Julio Mayol

Risks of the Minimal Access Approach for Laparoscopic Surgery: Multivariate Analysis of Morbidity Related to Umbilical Trocar Insertion

Abstract. The objective of this study was to determine the morbidity associated with trocar and needle insertion for laparoscopic surgery and to identify risk factors for complications. Data from a prospectively collected database of all laparoscopic operations performed at a major teaching hospital over a 4-year period were analyzed. In 203 patients closed laparoscopy (Veress needle plus blind trocar insertion) was used to establish the pneumoperitoneum. Open laparoscopy with a Hasson’s trocar was performed in 200 patients. A total of 1206 operative trocars were inserted (mean ± SD 2.99 ± 0.4). Sixty-nine percutaneous punctures for cholangiography or liver biopsy were carried out. Of the 403 patients undergoing laparoscopic surgery, 20 (5%) had developed complications specifically related to the access to the abdominal cavity after a minimum follow-up of 3 months, abdominal wall hematoma being the most frequent (n= 8, 2.0%), followed by umbilical hernias (n= 6, 1.5%) and umbilical wound infection (n= 5; 1.2%). The rate of penetrating injuries was 0.2% (n= 1). Of 20 complications, 15 (75%) were related to the umbilical insertion site. Female sex and closed laparoscopy were associated with umbilical morbidity by univariate analysis. In a multivariate analysis, closed laparoscopy was the only factor associated with these complications (odds ratio = 6.0;p= 0.04). Age, gender, obesity, diabetes mellitus, previous abdominal surgery, and the specific procedure had no influence. In conclusion, gaining access to the peritoneal cavity for laparoscopic surgery may cause severe complications, most of which are related to the umbilical trocar. Although closed laparoscopy can be safely used, open laparoscopy is associated with a lower morbidity rate; therefore its utilization is recommended.

Single-blinded Randomized Trial of Mechanical Bowel Preparation for Colon Surgery with Primary Intraperitoneal Anastomosis

IntroductionWe report the final analysis of a prospective single-blinded randomized trial designed to investigate whether omission of preoperative mechanical bowel preparation increases the rate of surgical-site infection and anastomotic failure after elective colon surgery with intraperitoneal anastomosis by a single surgeon.Patients and MethodsPatients scheduled to undergo an elective colon or proximal rectal resection with a primary anastomosis by a single surgeon were randomized to receive either oral polyethylene glycol (Group A) or no mechanical bowel preparation (Group B). Patients were followed by an independent surgeon.ResultsOne hundred and forty nine patients were enrolled. Three patients (2%) were preoperatively excluded because of active immunosuppression and 13 (9%) were excluded from the final analysis. Of the remaining 129 patients, 65 were assigned to Group A and 64 to Group B. Thirty patients (23.2%) developed wound infection, (Group A = 24.6% and Group B = 17.2%; NS). There were three cases of intra-abdominal sepsis a (Group A 4.6%). The anastomotic failure rate was 5.4% (n = 7), four patients in Group A (6.2%) vs. three patients in Group B (4.7%) (NS). When SSI and anastomotic failure were combined, the complication rate in Group A was 35.4% vs. 21.9% for Group B. The NNH was 7.4.ConclusionOur final analysis shows that a single surgeon will not have a higher rate of either surgical-site infection or anastomotic failure if he/she routinely omits preoperative mechanical bowel preparation.

Mechanical bowel preparation for elective colorectal surgery with primary intraperitoneal anastomosis by a single surgeon: interim analysis of a prospective single-blinded randomized trial.

