Adenocarcinoma primario de intestino delgado

Introduction

Primary small bowel adenocarcinoma is an uncommon tumour, with non-specific symptoms that cause a delay in the diagnosis and consequently a worse outcome for the patient. We analyse our experience in the management of this disease.

Material and method

We performed a retrospective study of our experience with 17 patients diagnosed with primary small bowel adenocarcinoma, excluding all the cases suggesting secondary involvement of the small bowel from an adenocarcinoma in other locations.

Results

We analysed 9 females (53%) and 8 males (47%) with a mean age of 61.8 years. Tumour location was duodenum (8 cases), jejunum (5) and ileum (4). Those with duodenal tumours underwent 4 pancreaticoduodenectomies, 3 gastroenterostomies and 1 diagnostic biopsy; 6 bowel resections with lymphadenectomy, 2 en-bloc resections and 1 by-pass were performed on those with jejuno-ileal tumours. There were complications in 3 patients (18%). General survival was 18 months; in duodenal and jejunal tumours it was 15 months vs. 58 in ileal ones (p=0.048). Survival was 48 months in the absence of lymph node metastases vs. 11 in those with (p=0.067). In those tumours infiltrating the retroperitoneum, survival was 15 months compared to 23 when not affected (p=0.09).

Conclusions

Curative treatment consists of small bowel resection. Retroperitoneal infiltration was a non-resectability criterion in our series. Ileal location is associated with a better outcome. Advanced stages, lymph node metastases, non-resected cases and retroperitoneal infiltration tended to be associated with a poor prognosis in our group.     

Implementation of a perioperative multimodal rehabilitation protocol in elective colorectal surgery. A prospective randomised controlled study

Introduction

Multimodal rehabilitation (MMR) consists of a combination of several methods for management of the surgical patient, designed to reduce the response to surgical stress and a more comfortable and earlier recovery.

Objective

To assess the implementation of an MMR protocol in a Colorectal Surgery Unit, and to compare the results with the traditional model, as well as assessing its efficacy as regards recovery and hospital stay.

Material and methods

A total of 119 patients who received elective surgery for colorectal diseases in a period during 2009-2010 were prospectively and randomly analysed. The patients were divided into 2 groups: 58 patients were assigned to the traditional group and 61 to the MMR group. The MMR group protocol consisted of, preoperative education, early feeding and mobilisation.

Results

Both groups were homogeneous as regards the preoperative variables evaluated, the type of disease and the procedures carried out. The nasogastric tube was kept in place for 4 (1-9) days compared to 1 day (0-2) in the MMR group, with no differences in the number of re-insertions. Significant differences were found in the introduction of a liquid diet (3 [1-5] days traditional versus 0 [0-2] MMR) (P < .001), and passing of first flatulence (3 [1-6] days traditional versus 1 [1-3] MMR) (P < .001). The MMR group had a postoperative stay of 4.15 ± 2.18 versus 9.23 ± 6.97 days in the traditional group (P < .001). No significant differences were found in complications or readmissions.

Conclusions

MMR in colorectal surgery in the Spanish public health system is feasible and enables surgical patients to have a faster recovery without increasing complications, leading to an earlier hospital discharge.     

Transanal resection using a single port trocar: a new approach to NOTES

Introduction

The morbidity and mortality, along with the functional changes that arise from radical surgery of rectal cancer, has led to an increasing interest in local treatment in the early stages of cancer of the rectum. Conventional transanal surgery has a high recurrence rate, for this reason transanal endoscopic microsurgery (TEM) is considered the treatment of choice in the last few years in large rectal adenomas and in early rectal cancer (low risk T1).

Patients and method

We have intervened five patients, four with a diagnosis of villous adenoma of the rectum, and one in situ rectal carcinoma, using this new transanal approach, with a single port device.

Results

The locations of the lesions were in the mid-rectum, at a mean distance of 9 cm (range 6-10) from the anal margin. All of them were situated in the posterior side. The resection margins were negative in all cases. The mean size of the adenomas was 4 cm, three being sessile shaped, and one with a short, thick pedicle (>1 cm); the size of the carcinoma was 3 cm. The mean surgical time was 55 minutes. All the patients were discharged 48 hours after the surgical procedure.

Conclusion

We believe that the transanal endoscopic approach with a single port device is a simple, easily reproducible and cost-effective procedure when compared to TEM.     

