected. Morbidity and mortality after resection of these tumors is very low since excision is limited, performed in young people without concomitant disease, and in healthy liver.     

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.     

Impacto de un programa de rehabilitación multimodal en cirugía electiva colorrectal sobre los costes hospitalarios

Introduction

Multimodal rehabilitation (MMRH) programs in surgery have proven to be beneficial in functional recovery of patients. The aim of this study is to evaluate the impact of a MMRH program on hospital costs.

Method

A comparative study of 2 consecutive cohorts of patients undergoing elective colorectal surgery has been designed. In the first cohort, we analyzed 134 patients that received conventional perioperative care (control group). The second cohort included 231 patients treated with a multimodal rehabilitation protocol (fast-track group). Compliance with the protocol and functional recovery after fast-track surgery were analyzed. We compared postoperative complications, length of stay and readmission rates in both groups. The cost analysis was performed according to the system «full-costing».

Results

There were no differences in clinical features, type of surgical excision and surgical approach. No differences in overall morbidity and mortality rates were found. The mean length of hospital stay was 3 days shorter in the fast-track group. There were no differences in the 30-day readmission rates. The total cost per patient was significantly lower in the fast-track group (fast-track: 8.107 ± 4.117 euros vs. control: 9.019 ± 4.667 Euros; P=.02). The main factor contributing to the cost reduction was a decrease in hospitalization unit costs.

Conclusion

The application of a multimodal rehabilitation protocol after elective colorectal surgery decreases not only the length of hospital stay but also the hospitalization costs without increasing postoperative morbidity or the percentage of readmissions.     

La influencia del tipo de abordaje torácico sobre el desarrollo de complicaciones respiratorias tras la esofagectomía

Introduction

A systematic review of the literature was performed with the aim to determine differences in the rate of respiratory complications after esophagectomy for esophageal cancer using minimally invasive access vs traditional thoracic access.

Methods

A literature search was performed using Medline and Cochrane Library, identifying studies that compared the 2 types of thoracic access, regardless of the type of abdominal access (laparotomy/laparoscopy). The studies selected described respiratory complications in absolute numbers and different categories. Studies that considered minithoracotomy as a minimally invasive technique were excluded. Inclusion criteria were: studies decribing the different types of respiratory complications (9 in total), and analysing the most common complications: respiratory infection, respiratory failure and pleural effusion.

Results

Nine studies were selected (one prospective randomized trial and 8 case control studies) including 1,190 patients, 1,167 of which were operated on for esophageal cancer: 482 patients by thoracotomy and 708 by thoracoscopy. Three studies included definitions of respiratory complications, and one stratified them. The more frequent complications that allowed a meta-analysis were: respiratory infections, pleural effusion, and respiratory failure. No significant differences were found between the 2 types of access in the global analysis.

Discussion

The type of thoracic access (thoracotomy or thoracoscopy) does not seem to influence the development of respiratory complications after esophagectomy for cancer. However, the design of the studies analysed, the absence of clear definitions and stratification of the complications makes this conclusion questionable. A consensus on the definition of complications and further prospective randomized clinical trials are necessary.     

Resección hepática por laparoscopia: lecciones aprendidas tras 132 resecciones

Introduction

After 20 years of experience in laparoscopic liver surgery there is still no clear definition of the best approach (totally laparoscopic [TLS] or hand-assisted [HAS]), the indications for surgery, position, instrumentation, immediate and long-term postoperative results, etc.

Aim

To report our experience in laparoscopic liver resections (LLRs).

Patients and method

Over a period of 10 years we performed 132 LLRs in 129 patients: 112 malignant tumours (90 hepatic metastases; 22 primary malignant tumours) and 20 benign lesions (18 benign tumours; 2 hydatid cysts). Twenty-eight cases received TLS and 104 had HAS. Surgical technique: 6 right hepatectomies (2 as the second stage of a two-stage liver resection); 6 left hepatectomies; 9 resections of 3 segments; 42 resections of 2 segments; 64 resections of one segment; and 5 cases of local resections.

Results

There was no perioperative mortality, and morbidity was 3%. With TLS the resection was completed in 23/28 cases, whereas with HAS it was completed in all 104 cases. Transfusion: 4,5%; operating time: 150 min; and mean length of stay: 3,5 days. The 1-, 3- and 5-year survival rates for the primary malignant tumours were 100, 86 and 62%, and for colorectal metastases 92, 82 and 52%, respectively.

