Jesús Abrisqueta

Randomized Prospective Study to Compare Laparoscopic Appendectomy Versus Umbilical Single-incision Appendectomy

Introduction: The use of single-incision laparoscopic surgery may represent an improvement over conventional laparoscopic surgery. In recent years, more and more articles have been published demonstrating the feasibility of this approach. Hence, for this reason, we present this randomized prospective study to compare the 2 techniques. Methods: Between September 2009 and December 2010, a total of 184 patients with a diagnosis of acute appendicitis and indicated for surgery were included in the study, of whom, 91 received an appendectomy via a single umbilical incision and 93 via conventional laparoscopy. The study protocol was approved by the ethical committee of the Virgen de la Arrixaca University Hospital (Murcia). The study was registered on ClinicalTrials.gov with inscription number NCT0151529. All the operations were performed by the same team of surgeons. Results: As far as the demographical results of the study population are concerned, there were no significant differences between the 2 groups for age, weight, sex, body mass index, and removed appendix type. Operating time was longer with the single-port approach: 38.13 ± 13.49 versus 32.12 ± 12.44 minutes (P = 0.02). Significant differences were observed for postoperative pain, which was measured on the visual analog scale, with less pain reported in the single-incision group: 2.76 ± 1.64 versus 3.78 ± 1.76 (P < 0.001). There were no significant differences between the 2 groups for early and late complications and lengths of hospital stay measured in postoperative hours. Conclusions: The transumbilical single-port approach is seen as a feasible technique for performing appendectomy. It does not increase the rate of complications and represents a possible alternative to conventional laparoscopic appendectomy.

Colectomía mediante puerto único vs colectomía mediante laparoscopia multipuerto. Revisión sistemática y metaanálisis de más de 2.800 procedimientos

OBJECTIVE Multiport laparoscopic surgery in colon pathology has been demonstrated as a safe and effective technique. Interest in reducing aggressiveness has led to other procedures being described, such as SILS. The aim of this meta-analysis is to evaluate feasibility and security of SILS technique in colonic surgery. MATERIAL AND METHODS A meta-analysis of twenty 7 observational studies and one prospective randomized trial has been conducted by the use of random-effects models. RESULTS A total amount of 2870 procedures was analyzed: 1119 SILS and 1751 MLC. We did not find statistically significant differences between SILS and MLC in age (WMD 0.28 [-1.13, 1.68]; P=.70), BMI (WMD -0.63 [-1.34, 0.08]; P=.08), ASA score (WMD -0.02 [-0.08, 0.04]; P=.51), length of incision (WMD -1.90 [-3.95, 0.14]; P=.07), operating time (WMD -2.69 (-18.33, 12.95]; P=.74), complications (OR=0.89 [0.69, 1.15]; P=.37), conversion to laparotomy (OR=0.59 [0.33, 1.04]; P=.07), mortality (OR=0.91 [0.36, 2.34]; P=.85) or number of lymph nodes harvested (WMD 0.13 [-2.52, 2.78]; P=.92). The blood loss was significantly lower in the SILS group (WMD -42.68 [-76.79, -8.57]; P=.01) and the length of hospital stay was also significantly lower in the SILS group (WMD -0.73 [-1.18, -0.28]; P=.001). CONCLUSION Single-port laparoscopic colectomy is a safe and effective technique with additional subtle benefits compared to multiport laparoscopic colectomy. However, further prospective randomized studies are needed before single-port colectomy can be considered an alternative to multiport laparoscopic surgery of the colon.

The influence of the percentage of the common limb in weight loss and nutritional alterations after laparoscopic gastric bypass

