Juan C. Rodríguez-Sanjuán

Acute cholecystitis in high surgical risk patients: percutaneous cholecystostomy or emergency cholecystectomy?

BACKGROUND Percutaneous cholecystostomy (PC) is an alternative treatment in acute cholecystitis (AC) in high-risk or elderly patients although its advantage over emergency cholecystectomy has not yet been established. STUDY DESIGN AC prospective database analysis in high-risk patients treated by PC (group 1, 29 patients) or emergency cholecystectomy (group 2, 32 patients). Surgical risk was estimated by physiological POSSUM, Charlson, Apache II, and American Society of Anesthesiologists (ASA) scores. RESULTS The groups showed homogeneity concerning age and surgical risk. PC allowed AC resolution in 19 patients (70.4%), but 8 (29.6%) needed emergency cholecystectomy. Morbidity and mortality rates were 31% and 17.2%, respectively. Mortality was significantly associated with ASA IV (P = .01). In group 2, the morbidity rate was 28.1% without mortality. There was no statistical difference in morbidity (P = .6) although mortality was significantly higher in group 1 (P = .02). CONCLUSIONS PC seems of little benefit and ought to be left for those very old patients with surgical contraindication.

Perforated Peptic Ulcer Treated by Simple Closure and Helicobacter Pylori Eradication

Simple closure followed by Helicobacter pylori (Hp) eradication has become the most used procedure in perforated ulcer treatment. However, its efficacy and safety are still to be determined. To assess recurrence and re-perforation rates, and as a secondary objective, to analyze Hp infection rates in perforated ulcer patients and controls, we conducted a prospective study. Ninety-two consecutive patients (ages: 19–96 years) were operated on between 1996 and 2002, and treated by simple closure followed by Hp eradication and NSAID avoidance. The data were prospectively collected in a database. Hp infection was diagnosed in 68 patients (73.9%). Thirty-four patients (37%) consumed nonsteroidal anti-inflammatory drugs (NSAIDs), and 23 (25%) had both Hp infection and NSAID antecedents. The perforation was gastric in 4 cases and pre-pyloric, pyloric or duodenal in 88. There were postoperative complications in 24 patients (26%) and 4 patients died (4.3%). Hp eradication was shown in 46 patients. There was clinical ulcer recurrence in 4 (4.3%); in 3 of them recurrence manifested as re-perforation, all in gastric locations. Overall relapse and re-perforation 1-year crude rates were 6.1% and 4.1%, respectively. Crude rates for non-gastric ulcer recurrence were 0 at 1 year and 2.6% at 2 years and for non-gastric ulcer re-perforation rates were 0 at 1 and 2 years. This therapeutic strategy is associated with a low rate of recurrence and no re-perforations in case of duodenal, pyloric, or pre-pyloric perforated ulcers, but it is not acceptable for perforated gastric ulcers.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissens fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Initial results of robot‐assisted Ivor–Lewis oesophagectomy with intrathoracic hand‐sewn anastomosis in the prone position

There is scanty experience concerning robot‐assisted Ivor–Lewis oesophagectomy, so every new experience is helpful.

Fatal portal thrombosis after laparoscopic Nissen fundoplication

Portal and mesenteric vein thrombosis is a very uncommon complication of laparoscopic surgery, especially after anti-reflux procedures. We report the case of a twenty-year-old man with a history of alcohol and cocaine consumption. A Nissen fundoplication was performed. The patient received a single 20-mg dose of enoxaparin (Clexane, Aventis Pharma, Spain) two hours before surgery for antithrombotic prophylaxis. On the seventh postoperative day the patient had a portal and mesenteric venous thrombosis, which was confirmed at laparotomy, with both extensive small-intestine necrosis and partial colon necrosis. Despite anticoagulant therapy, the patient died 24 hours later. Surgical findings were confirmed at necropsy. Portal and mesenteric venous thrombosis is an uncommon but severe and even fatal complication after laparoscopic anti-reflux surgery. When other pro-thrombotic, predisposing conditions such as laparoscopic surgery and cocaine consumption are present, the usual prophylactic doses of low molecular weight heparin might not be sufficient to protect against this life-threatening complication.

Resultados iniciales de la esofaguectomía robótica en el cáncer de esófago

INTRODUCTION There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. PATIENTS AND METHODS Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. RESULTS Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23). CONCLUSIONS Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards.

Anestesia local por tumescencia con solución de Klein modificada comparada con anestesia general en la intervención por sinus pilonidal

