Jaime Ruiz-Tovar

Prophylactic Mesh vs Suture in the Closure of the Umbilical Trocar Site after Laparoscopic Cholecystectomy in High-Risk Patients for Incisional Hernia. A Randomized Clinical Trial

BACKGROUND Prosthetic repair has become the standard method for hernia repair. Mesh placement for the prevention of trocar site incisional hernia (TSIH) is still a controversial issue. We tested the hypothesis that closure with an intraperitoneal prophylactic mesh of the umbilical trocar after a laparoscopic cholecystectomy can reduce the incidence of a TSIH in high-risk patients. STUDY DESIGN A randomized clinical trial was conducted among patients undergoing elective laparoscopic cholecystectomy who presented the following high-risk factors for incisional hernia, according to the literature: age 65 years and older, diabetes mellitus, chronic pulmonary disease, and obesity (ie, body mass index ≥30 kg/m(2)). Patients were assigned to have closure of the umbilical trocar site with either nonabsorbable sutures (group A) or intraperitoneal polypropylene omega-3 mesh (group B). Trocar site incisional hernia, pain, and surgical complications were evaluated at the early postoperative course and at 1, 6, and 12 months after surgery. RESULTS A total of 106 patients were randomized into the study and 92 patients were finally analyzed, including 47 in group A and 45 in group B. The TSIH rate was higher in group A (31.9%) than in group B (4.4%) (odds ratio = 10.1; 95% CI, 2.15-47.6; p < 0.001)). The wound infection rate was 4.3%; 8.5% in group A and 0% in group B (odds ratio = 2.04; 95% CI, 1.7-2.5; p = 0.045). Median postoperative pain evaluated by a visual analogue scale was 3 in group A and 2 in group B (p = 0.05). No differences were observed in complication rate, operative time, or hospital stay between the groups. CONCLUSIONS Prosthetic closure of the umbilical trocar site after laparoscopic surgery could become the standard method for preventing TSIH in high-risk patients.

Incidence of Deep Vein Thrombosis and Thrombosis of the Portal–Mesenteric Axis After Laparoscopic Sleeve Gastrectomy

BACKGROUND Venous thromboembolism is the most common postoperative medical complication after bariatric surgery. Mortality associated with thromboembolic processes can reach up to 50%-75%. The aim of this study was to determine the incidence of deep vein thrombosis (DVT) and portal-splenic-mesenteric vein thrombosis (PSMVT) in our population undergoing laparoscopic sleeve gastrectomy (LSG) as the bariatric technique, with an anti-thromboembolic dosage scheme of 0.5 mg/kg/day 12 hours preoperatively and maintained during 30 days postoperatively. PATIENTS AND METHODS A prospective observational study was performed, including 100 consecutive patients undergoing LSG between October 2007 and September 2013. To determine the incidence of DVT and PSMVT, all patients undergo contrast-enhanced abdominal computed tomography (CT) and Doppler ultrasonography (US) of both lower limbs on the third postoperative month, whether they were asymptomatic or symptomatic. RESULTS Contrast-enhanced CT showed 1 case of PSMVT (1%). Two patients presented DVT in the right leg (2%). All the cases were asymptomatic. CONCLUSIONS The incidence of PSMVT and DVT after LSG with a prophylactic low-molecular-weight heparin dose of 0.5 mg/kg/day and maintained during 30 days postoperatively is 1% and 2%, respectively. According to these results, a postoperative screening with Doppler US and/or contrast-enhanced CT seems to be unnecessary.

Pre-operative and early post-operative factors associated with surgical site infection after laparoscopic sleeve gastrectomy.

BACKGROUND Surgical procedures on obese patients are expected to have a high incidence of surgical site infection (SSI). The identification of pre-operative or early post-operative risk factors for SSI may help the surgeon to identify subjects in risk and adequately optimize their status. We conducted a study of the association of comorbidities and pre- and post-operative analytical variables with SSI following laparoscopic sleeve gastrectomy for the treatment of morbid obesity. PATIENTS AND METHODS We performed a prospective study of all morbidly obese patients undergoing laparoscopic sleeve gastrectomy as a bariatric procedure between 2007 and 2011. An association of clinical and analytical variables with SSI was investigated. RESULTS The study included 40 patients with a mean pre-operative body mass index (BMI) of 51.2±7.9 kg/m(2). Surgical site infections appeared in three patients (7.5%), of whom two had an intra-abdominal abscess located in the left hypochondrium and the third had a superficial incisional SSI. Pre-operatively, a BMI >45 kg/m(2) (OR 8.7; p=0.008), restrictive disorders identified by pulmonary function tests (OR 10.0; p=0.012), a serum total protein concentration <5.3 g/dL (OR 13; p=0.003), a plasma cortisol >30 mcg/dL (OR 13.0; p=0.003), and a mean corpuscular volume (MCV) <82 fL (OR 1.6; p=0.04) were associated with post-operative SSI. Post-operatively, a serum glucose >128 mg/dL (OR 4.7; p=0.012) and hemoglobin <11g/dL (OR 7.5; p=0.002) were associated with SSI. CONCLUSIONS The study supports the role of restrictive lung disorders and the values specified above for preoperative BMI, serum total protein and cortisol concentrations, and MCV, and of post-operative anemia and hyperglycemia as risk factors for SSI. In these situations, the surgeon must be aware of and seek to control these risk factors.