BACKGROUND Roux-en-Y gastric bypass (RYGB) is considered the gold standard for the treatment of morbid obesity. There is no consensus over ideal limb length when the bypass is created and published studies do not take into account the influence of the common limb (CL) on weight loss. The objective was to study the influence of the common limb after RYGB. The setting was the Virgen de la Arrixaca University Clinical Hospital in Murcia, Spain. MATERIAL AND METHODS This prospective study includes 151 patients undergoing laparoscopic RYGB surgery for morbid obesity. The patients were divided into 2 groups according to their body mass index. The small intestine (SI) was measured using micro forceps so that the percentage of common limb (%CL) could then be compared against the total SI in each patient. The percentage of excess weight loss (%EWL) in relation to the %CL was calculated at 3, 12, and 24 months. A series of tests was conducted simultaneously to analyze nutritional deficiencies and their relation to the %CL. RESULTS The total jejunoileal segment and the %CL in the groups of both obese and super-obese patients had no influence on the %EWL in either group for any of the periods studied. The patients with a %CL<50% had greater nutritional deficiencies in the follow-up period and required supplements and more frequent laboratory tests. CONCLUSIONS The %CL has no effect on weight loss in RYGB patients. A lower %CL is related to greater nutritional deficiencies.

Apendicectomía laparoscópica mediante incisión única transumbilical: experiencia inicial

INTRODUCTION Appendicitis is the most common abdominal emergency. The treatment is surgical and single incision laparoscopic surgery (SILS) involves performing laparoscopic surgery through a single transumbilical point, in an attempt to improve the results of laparoscopic surgery. MATERIAL AND METHOD A total of 73 patients with suspected acute appendicitis were operated on using the SILS technique between June 2009 and August 2010. All patients were operated on by the same surgical team, and the navel was the only point of entrance. Post-surgical pain was assessed using a numerical scale at the time of discharge. RESULTS None of the patients required conversion to conventional laparoscopy. The mean surgical time was 40±14 (16-80) minutes. There were no complications during or after the surgery. The mean post-surgical pain score was 3±1 (1-7) and the mean hospital stay was 18±7 (9-42) hours. CONCLUSION SILS is a safe and effective technique for appendicitis. In the future, the most common surgical procedures could be performed through the navel. This would be by surgeons, highly experienced in advance laparoscopic surgery in order to introduce this new technique safely without increasing morbidity and mortality.

Aprendizaje de la cirugía del cáncer de recto por laparoscopia sin aumento de la morbimortalidad

INTRODUCTION The treatment of rectal cancer via laparoscopy is controversial due to its technical complexity. Several randomized prospective studies have demonstrated clear advantages for the patient with similar oncological results to those of open surgery, although during the learning of this surgical technique there may be an increase in complications and a worse prognosis. OBJECTIVE Our aim is to analyze how the learning curve for rectal cancer via laparoscopy influences intra- and postoperative results and oncological markers. A retrospective review was conducted of the first 120 patients undergoing laparoscopic surgery for rectal neoplasia. The operations were performed by the same surgical team with a wide experience in the treatment of open colorectal cancer and qualified to perform advanced laparoscopic surgery. We analyzed sex, ASA, tumour location, neoadjuvant treatment, surgical technique, operating time, conversion, postoperative complications, length of hospital stay, number of lymph nodes, stage and involvement of margins. RESULTS Significant differences were observed with regard to surgical time (224 min in the first group, 204 min in the second group), with a higher rate of conversion in the first group (22.5%) than in the second (11.3%). No significant differences were noted for rate of conservative sphincter surgery, length of hospital stay, post-surgical complications, number of affected/isolated lymph nodes or affected circumferential and distal margins. CONCLUSIONS It is possible to learn this complex surgical technique without compromising the patients safety and oncological outcome.

Stimulation of the efferent limb before ileostomy closure: a randomized clinical trial.