Conclusion

LLR via both TLS and HAS in selected cases are similar to the results of open surgery (similar 5-year morbidity, mortality and survival rates) but with the advantages of minimally invasive surgery.     

Cambios en el manejo diagnóstico-terapéutico del traumatismo hepático. Estudio retrospectivo comparando 2 series de casos en periodos diferentes (1997-1984 vs. 2001-2008)

Introduction

We present a series of 146 cases of hepatic trauma (HT) treated in our hospital over a period of 8 yearsm (2001-2008), and comparing it with a previous series of 92 cases (1977-1984).

Material and method

The mean age in the current series was 28.6 years and the majority were male. The closed traumas were mainly penetrating, with the most frequent cause being road traffic accidents.

Results

The American Association for the Surgery of Trauma (AAST) classification was used to evaluate the grade of the hepatic injury. Associated abdominal and /or extra-abdominal injuries were seen in 79.5% of the patients, with the most frequent being chest trauma, compared to bone fractures in the previous series. The most common associated intra-abdominal injury was the spleen in both series. The most used diagnostic technique in the current series was abdominal CT. Simple peritoneal puncture and lavage (PLP) were the most used examinations used in the previous series. Non-surgical treatment (NST) was given in 98 cases and the surgery was indicated in the remaining 48. In the previous series, 97.8% of patients were operated on. In the current series, on the 15 patients with severe liver injuries, 5 right hepatectomies, 2 segmentectomies and 6 packing compressions were performed, with the remaining two dying during surgery due to hepatic avulsion. The overall mortality was 3.4%, being 1% in the NST group and 8.3% in the surgical patients. In the previous series, the overall mortality was 29.3%.

Conclusions

The key factor for using NST is to control haemodynamic stability, leaving surgical treatment for haemodynamically unstable patients.     

La resección laparoscópica de los segmentos del lóbulo hepático izquierdo debe ser el abordaje inicial en centros con experiencia

Introduction

The resection of tumours of the anatomical left lobe is normally straightforward using either left lateral sectionectomy (LLSEC) or segmentectomy II or III. Our objective is to present the results of the laparoscopic approach and to consider whether this could be the “ideal technique” in liver surgery units where the surgeons have experience of laparoscopic liver surgery (LLSURG).

Patients and methods

We have studied patients with resected solid tumours of the anatomical left lobe using LLSURG (n=18): 10 cases with LLSEC and 8 cases with segmentectomy II or III. We carried out a comparative study with a control group of 18 patients operated on using the same surgical technique using open surgery (OS).

Results

There were no cases of mortality in either of the 2 groups (n=36). Morbidity was similar (5.5% per group). For LLSEC, the LLSURG group (n=10) had a shorter hospital stay (p=0.005) and less surgical time (141 vs. 159 min) (differences not significant.), than the OS group. For segmentary resections II or III, in the LLSURG group (n=8) there was greater use of the Pringle manoeuvre (p=0.05), greater surgical time (p=0.05) and a shorter hospital stay (4.8 vs. 5.6 days) (differences not significant), than in the OS group.

Conclusions

LLSEC should be carried out by laparoscopy in centres where they have considerable experience. The patients may have a shorter hospital stay and spend less time in surgery than when OS is performed, with the same morbidity and mortality rates. Segmentectomy resections II or III carried out by laparoscopy involve a shorter hospital stay but longer surgery time and therefore the advantages are not as evident as they are for LLSEC.     

Estudio prospectivo controlado y aleatorizado sobre la necesidad de la preparación mecánica de colon en la cirugía programada colorrectal

Introduction

Mechanical preparation of the colon (MPC) in colorectal surgery has been a dogma that has been questioned over the last few years. The objective of this study is to demonstrate that morbidity in scheduled colorectal surgery is the same or lower without MPC.

Material and method

Patients subjected to scheduled left colon and rectal surgery with primary anastomosis randomised into two groups. The “Preparation” group (MPC) received MPC and the “non-preparation” group (No-MPC) had only cleaning enemas. The variables collected were: demographic, oncological, nutritional, risk prediction models and morbidity-mortality.