Tratamiento de la eventración subxifoidea: técnica de doble malla ajustada al defecto

Introduction

Subxiphoid incisional hernia has characteristics that differentiate it from the rest and make it a distinctive entity. The fact that it has its sac very near the rib cage and sternum determines the pressure in the margins. The repair, by open or by laparoscopic approach, has not demonstrated good results despite the generalised use of a prosthesis. They are uncommon, and have a significant comorbidity in patients (severe heart diseases, transplants, immunosuppressed), after surgery of the hepato-bilio-pancreatic area with transverse incisions, or very high mid-laparotomies for gastro-oesophageal surgery.

Material and methods

A new technique has been developed in our Unit, based on a double mesh and adapted to the anatomical and physiological characteristics of the region. The series consisted of 35 consecutive patients operated on between 2004 and 2010, following an agreed surgical and management protocol.

Results

There were no significant complications -the most frequent (17.4%) was a seroma- except one case of a wound infection due to skin ischaemia in one patient who had had multiple operations and a transplant. During the post-surgical follow up to the present (between 4 and 80 months), there has been no recurrence of the incisional hernia and no significant local discomfort has been reported.

Conclusions

The «adjusted double mesh» technique achieved good results in our hands, from the surgical point of view (reproducibility, recurrence), and for the patient, with minimal discomfort and recovery of quality of life.     

Transanal endoscopic surgery with conventional laparoscopy materials: is it feasible?

Introduction

Transanal endoscopic surgery with conventional laparotomy materials may be an alternative to transanal endoscopic microsurgery (TEM) for the excision of rectal lesions susceptible to local resection.

Material and method

We prospectively analysed 27 patients included consecutively between 1999 and 2009, on whom a Transanal endoscopic operation (TEO) was performed by total resection of the rectal wall. All procedures were performed with a 40 mm rectoscope, initially designed by us and later with the Storz rectoscope, using conventional laparoscopic tools and material.

Results

We operated on 27 patients with a mean age of 69.4 years: 23 due to benign lesions and 4 malignant. The medium distance of the tumour to the anal margins was 8.2 cm (range 5-15) and a mean tumour diameter of 3.38 ± 1.2 cm. There were 4 postoperative complications, 3 due to bleeding and one case of perforation. The mean hospital stay was 6 ± 3.75 days. There was no perioperative mortality or recurrences..

Conclusion

Performing transanal endoscopic surgery with conventional laparoscopy material is feasible, with a reduction in costs and accessible to laparoscopy surgeons.     

Improvement in the quality of life of faecal incontinent patients after sacral root stimulation treatment

Introduction

Faecal incontinence (FI) is a highly prevalent disorder that severely affects the health related quality of life (HRQOL) of the patients who suffer from it. Neuromodulation is a minimally invasive treatment that has demonstrated its efficacy in the treatment of FI symptoms over the past 10 years. The aim of this study is to check whether there is an improvement in the quality of life, using EuroQuol (EQ-5D), in patients with faecal incontinence treated with sacral root neuromodulation.

Methodology

An observational study with prospective recording of quality of life data, before and after, using the EQ-5D on a series of patients diagnosed with moderate to severe FI with a complete or repaired sphincter who had a definitive MEDTRONIC Interstim^® 3023 implant after a subchronic stimulation phase with a good response.

Results

The initial mean number of leaks was 3.1 ± 1, and the final was 0.5 ± 0.6. The mean number of escapes per week decreased to 2.6 escapes (CI 95%: 2.1-3.1) after the definitive implant of the sacral root stimulator (P<.001). The mean baseline health status score was 55.9 ± 13, and after neuromodulation it was 63.1 ± 13. Thus, the visual analogue scale score increased by 7.1 points (CI 95%: 0.37-14) after the definitive implant of the sacral root stimulator (P<.05). In the HRQOL variables studied with the EQ-5D questionnaire, we found an improvement with neuromodulation in the mobility and the presence of anxiety and/or depression variables. On the other hand we found an improvement with the neurostimulator implant, which was not significant, in personal care, performing daily activities and the presence of pain and/or discomfort. The current health was better in 11 patients (57.9%), the same in 7 (36.8%) and worse in 1 (5.3%).