BACKGROUND:Postoperative ileus is the most common complication after ileostomy closure with an increase in morbidity, hospital stay, and health care costs. OBJECTIVE:The aim of this study is to assess the utility of a new technique for reducing postoperative ileus after protective ileostomy closure. DESIGN:This is a prospective randomized study registered at ClinicalTrials.gov (NCT01881594). Patients were randomly assigned to undergo either stimulation through the efferent limb of the ileostomy before surgery or nonstimulation before surgery. SETTING:This study was conducted at the Department of Surgery of the Virgen de la Arrixaca Clinical University Hospital (Murcia). PATIENTS:Seventy patients underwent surgery for ileostomy closure. In 35 patients, during the 2 weeks before surgery, daily stimulation of the defunctionalized stomal segment was performed by using a thick solution (500 mL of physiological saline associated with 30 g of thickening agent, Nestle Resource, Vevey, Switzerland). In the other 35 patients, stimulation was not performed before surgery. MAIN OUTCOME MEASURES:The primary outcome was postoperative ileus. The secondary outcomes included time to tolerating a diet and postoperative stay. RESULTS:Both groups of patients were homogenous for demographic data, characteristics of the first rectal cancer operation, and intersurgery periods. After ileostomy closure, the stimulated group of patients had an earlier return to oral tolerance (1.06 vs 2.57 days; p = 0.007) and passage of flatus or stool (1.14 vs 2.85 days; p <0.001) than the nonstimulated group of patients. The incidence of postoperative ileus (2.85% vs 20%; p = 0.024) and hospital stay (2.49 vs 4.61 days; p = 0.002) was also lower in the stimulated patients. LIMITATIONS:Small numbers of patients means that no definitive statements can be made regarding the effectiveness of this technique. CONCLUSIONS:Stimulation of the efferent limb of the ileostomy before closure is a safe technique that reduces postoperative ileus and fosters early intestinal transit and oral tolerance with a shorter postoperative hospital stay.

Estimulación del asa eferente previa al cierre de ileostomía

There is a 17% complications rate after ileostomy closure, with paralytic ileus being the most common. With the aim of reducing this complication, stimulation via the afferent loop was performed daily for the 2 weeks prior to the stoma.

Utility of rectoscopy in the assessment of response to neoadjuvant treatment for locally advanced rectal cancer.

Background/Aims: The management of locally advanced rectal cancer has changed substantially over the last few decades with neoadjuvant chemoradiotherapy. The aim of the present study is to compare the results between neoadjuvant post-treatment rectoscopy and the anatomopathological findings of the surgical specimen. Patients and Methods: We conducted a prospective study of 67 patients with locally advanced adenocarcinoma of the rectum (stages II and III). Two groups were established: One with complete clinical response (cCR) and one without (non-cCR), based on the findings at rectoscopy. Assessment of tumor regression grade in the surgical specimen was determined using Mandards tumor regression scale. Results: Seventeen patients showed a cCR. Thirty-five biopsies were negative and 32 were positive for mailgnancy. All the cCR patients had a negative biopsy (P < 0.0001). All 32 positive biopsies revealed the presence of adenocarcinoma, and of the 35 negative biopsies, 18 had no malignancy and 17 were diagnosed with adenocarcinoma (P < 0.0001). Sixteen of the 17 cCR patients showed a complete pathological response and one patient showed the presence of adenocarcinoma. Of the 50 non-cCR patients 48 revealed the presence of adenocarcinoma and two had absence of malignancy. According to the Mandard classification, 16 of the 17 cCR patients were grade I and 1 grade II; 2 non-cCR patients were grade I, 7 grade II, 13 grade III, 19 grade IV, and 9 grade V. Conclusions: Endoscopic and histological findings could be determinants in the assessment of response to neoadjuvant treatment.

Valoración del resultado estético percibido por los pacientes apendicectomizados vía laparoscópica mediante tres incisiones

INTRODUCTION The aesthetic result has lately been used in General Surgery as an argument for the development of new approaches. On numerous occasions attempts have been made to evaluate the perception that the patients themselves have after their operation by whatever approach, with the aim of finding where we differ and if there is a real option for improvement. The objective of this study was to analyse, using a simple questionnaire, the assessment of the aesthetic results as perceived by patients after appendectomy, and to attempt to determine what are the variables involved in an aspect so subjective as this. PATIENTS AND METHOD The variables collected were: age, sex, time since operation, infection of surgical wound, and presence of a drainage, as well as the responses on the aesthetic result of 70 patients who had a 3-port laparoscopic appendectomy. RESULTS Infection of the surgical wound, as well as the age of the patients and the time since the operation determined statistically significant differences in their opinions as regards the number, size and overall aesthetic result of the laparoscopic appendectomy. The median overall satisfaction of the aesthetic result was 9 on a scale from 0 to 10. CONCLUSIONS The assessment of the aesthetic result by patients after a 3-port laparoscopic appendectomy is good and is difficult to improve. It is recommended to prevent infection of the three ports after the intervention to obtain better results.

Tratamiento de la hemorragia presacra tras cirugía colorrectal mediante el uso del balón de Bakri

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