Results

Of the 193 patients included: 69 received MPC and 71 did not; 89 patients with colocolic anastomosis (MPC, 38; no MPC, 51) and 50 colorectal (MPC, 31; no MPC, 19). Statistically significant differences were seen in the overall analysis in favour of “no preparation” as regards morbidity (43.55 % with MPC and 27% with No MPC) and nosocomial infection (27.5% and 11.4%). There was 11.6% wound infections in the MPC compared to 5.7% in the no MPC, which was not statistically significant. The only mortalities were in the MPC group 2/69 (2.9% of patients). As regards the location of the anastomosis, in the colocolics the differences were more pronounced, with statistically significant differences in the morbidity, anastomosis dehiscence, and nosocomial infection variables. The effect of no MPC was not so evident in colorectal anastomosis.

Conclusions

Our results suggest that there is no benefit in MPC before surgery in colocolic anastomosis. No-MPC is not associated with a higher morbidity in wound infection or anastomotic dehiscence. In colorectal anastomosis the differences are not so evident, therefore a much bigger series needs to be studied.     

Elegir a la cirugía como especialidad: Opiniones de los estudiantes de la Universidad de Buenos Aires sobre la cirugía y los cirujanos

Introduction

Since the number of applicants to residencies in general surgery in Argentina seems to be decreasing, we designed this work with the objective of studying the factors considered undesirable by students when choosing surgery as a specialty.

Material and methods

Between March and April 2012, one-hundred students were surveyed with a structured questionnaire with true/false binary answers in an observational case-control design. The survey contained 26 statements that made reference to characteristics of surgery as a specialty, or about the personality and lifestyle of surgeons, as they could be perceived by students. As a control group the same survey was applied to 20 surgeons who were in contact with the students and that could represent a role model for them during their rotation in surgery.

Results

Comparison between students and surgeons showed no difference in most answers, except in «surgery has poor reimbursement» (OR: 8,9; P=.0001), «there is not enough job demand» (OR: 8,1; P=.015), «surgery restrains intellectual development» (OR: 17,5; P=.014), «surgeons have too many non-scheduled activities» (OR: 9,36; P=.024), «they have a limited patient-physician relationship» (OR: 3,61; P=.009), «they have little time for family» (OR: 4,27; P=.036) and «they are exposed to infectious diseases» (OR: 5,90; P=.007).

Conclusions

Women would be as interested as men in working as surgeons; a remarkable fact when considering that the surgical specialties have been predominantly filled by men. The fact that surgeons mostly coincide with the views of students means that role models should be reviewed to promote vocations.     

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.     

Fijación con sutura frente a sellante de fibrina en hernioplastia con prótesis reabsorbible (ácido poliglicólico y carbonato trimetileno). Estudio experimental en animales

Introduction

Current studies have shown the validity of the atraumatic fixation with fibrin glue (Tissucol^®) compared to conventional sutures in polypropylene mesh fixation. We propose to study the behaviour of absorbable mesh.

Material and methods

We used 20 Wistar white rats. Two hernia defects were made in the abdominal wall, which were repaired using absorbable PGA-TMC preperitoneal mesh. The right side of the mesh was fixed with Tissucol and left side with conventional suture attached to the muscle fascia. One group of 10 rats were sacrificed at day 14 (Series A) and the other 10 rats at 28 days (Series B). We used two tests to assess the contingency of the abdominal wall; Pressure Test: pneumoperitoneum more than 40 mmHg maintained for 1 min, Traction Test: dynamometry of the affected area more than 300 mg per cm² of traction. Abdominal wall was analysed to determine the integration of the new generation mesh.

Results

The fixation of the mesh after the pressure and traction tests showed no statistically significant changes in either group. The integration of the mesh and vessel neoformation was higher in the cases of fixation with fibrin glue.

Conclusions

Biological fixation with fibrin glue is similar to the conventional. Absorbable mesh was suitably integrated and vascular neoformation and integration of the mesh was also found to be better than conventional sutures when fibrin sealant was applied.     

Estudio epidemiológico de la anemia preoperatoria en pacientes sometidos a cirugía oncológica en España. Estudio RECIRON

Introduction

Anaemia is common in oncology patients who are going to have surgery for tumour resection. Allogenic blood transfusion has been associated with a greater incidence of postoperative complications. The aim of this study is to analyse current clinical practice as regards the preoperative treatment and conditions of these patients in Spain.