Conclusions

Neuromodulation is a therapy that has demonstrated a significant improvement in HRQOL measured with the EQ-5D.     

Review and update of the prognostic factors in lung metastasis surgery

Introduction

Since the International Registry of Lung Metastases established the factors that determine survival after performing lung metastasectomy in 1997, numerous studies have attempted to determine these prognostic factors of survival. Our objective has been to analyse the mortality, survival and disease-free survival lung metastasis surgery by studying the different variables that determine them.

Patients and method

All patients subjected to surgery for lung metastasectomy between 1998 and 2008 were included in this study. The Kaplan-Meier and log-rank tests were performed, as well as a Cox regression using multivariate analysis.

Results

A total of 178 lung metastases were removed in 146 patients during this period. The mean age was 62.22 years (median 63 years) and 64.6% were males. There were 2 cases (1.1%) of mortality and the incidence of complications was 5.02% (9 cases). The overall survival was 67.75 months with a 3 and 5 year survival of 67.4% and 52.4%, respectively. The variables that showed statistical significance in the multivariate analysis were: age disease free interval, number of nodules and size of nodules. The “state of the margins” variable was almost significant (P = .054).

Discussion

To have only one metastasis and it is less than 1 cm, a long disease free interval, and a resection with free margins, are the most favourable prognostic factors after resection of lung metastasis.     

Is body mass index a prognostic factor of survival in colonic cancer? A multivariate analysis

Introduction

The long-term survival of patients operated on for colonic cancer depends on many factors. Obesity decreases the life expectancy of the general population who suffer from it, but it is not clear whether obesity, measured by the Body Mass Index (BMI), is a prognostic factor of survival for patients operated on for colonic cancer.

Material and methods

The patients included in this study had TNM stage I, II y III, and were subjected to elective surgery for cancer of the colon in the Girona University Hospital between 1990 and 2001. The BMI was classified according to the WHO classification. A total of 38 different variables were studied using a bivariate analysis with BMI. A Cox model was subsequently constructed with the most clinically relevant parameters, and with those most strongly associated with survival in the bivariate analysis.

Results

BMI was not associated with survival in the bivariate analysis. Neither did the multivariate analysis show that BMI was an independent prognostic factor of long-term survival in cancer of the colon without metastasis, but it did show that the TNM stage, ASA score, surgical technique, age at surgery, and the immune cell response were prognostic factors.

Conclusions

The body mass index is not a prognostic factor of the long-term survival of patients with colonic cancer.     

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.     

The transverse musculocutaneous gracilis free flap for breast reconstruction: experience with 6 cases

Introduction

Microsurgical techniques have allowed reconstronstruction procedures after mastectomy to take a qualitative leap with the development of different technical options. Although the abdomen is the main donor area destined for breast reconstruction, occasionally this skin is not sufficient or unsuitable for this purpose. In these cases, alternative donor areas are required, such as the flap of the transverse myocutaneous gracilis (TMG) muscle. The objective of this study is to evaluate the reliability of the TMG flap and the level of patient satisfaction with the result obtained.

Material and methods

During a nine-month period in 2009, 72 breast reconstructions were performed, of which 17 required the use of free flaps. In 7 of these cases, the abdominal wall could not be used as a donor area; therefore 6 of them opted for the TMG flap. The surgical technique and its results have been analysed, as well as the patient satisfaction with the results obtained using a questionnaire.

Results

There was no total or partial loss of the flap or other complications at the transfer level. There was minor dehiscence in the donor area in 3 of the cases. The patients classified the results of the reconstruction as satisfactory or good.

Conclusions

The TMG flap is a good technical option, comparable to abdominal flaps, for patients with small or medium sized breasts which require reconstruction with autologous tissue. The evaluation of the results by the patients was satisfactory or good.     

Supercharged ileocoloplasty: an option for complex oesophageal reconstructions

Introduction

Oesophageal reconstruction in a second time is a complex surgical operation which, in some cases, requires combining microvascular techniques to increase vascular flow to the conduit. «Supercharged» ileocoloplasty allows creation of a longer conduit that makes it possible to replace the entire oesophagus. We describe our initial experience with this technique for the total reconstruction of the oesophagus.

Material and methods

A retrospective review of the period from October 2007 to December 2009 identified 4 patients on whom a deferred oesophageal reconstruction was performed with a «supercharged» ileocoloplasty. The indications of this technique, morbidity and mortality, as well as functional results during follow up were evaluated.

