José Luis Muñoz

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.

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 Peritoneal Lavage with Clindamycin-Gentamicin Solution on Post-Operative Pain and Analytic Acute-Phase Reactants after Laparoscopic Sleeve Gastrectomy.

BACKGROUND Peritoneal lavage has been proposed to remove bacterial contamination and other materials promoting bacterial proliferation and pro-inflammatory cytokines that may enhance local inflammation. The aims of this study were to evaluate the effects of peritoneal lavage with physiologic saline or an antibiotic solution (clindamycin-gentamicin) on post-operative pain and analytic acute-phase reactants and to determine the microbiologic impact of both irrigations on peritoneal contamination in patients undergoing laparoscopic sleeve gastrectomy (LSG) as a bariatric procedure. METHODS The patients were randomized into two groups: Those undergoing an intra-abdominal lavage with physiologic saline (Group 1; n = 40) and those undergoing a similar lavage with a gentamicin-clindamycin solution (Group 2; n = 40). Peritoneal contamination, post-operative pain, and analytic acute-phase reactants 24 h after surgery were investigated. RESULTS The median pain score 24 h after surgery was 3.5 in Group 1 and 1.5 in Group 2 (p = 0.021). The glucose concentration (mean difference 33.1 mg/dL; p = 0.004), aspartate aminotransferase (AST) concentration (mean difference 41.8 U/L; p = 0.009), alanine aminotransferase (ALT) concentration (mean difference 34.2 U/L; p = 0.029), white blood cell count (mean difference 1930/mm(3); p = 0.029); C-reactive protein concentration (mean difference 27.3 mg/L; p = 0.036), and serum lactic acid concentration (mean difference 0.34 mg/L; p = 0.049) were significantly higher in Group 1. Peritoneal contamination also was significantly higher in Group 1 (17.5% vs 0; p = 0.006). CONCLUSIONS Intra-peritoneal irrigation with a gentamicin and clindamycin solution in patients undergoing LSG leads to a reduction in post-operative pain and peritoneal contamination, less alteration of acute-phase reactants, lower blood glucose concentration, a smaller increase in liver enzymes, and a shorter hospital stay.

Implementation of the Spanish ERAS program in bariatric surgery

Abstract Introduction: The essence of Enhanced Recovery After Surgery (ERAS) programs is the multimodal approach, and many authors have demonstrated safety and feasibility in fast track bariatric surgery. According to this concept, a multidisciplinary ERAS program for bariatric surgery has been developed by the Spanish Fast Track Group (ERAS Spain). The aim of this study was to analyze the initial implementation of this Spanish National ERAS protocol in bariatric surgery, comparing it with a historical cohort receiving standard care. Material and methods: A multi-centric prospective study was performed, including 233 consecutive patients undergoing bariatric surgery during 2015 and following ERAS protocol. It was compared with a historical cohort of 286 patients, who underwent bariatric surgery at the same institutions between 2013 and 2014 and following standard care. Compliance with the protocol, morbidity, mortality, hospital stay and readmission were evaluated. Results: Bariatric techniques performed were Roux-en-Y gastric bypass and sleeve gastrectomy. There were no significant differences in complications, mortality and readmission. Postoperative pain and hospital stay were significantly lower in the ERAS group. The total compliance to protocol was 80%. Conclusion: The Spanish National ERAS protocol is a safe issue, obtaining similar results to standard care in terms of complications, reoperations, mortality and readmissions. It is associated with less postoperative pain and earlier hospital discharge.

Incidence of postoperative nausea and vomiting after laparoscopic sleeve gastrectomy with staple line reinforcement with oversewing and staple line inversion vs buttressing material: A randomized clinical trial

BACKGROUND Postoperative nausea and vomiting are relevant complications after restrictive bariatric procedures, such as sleeve gastrectomy, mainly secondary to a drastic reduction in the gastric volume. However, other causes can be involved. The aim of this study was to determine the incidence of postoperative nausea and vomiting (PONV) after laparoscopic sleeve gastrectomy (LSG), with staple line reinforcement with oversewing vs buttressing material. PATIENTS AND METHODS A prospective randomized clinical trial of all the patients undergoing LSG was performed. Patients were divided into 2 groups: patients undergoing staple line inversion (Group 1) and patients undergoing staple line reinforcement with buttressing material (Group 2). Nausea and vomiting were assessed by the Postoperative Nausea and Vomiting Intensity Scale. RESULTS A total of 100 females were included in the study, 50 in each group. Mean operative time was 66.1 ± 11.6 min in Group 1 and 55.4 ± 9.4 in Group 2 (p < 0.001). There were no significant differences in staple line leaks and bleeds between groups. The PONV intensity score at 6 h was 316.4 in Group 1 and 77.1 in Group 2 (p < 0.001). 24 h after surgery, the PONV intensity score was 86 in Group 1 and 7.9 in Group 2 (p = 0.022). CONCLUSION The reinforcement with a running suture in LSG creates more PONV and increases the duration of the symptoms during the first hours after surgery, and prevents from early oral intake in a greater number of cases, when compared with the use of buttressing material as reinforcement method.