Total Occlusive Ionic Silver-Containing Dressing vs Mupirocin Ointment Application vs Conventional Dressing in Elective Colorectal Surgery: Effect on Incisional Surgical Site Infection

BACKGROUND Several pre- and intraoperative factors have been associated with incisional surgical site infection (SSI), but little is known about the influence of postoperative wound care and especially, the use of different dressings on incisional SSI. The aim of this study was to compare 3 methods of wound dressings (conventional dressing, silver-containing dressing, and mupirocin ointment dressing) for their ability to prevent SSI, as measured by SSI rates, in patients with colorectal cancer undergoing elective open surgery. STUDY DESIGN A prospective, randomized study was performed. Inclusion criteria were diagnosis of colorectal neoplasms and plans to undergo elective surgery with curative aims. Patients were randomized using a 1:1:1 allocation into 3 groups: patients receiving an ionic silver-containing dressing (ISD) (group 1), a mupirocin ointment application (MOA) (group 2), and a conventional dressing (group 3 or standard dressing). The primary outcomes variable was occurrence of incisional SSI. Follow-up was 30 days postoperatively. RESULTS A total of 147 patients were included, 49 in each group. Incisional SSI occurred in 9 patients (18.4%) in the ISD group, 2 (4.1%) in the MOA group, and 10 (20.4%) in the standard dressing group (p = 0.028). Adjusting for multiple comparisons, there were no significant differences between ISD and standard dressing groups; a significant difference was observed between ISD and MOA (relative risk [RR] 4.5; 95% CI (1.1 to 19.8); p = 0.046) and between the standard group and the MOA group (RR 5; 95% CI (1.2 to 21.7); p = 0.031). CONCLUSIONS Topical application of mupirocin ointment achieves better results for the prevention of SSI than ionic silver-containing dressing or standard dressing in patients undergoing elective open colorectal surgery.

Efecto de los patrones de conducta alimentaria y de la pérdida de peso preoperatoria sobre los resultados a corto y medio plazo en pérdida de peso tras gastrectomía vertical laparoscópica

INTRODUCTION Weight loss depends directly on the adhesion to the postoperative diet in patients undergoing a sleeve gastrectomy. The aim of this study is to evaluate the effect of different preoperative feeding patterns and the adhesion to a preoperative diet on short and mid- term postoperative weight loss. MATERIAL AND METHODS A prospective study of all morbidly obese patients undergoing a laparoscopic sleeve gastrectomy as a bariatric procedure between 2008 and 2012 was performed. Preoperative feeding patterns and weight loss, preoperatively and postoperatively at 12 and 24 months, were evaluated. RESULTS A total of 50 patients were included, with a mean preoperative BMI of 51,2+7,9 kg/m(2). All the patients presented a feeding pattern of big eaters, 44% of snackers, 40% of sweet eaters and 48% reported regular ingestion of «light» soft drinks. Mean preoperative excess weight loss (EWL) was 13,4% (range 10-31,4%). At 12 months mean EWL was 83,7% and at 24 months 82,4%. Pre and postoperative EWL showed a direct correlation at 12 and 24 months. Mean EWL was significantly lower in snackers, sweet eaters and those drinking «light» soft drinks regularly. CONCLUSION Preoperative weight loss correlates directly with postoperative weight loss at 1 and 2 years. Snackers, sweet eaters and «light» soft drink consumers, associated with a big eater pattern, achieve a significantly lower postoperative weight loss.