Results

The indications of this technique were: previous failure of a left colon interposition (1), oesophageal disconnection due to a gastro-pleural fistula (1), total oesophagogastrectomy (1) and partial oesophagogastrectomy (1) due to the ingestion of caustic substances, respectively. Gastrointestinal complications were the most frequent. Two cervical fistulas were diagnosed which were resolved with an absolute diet, antibiotic therapy and enteral nutrition. There was no mortality. After a median follow up of 14.7 months, two patients were nourished exclusively by mouth, one by a mixed route (oral-enteral) and another exclusively by the enteral route due to an oesophageal stenosis 11 centimetres from the dental arch; this patient required dilations and is awaiting a jejunal graft.

Conclusions

«Supercharged» ileocoloplasty is a complex treatment option for the total reconstruction of the oesophagus when no other alternatives are available. Postoperative morbidity is significant but the functional results are good.     

Selective intestinal preparation in a multimodal rehabilitation program. Influence on preoperative comfort and the results after colorectal surgery

Introduction

Despite there being no evidence of the advantages of its use, mechanical bowel preparation (MBP) continues to be routine in colorectal surgery. Our objective is to analyse the impact of its selective use, as regards patient comfort and results, comparing a perioperative multimodal rehabilitation program (MMRH) with conventional care (CC).

Material and methods

A prospective study of 108 patients proposed for elective surgery, assigned consecutively 2:1 to an MMRH protocol which only included MBP in rectal surgery with low anastomosis, or to CC in whom MBP was used except in right colon surgery. We also studied two Groups (A and B) with and without the use of MBP. Their tolerance, results and postoperative recovery variables were analysed.

Results

Thirty-nine patients were included in Group A, and 69 in Group B. A MMRH protocol was used in another 69 patients. The Group A patients had more abdominal pain, anal discomfort, nausea and thirst, but there were no differences as regards, death, overall or local complications, whilst there was less complications, suture failures and death in the MMRH when compared with CC Group (P < .05). There were no advantages observed in the use of MBP as regards the start of bowel movements, tolerance to diet or hospital stay, but these parameters were favourable to the MMRH when compared with CC Group.

Conclusions

The restriction of MBP is safe, and associated with an MMRH program, contributes to a faster and more comfortable recovery, without increasing complications.     

Complicaciones del tratamiento de la oclusión del colon distal con prótesis endoluminales

Introduction

The high morbidity and mortality of emergency surgery, has led to the use of endoluminal self-expanding metal implants (stents) in the management of intestinal occlusion.The purpose of this study was to review the results of the management of intestinal occlusion treatment in a Colorectal Surgery Unit in those patients who had a stent implant, and the relationship between chemotherapy and complications.

Material and methods

A retrospective study was carried out on patients treated with a stent in a university hospital between 2004 and 2010.

Results

A total of 93 patients were treated, of which 77 were considered palliative for a stage IV neoplasm of the colon with non-resectable metastases or due to a performance status > 2. Other indications were 7 ASA IV patients with acute renal failure, 6 with benign disease, and 3 due to other causes.The technical and clinical success of the procedure was 93.5% and 78.5%, respectively. Delayed occlusion was 19.3% and perforation 6.4%. There was migration (2.1%) and intestinal bleeding (2.1%) and 1.1% with tenesmus. No significant differences were seen between complications and chemotherapy.The overall mortality was 17.2%.

Conclusions

Stents, as a definitive treatment option in palliative patients with and without chemotherapy, is an alternative treatment that is not exempt from complications. We believe that in patients with mortality risk factors and patients with tumours with non-resectable metastases it could be the initial treatment of choice.     

Factors that influence interdepartmental referrals between Surgical Departments and Internal Medicine

Introduction

To analyse the long term outcome of the age and comorbidity of patients admitted to Surgical Departments, the number of referrals to Internal Medicine made by these Departments, and to assess whether there are seasonal variations and the call/reject effect.

Material and methods

We compared the age, Charlson Comorbidity Index (CCI), and the number of referrals made by Traumatology, General Surgery and Urology of patients discharged in 2000, with those discharged in 2007. Seasonal variations and the call/reject effect were studied by analysing all the interdepartmental referrals made by all the surgical departments from the year 2000 to 2007.