Material and method

This is an epidemiological observational study which included 472 patients from different hospitals. The data included in the clinical history was analysed: tumour location, preoperative laboratory tests, functional situation (Karnofsky index [KI]), anaemia treatment and transfusions given since the diagnosis.

Results

As regards the tumour location, 181 were urological (38.3%), 161 digestive system (34.1%), and 130 gynaecological (27.5%). The time from the initial diagnosis until surgical intervention was 6.2±6 weeks, and 19.1±23 days from the anaesthetist visit to the surgical operation. The mean pre-operative haemoglobin (Hb) was 13.1±2 g/dl. The anaemia was treated in 12.9% of the patients and 15% (69 patients) received a transfusion before surgery. A total of 28.1% patients had a KI≤80. The lowest preoperative haemoglobin levels are associated with the lowest KI.

Conclusions

Anaemia is present in a high percentage of oncology patients who are going to be surgically treated. Preoperative blood transfusion is the most common treatment. It was observed that there is sufficient preoperative time to be able to improve preparation of the patient for surgery.     

Resultados tras resección hepática laparoscópica: una opción adecuada en patología maligna

Introduction

The laparoscopic approach is not yet widely used in liver surgery, but has proven to be safe and feasible in selected patients even in malignant disease. The experience and results of a hepato-pancreato-biliary (HPB) surgery unit in the treatment of malignant liver disease by laparoscopic approach is presented.

Material and methods

Between February 2002 and May 2011, 71 laparoscopic liver resections were performed, 43 for malignant disease (only patients with more than one year of follow-up were included). Mean age was 63 years old and 58% of the patients were male. Forty-nine per cent of the lesions were located in segments ii-iii. Thirty segmentectomies were performed, 7 limited resections and 6 major hepatectomies.

Results

The median operative time was 163 min. There were 3 conversions. Five cases (11%) required blood transfusion. The oral intake began at 32 h and the median hospital stay was 6.7 days. There were no reoperations and there was one case of mortality. Nine patients (21%) had postoperative complications. The mean number of resected lesions was 1.2, with an average size of 3.5 cm. All resections were R0. The median survival after resection of colorectal liver metastases (CLM) was 69% and 43.5% at 36 and 60 months, respectively, and 89% and 68% at 36 and 60 months, respectively, in hepatocellular carcinoma (HCC).

Conclusion

The laparoscopic liver resection in malignant disease is feasible and safe in selected patients. The same oncological rules as for open surgery should be followed. In selected patients it offers similar long-term oncological results as open surgery.     

Legibilidad del consentimiento informado quirúrgico en España

Introduction

To assess the readability of informed consent documents (IC) of the different national surgical societies.

Methods

During January 2012 we collected 504 IC protocols of different specialties. To calculate readability parameters the following criteria were assessed: number of words, syllables and phrases, syllables/word and word/phrase averages, Word correlation index, Flesch-Szigriszt index, Huerta Fernández index, Inflesz scale degree and the Gunning-Fog index.

Results

The mean Flesch-Szigriszt index was 50.65 ± 6,72, so readability is considered normal. There are significant differences between specialties such as Urology (43.00 ± 4.17) and Angiology and Vascular Surgery (63.00 ± 3.26, P<.001). No IC would be appropriate for adult readability according to the Fernández-Huerta index (total mean 55.77 ± 6.57); the IC of Angiology and Vascular Surgery were the closest ones (67.85 ± 3.20). Considering the Inflesz scale degree (total mean of 2.84 ± 3,23), IC can be described as «somewhat difficult». There are significant differences between the IC of Angiology and Vascular Surgery (3.23 ± 0.47) that could be qualified as normal, or Cardiovascular Surgery (2.79 ± 0.43) as «nearly normal readability»; and others such as Urology (1, 70 ± 0.46, P<.001) and Thoracic Surgery (1.90 ± 0.30, P<.001), with a readability between «very» and «somewhat» difficult. The Gunning-Fog indexes are far from the readability for a general audience (total mean of 26.29 ± 10,89).

Conclusions

IC developed by scientific societies of different surgical specialties do not have an adequate readability for patients. We recommend the use of readability indexes during the writing of these consent forms.