Percutaneous posterior tibial nerve stimulation (PPTNS) in faecal incontinence associated with an anal sphincter lesion: Results of a prospective study

PURPOSE Establish the efficacy of posterior tibial nerve stimulation in treating faecal incontinence associated to sphincter defect. METHODS Prospective study that included patients with faecal incontinence associated to sphincter lesions between 90 and 180°. Clinical anamnesis, physical examination, reverse visual analogic scale, incontinence diary and Wexner score were recorded at baseline and 6 months. Anal manometry was realized at baseline and 6 months. Subjects underwent one 30-min session every week for 12 consecutive weeks and was continued with 6 additional sessions every 2 weeks. RESULTS Sixteen patients were analysed, 15 women and 1 men, with a mean age of 56.5 years. The incontinence were obstetric origin (50%) and perineal surgeries (50%). Four patients who did not continue with the second stage. Referring to the retention time, at baseline 12 patients (75%) did not bear even 1 min. At 6 months the retention time was <1 min in only 2 patients (p = 0.008). Median Wexner baseline values were 10; at 6 months decrease to 5 (p = 0.006). The visual analogical scale (VAS) increased from 6 to 7.5 (p > 0.05). After 6 months, maximum resting pressure increased from 40.9 to 51 mmHg (p < 0.001) and maximum squeeze pressure from 82.5 to 94 mmHg (p < 0.001). CONCLUSION PTNS is an effective treatment for faecal incontinence associated to sphincter lesions because the number of incontinence episodes per week, the Wexner Score, the ability to defer defaecation and the manometric determinations improved significantly.

Effect of gentamicin lavage of the axillary surgical bed after lymph node dissection on drainage discharge volume

UNLABELLED The purpose of this study was to evaluate the effect of axillary lavage with a gentamicin solution before wound closure on drainage volume. PATIENTS AND METHODS A prospective, randomized study was performed. Inclusion criteria were a diagnosis of breast neoplasms and plans to undergo an elective axillary lymph node dissection due to axillary metastasis. The patients were randomized into 2 groups: patients undergoing 2 lavages with 500 ml normal saline (Group 1) and patients first undergoing lavage with 500 ml normal saline followed by a second lavage with a 500 ml of a gentamicin (240 mg) solution (Group 2). Microbiological samples were obtained before any lavage, after each lavage and at the time of drain removal. RESULTS 40 patients were included. Mean number of days maintaining the drain in place was 7.7 ± 3.2 days in Group 1 and 4.3 ± 1.4 days in Group 2 (p = 0.001). Total drainage volume before removal was 465 ± 250.9 ml in Group 1 and 169 ± 102.2 ml in Group 2 (p = 0.003). After a second lavage with normal saline in Group 1 and after a lavage with gentamicin solution in Group 2, microbiological culture was positive in 10 patients (50%) in Group 1 and 1 case (5%) in Group 2 (p = 0.016). Positive cultures were associated with higher drainage volumes. CONCLUSION The postoperative drainage volume of the axillary drain is significantly lower in the patients undergoing a lavage of the surgical bed with a gentamicin solution than in the control group undergoing a lavage with normal saline. A significant reduction in the contamination is only obtained after a lavage with gentamicin solution. CLINICAL TRIAL REGISTRATION NUMBER NCT01700504.

Percutaneous Posterior Tibial Nerve Stimulation vs Perianal Application of Glyceryl Trinitrate Ointment in the Treatment of Chronic Anal Fissure: A Randomized Clinical Trial.

BACKGROUND: Current therapeutic guidelines for the treatment of chronic anal fissure establish a medical approach as the first step. Glyceryl trinitrate ointment is the most popular of the available topical treatments in Spain but it is associated with the appearance of headache. OBJECTIVE: The purpose of this study was to compare the compliance rate among patients receiving glyceryl trinitrate treatment for chronic anal fissure with that among patients receiving percutaneous posterior tibial nerve stimulation. DESIGN: This was a prospective randomized study. SETTINGS: The study was conducted at Garcilaso Clinic (Madrid, Spain). PATIENTS: Subjects with persistent anal fissure despite hygiene and dietary measures applied over at least a 6-week period were included. INTERVENTIONS: Study interventions were perianal application of glyceryl trinitrate ointment (twice daily for 8 weeks) and percutaneous posterior tibial nerve stimulation (30-minute session 2 days per week for 8 weeks). MAIN OUTCOME MEASURES: Compliance with the treatment and healing rate of chronic anal fissure in patients receiving glyceryl trinitrate ointment or undergoing percutaneous posterior tibial nerve stimulation were evaluated. RESULTS: Forty patients were included in each group. In the glyceryl trinitrate ointment group, 15% of the patients discontinued treatment because of disabling headaches. There were no adverse effects or treatment withdrawals in the percutaneous posterior tibial nerve stimulation group (p = 0.033). After 8 weeks of treatment, the healing rate in the percutaneous posterior tibial nerve stimulation group was 87.5% vs 65.0% in the glyceryl trinitrate ointment group (p = 0.018). LIMITATIONS: Because the patients were not blinded to the treatment, we cannot rule out a placebo effect derived from the needle insertion in the percutaneous posterior tibial nerve stimulation group. CONCLUSIONS: Percutaneous posterior tibial nerve stimulation is a safe and effective alternative that is in some ways superior to glyceryl trinitrate ointment for the treatment of chronic anal fissure.