Results

Age increased by 5.6% between 2000 and 2007, the CCI by 5.8%, and interdepartmental referrals by 60%. Interdepartmental referrals decreased in July and August, whilst they increased in January, February, June and October, up to 64% more in January, although with variations of almost 50% in the same month. We detected differences of up to 68.2% in the referrals requested to different physicians.

Conclusions

We observed a sharp increase in the requests for referral to Internal Medicine by Surgical Departments of our hospital, which is not explained by the increase in admissions to these Departments, and which could be associated with the increase in age and comorbidity of their patients. Requests for interdepartmental referral have marked monthly variations and also as regards the Consulting Physician.     

Pericardial window by videothorascopy

Introduction

Pericardial effusion is a clinical condition requiring multidisciplinary management. There are several surgical techniques for its diagnosis and treatment. In the present study we report our experience in performing a pericardial window (PW) by videothorascopy.

Material and methods

We performed surgery on 56 patients (20 females and 36 males), with a mean age of 56 ± 1.22 years, and diagnosed with moderate to severe chronic pericardial effusion. The side chosen for the approach depended on whether there was an associated pleural effusion or lung lesion, and if not the left side was chosen.

Results

The mean duration of the surgery was 37.6 ± 16 minutes. The definitive diagnoses were malignant processes in 23% of cases, including bronchogenic carcinoma and breast cancer. The intra-operative mortality was 0%.

Conclusions

Videothorascopic pericardial window is an effective and safe technique for the diagnosis and treatment of chronic pericardial effusion, and which enables it to be drained and perform a pleuro-pulmonary and/or mediastinal biopsy during the same surgical act.     

Study of accessibility costs and satisfaction comparing a MAS unit incorporated in a Hospital versus a theoretical model in a peripheral centre

Introduction

Geographical barriers are a determining factor in the accessibility of Hospital health care, and structural changes to improve geographic accessibility must be introduced. The purpose of this study is to compare accessibility costs and the level of satisfaction obtained in an adapted Specialist Centre with a peripheral MAS (Major Ambulatory Surgery) Unit, with an already existing one incorporated into the Virgen de la Luz Hospital (Cuenca, Spain) to obtain quality health care in the sub-population nearest the peripheral Centre.

Material and methods

A study was made on a comparison of the costs attributable to accessibility of 133 patients operated on due to hernia disorders in 2008 in the Cuenca Hospital of Castille-La Mancha Health Service (SESCAM), and who lived in its health area. These were compared using a simulation study for an ambulatory surgical Centre, functionally operational, but with no Major Ambulatory Surgery activity nearest to this patient population. The opinions of the patients and the increased cost-effectiveness for each alternative proposal were studied.

Results

The accessibility cost, taking into account the theoretical use of the Ambulatory Centre would be 208,028.09 € and the real costs of the Hospital were 209,088.94 €, with a minimum difference between the two of 1,060.85 €, assuming similar clinical results.

Conclusions

Although there are no significant differences in accessibility costs by using an ambulatory surgery Centre compared to the Hospital, a special assessment of the use of the former is important, expressed in the satisfaction of the patients.     

Impact of lymphadenectomy on axillary recurrence and morbidity of the upper limb in breast cancer patients with negative sentinel node. A prospective randomised study

Introduction

To determine the impact of axillary lymphadenectomy on regional recurrence, the overall and disease free survival, and upper limb morbidity in patients with breast cancer and negative sentinel node (SN).

Patients and methods

A total of 176 patients with breast cancer and negative SN (pN0_sn) were either randomised to lymphadenectomy (Group I) or to observation only (Group II). The triple technique was used to identify and remove the SN. Follow-up was carried out every 3 months for the first 3 years, and then every 6 months up to 5 years. Pain, numbness (paresthesia), limitations in shoulder mobility, and arm oedema were recorded.

Results

No axillary lymph node recurrence was detected in the patients of Group II after 60 months follow up. The overall and disease free survival was similar in both groups. The proportion of patients with morbidity and who had more than two complications was significantly higher in Group I.

Conclusions

Axillary lymphadenectomy may be avoided in patients with negative SN without compromising lymph node extension studies and the patient treatment results. Axillary lymphadenectomy is associated with a higher morbidity of the upper limb compared to SN biopsy.