Resumen Introduccion Existe controversia sobre el metodo anestesico para el tratamiento quirurgico del sinus pilonidal. Por un lado, la anestesia general se asocia con un indice de complicaciones poco frecuentes pero importantes, y puede dificultar en algunos casos el alta en los procedimientos de cirugia ambulatoria. Por otro, el uso de anestesia local pura puede no resultar eficaz, o bien puede asociarse a toxicidad si se emplean dosis altas. Los objetivos de este trabajo son: a) analizar los resultados anestesicos de la anestesia local por tumescencia (ALT) con solucion de Klein modificada, y b) realizar un estudio comparativo entre la ALT con solucion de Klein modificada y la anestesia general, en cuanto a complicaciones postoperatorias. Pacientes Y Metodo Realizamos un estudio prospectivo no aleatorizado sobre 100 pacientes intervenidos de sinus pilonidal en un intervalo de un ano (enero a diciembre de 1999). Estos pacientes se dividen en dos grupos en funcion de su metodo anestesico: grupo A (n = 50) con anestesia local con solucion de Klein modificada, con/sin sedacion, y grupo B (n = 50) con anestesia general. La estimacion del dolor intraoperatorio se realizo mediante escala visual analogica (EVA). Se valoran de forma comparativa las complicaciones postoperatorias como supuracion, seroma, hemorragia e imposibilidad de cumplir criterios de cirugia mayor ambulatoria. Resultados La estimacion del dolor por el paciente mediante EVA arrojo una puntuacion media de 1,4, con un rango de 0-8. El porcentaje de pacientes con EVA ≤ 2 es del 80%. La supuracion aparece en 0% en el grupo A y en el 6% en el grupo B, en ambos casos en los primeros 3 meses postoperatorios. El seroma aparece en el 2% (un caso) en el grupo A y en el 6% en el grupo B (3 casos). La hemorragia postoperatoria ocurre en el 10% del grupo A (5 casos) y en el 12% del grupo B (6 casos). Conclusiones La ALT mediante solucion de Klein modificada es eficaz en el tratamiento quirurgico del sinus pilonidal. No se produce una mayor hemorragia postoperatoria con esta tecnica que con anestesia general y, globalmente, se aprecian pocas complicaciones postoperatorias, por lo que creemos que la utilizacion de este metodo anestesico es una buena opcion y obtiene ventajas en la practica diaria sobre la anestesia general, especialmente si se realiza cirugia mayor ambulatoria.

Evaluation of Early Cholecystectomy versus Delayed Cholecystectomy in the Treatment of Acute Cholecystitis

Objective. To evaluate if early cholecystectomy (EC) is the most appropriate treatment for acute cholecystitis compared to delayed cholecystectomy (DC). Patients and Methods. A retrospective cohort study of 1043 patients was carried out, with a group of 531 EC cases and a group of 512 DC patients. The following parameters were recorded: (1) postoperative hospital morbidity, (2) hospital mortality, (3) days of hospital stay, (4) readmissions, (5) admission to the Intensive Care Unit (ICU), (6) type of surgery, (7) operating time, and (8) reoperations. In addition, we estimated the direct cost savings of implementing an EC program. Results. The overall morbidity of the EC group (29.9%) was significantly lower than the DC group (38.7%). EC demonstrated significantly better results than DC in days of hospital stay (8.9 versus 15.8 days), readmission percentage (6.8% versus 21.9%), and percentage of ICU admission (2.3% versus 7.8%), which can result in reducing the direct costs. The patients who benefited most from an EC were those with a Charlson index > 3. Conclusions. EC is safe in patients with acute cholecystitis and could lead to a reduction in the direct costs of treatment.

Radiofrequency ablation must be assessed by pathological methods.

We read with interest the article by N’Kontchou et al.1 concerning hepatocellular carcinoma treatment by radiofrequency ablation (RFA). They report an excellent series with impressive results in terms of both very low major complication and tract seeding rates as well as a considerable long-term survival. Their complete response rate is 94.7%. However, this was assessed by radiological methods (magnetic resonance imaging and computed tomography) and not by pathological examination. As a result, the true response rate could be lower. Our modest experience with 30 hepatocellular carcinoma nodules treated by RFA before liver transplant was recently published.2 We performed a pathological analysis of the explanted liver and found that only 14 nodules (46.7%) showed complete tumor destruction. In our study, the detection of RFA incomplete response by means of computed tomography scan had a 50% sensitivity and 100% specificity. The reported rates of complete pathological response in other works were variable but lower than those reported by N’Kontchou et al.: 20%,3 34.2%,4 37.5%,5 46.7%,6 55%,7 70.3%,8 and 75%.9 In these studies, as in ours, pathological examination was performed using hematoxylin-eosin stains. Although RFA cannot be considered as a radical or curative treatment, and the ideal situation would be complete tumor destruction, partial destruction is probably enough to increase long-term survival and, especially, to avoid patient drop-out from liver transplant waiting lists.

Liver Transplant from Controlled Cardiac Death Donors using Normothermic Regional Perfusion. a Comparison with Liver Transplants From Brain Death Donors

BACKGROUND Liver transplantation from donors after either controlled or uncontrolled cardiac death (DCD) is associated with considerable rates of primary nonfunction (PNF) and ischemic cholangiopathy (IC). Normothermic regional perfusion (NRP) could significantly reduce such rates. METHODS Retrospective study to analyze short-term (mortality, PNF, vascular complications) and long-term (IC, survival) complications in 11 liver transplants from controlled DCDs using NRP with extracorporeal membrane oxygenation (ECMO) (group 1). They were compared with 51 patients transplanted with grafts from donors after brain death (DBD) (group 2). Mean recipient age, sex, and Model for End-stage Liver Disease (MELD) score were not significantly different. RESULTS In group 1, mean functional warm ischemia time was 15.8 (range, 7-40) minutes and 94.1 (range, 20-150) minutes on NRP. The ischemic damage was minimal, as shown by the slight alanine aminotransferase (ALT) and aspartate aminotransferase (AST) rises in the donor serum after 1 hour on NRP and similar rises 24 hours after transplantation in both groups. No patient had IC or acute renal failure. No significant difference was found between the groups for vascular or biliary complications. One group 1 patient had PNF (9.1%), resulting in death. Overall retransplantation and in-hospital death rates were 8.1% and 4.8%, respectively, with no significant difference between groups. Estimated mean survival was 24.6 (95% confidence interval [CI], 20.2-29.1) months in group 1 and 32.3 (95% CI, 30.4-34.2) months in group 2 (not a statistically significant difference). CONCLUSION In our experience, liver transplants from controlled DCDs using NRP with ECMO is associated with a low risk of PNF and IC, with short- and long-term results comparable to those in DBD transplants.