Long-term Effect of Percutaneous Electrical Neurostimulation of Dermatome T6 for Appetite Reduction and Weight Loss in Obese Patients.

Introduction: A continuous feeling of hunger is the major cause of dietary treatment failure and the patients abandon the diet. A previous study of our group demonstrated that percutaneous electrical neurostimulation (PENS) of T6 dermatome induces an appetite reduction and significantly greater weight loss compared with only diet as a preoperative measure in morbidly obese patients who are candidates for bariatric surgery. The aim of this study was to evaluate the long-term effect of this therapy. Patients and Methods: A prospective study was performed, including obese patients with a body mass index between 30 and 40 kg/m2 undergoing PENS of dermatome T6. Weight loss, dietary compliance, and appetite were assessed before the treatment, after 12 weeks of treatment, and 3 and 9 months after completing the therapy. Results: A total of 150 patients were included in the study. A mean weight loss of 11.8±2.6 kg was obtained after 12 weeks of treatment. Three months after completing the therapy, mean weight loss was 14.6±2.7 kg and 9 months after completing the treatment mean weight loss was 14.5±2.8 kg. Median appetite perception quantified by Visual Analogue Scale was 6 before the treatment, 1 after completing the treatment, 1 at 3 months after completing the treatment, and 4 at 9 months after completing the treatment. Dietary compliance after 12 weeks of treatment was 90%, 84% at 3 months after completing the treatment, and 62% at 9 months after completing the treatment. Conclusion: PENS of dermatome T6 achieves a significant appetite reduction, which is maintained 3 months after completing the therapy. Later, the patients’ appetite is restored, but they do not regain the weight lost.

Reduction of postoperative pain and improvement of patients' comfort after Milligan-Morgan hemorrhoidectomy using topical application of vitamin E ointment.

Dear Editor: Hemorrhoids are one of the most common anorectal disorders. Although hemorrhoidectomy is considered as a minor inpatient procedure, it is usually associated with significant postoperative pain during the first days after surgery, resulting in a protracted period of recovery and often preventing it from being an outpatient surgical procedure. The MilliganMorgan open hemorrhoidectomy is the most widely performed surgical approach for the management of hemorrhoids and is considered the Bgold standard^ procedure. However, an important postoperative pain is one of the main disadvantage of this procedure, negatively affecting the patients’ comfort, implying a delay until reincorporation to the normal activities. The aim of this study was to evaluate the effect of a topical application of vitamin E ointment on postoperative pain and incorporation of the patients to their usual activities. A prospective randomized clinical trial of patients undergoing Milligan Morgan hemorrhoidectomy between November 2014 and July 2015 at University Hospital King Juan Carlos (Mostoles—Madrid—Spain) was performed. The study has been approved by the local Ethics Committee and all the patients signed an informed consent form to be included in the study. Inclusion criteria were patients over 18 years old, with hemorrhoids grade III and IV, who underwent an elective Milligan-Morgan hemorrhoidectomy. Exclusion criteria were patients under 18 years old, with hemorrhoids grade I and II, and patients undergoing other surgical techniques for hemorrhoidectomy different than the Milligan-Morgan procedure. The sample size calculation was based on previously published studies reporting a median postoperative pain 24 h after Milligan-Morgan’s procedure measured by VAS in 6, despite intravenous analgesia, combinating acetaminophen and one NSAID (non-steroidal antiinflammatory drug), with rescue morphine bolus. We establish this point as median value for the control group. In the experimental group, a reduction of 33 % of the pain (median VAS 4) was expected. At 80 % power and a significance level of P<0.05, it was calculated that 30 patients were required in each arm of the study. Patients were randomly assigned using a random-number table into two groups: An experimental group (EG), including patients undergoing Milligan-Morgan’s procedure, who received the application of 2 ml vitamin E ointment (VEA Olio, Hulka SRL, Rovigo, Italy) on the surgical bed, and a control group (CG), including patients undergoing Milligan-Morgan’s procedure who received the application of 2 ml Vaseline ointment (Vaselina Orravan, Barcelona, Spain) on the surgical bed. Postoperatively, the same amount of ointment was applied every 12 h during 7 days. Postoperative analgesia included metamizole 2 g/8 h alternating with Dexketoprofen 50 mg/8 h iv. Morphine 3 mg was established as rescue treatment when VAS values overcame five points. The pain perception of the patient and the need for morphine rescue during the hospital stay were evaluated by a nurse, blinded to the treatment. After hospital discharge, the postoperative pain was evaluated in the outpatient clinic at the 3rd, 7th, and 30th postoperative days by a surgeon also blinded to the treatment. Pain was quantified by means of a ClinicalTrials.gov Identifier: NCT02554123