We report an interim analysis of a prospective single-blinded randomized trial designed to investigate whether preoperative mechanical bowel preparation influences the rate of surgical-site infection and anastomotic failure after elective colorectal surgery with primary intraperitoneal anastomosis performed by a single surgeon. Patients scheduled to undergo an elective colorectal procedure with a primary intraperitoneal anastomosis were randomized to receive either oral polyethylene glycol lavage solution and enemas (group A) or no preparation (group B). Surgical-site infection and anastomotic failure were investigated. Of 97 patients included, 48 were assigned to group A and 49 to group B. Twelve (12.4%) developed wound infections, six in each group (12.5 vs. 12.2%; NS). Intra-abdominal sepsis was only seen in group A (n = 3, 6.3%). Anastomotic failure occurred in four patients in group A (8.3%) vs. two patients in group B (4.1%) (NS). The overall complication rate in group A was 27.1%, vs. 16.3% in group B. The number needed to harm was 9.3. Our interim analysis of a prospective single-blinded randomized trial suggests that a surgeon may have the same or even worse outcomes when mechanical bowel preparation is routinely used for colorectal surgery with primary intraperitoneal anastomosis.

Social media in colorectal surgery.

The engagement of social media in healthcare continues to expand. For members of the colorectal community, social media has already made a significant impact on practice, education and patient care. The applications are unique such that they provide a platform for instant communication and information sharing with other users worldwide. The purpose of this article is to provide an overview of how social media has the potential to change clinical practice, training, research and patient care in colorectal surgery.

Open Biliary Tract Surgery: Multivariate Analysis of Factors Affecting Mortality

Background/Aim: The overall mortality rate in patients undergoing supraduodenal choledochotomy for benign biliary tract disease is around 3%. The aim of this study is to identify and quantify factors affecting the mortality in a group of patients undergoing open common bile duct exploration for benign biliary disease. Methods: Patients (n = 158) who underwent common bile duct exploration during a 5-year period in a teaching hospital were retrospectively reviewed. Results: Univariate and multivariate statistical analyses were performed. The former identified four statistically significant variables: age (p < 0.001), acute cholangitis on admission (p < 0.001), heart disease (p < 0.05), and a dilated common bile duct on preoperative ultrasound scan (p < 0.05). Multivariate analysis identified three variables which independently increased operative mortality: age (p = 0.05), heart disease (p = 0.03), and cholangitis (p = 0.008). The latter was associated with the greatest operative mortality, since it increased almost eight times the risk to die after surgical intervention. Conclusion: We conclude that an adequate perioperative cardiovascular management may be important in order to improve surgical outcome. Appropriate antibiotic prophylaxis and subsequent treatment after routine operative bile cultures may reduce septic complications and mortality. Finally, an alternative procedure, such as endoscopic sphincterotomy, may be indicated in high-risk patients in order to drain the common bile duct preoperatively and to decrease the risk of unresponsive biliary sepsis.

Twitter can enhance the medical conference experience

International communities on Twitter have emerged in many medical specialties, often collaborating around specific hashtags. In our own specialty, Twitter is the most common mobile application used by surgeons,1 and the hashtag #colorectalsurgery has become a unifying point for identifying specialty specific …

Electrogenic Ion Transport in Mammalian Colon Involves an Ammonia-Sensitive Apical Membrane K+ Conductance

It is remarkable that high ammonia concentrations can be present within the colonic lumen without compromising normal epithelial function. We investigated the impact of luminal ammonia on Cl− secretion in native tissue. Stripped human colonic mucosa and unstripped rat distal colon were used. Paired samples were mounted in modified Ussing chambers for electrophysiological studies. In rat distal colon, apical ammonia dose-dependently blocked forskolin-activated short-circuit current with an IC50 ≈ 5 mM. Basolateral NH4Cl was less effective. Luminal methylamine (50 mM), chromanol 293 B (10–50 μM), and Ba2+ (5 mM) blocked cAMP-activated short-circuit current but apical clotrimazole (100 μM) was without effect. In stripped human colonic mucosa, luminal but not basolateral NH4Cl (10 mM) and luminal Ba2+ (5 mM) suppressed forskolin-activated short-circuit current. Ammonia may be an endogenous regulator of colonic water and salt secretion. Apical K+ channels may be involved in the regulation of cAMP-stimulated Cl− secretion in mammalian colon.

Progesterone inhibits chloride transport in human intestinal epithelial cells.

Several pieces of evidence suggest that female sex hormones may play a role in the regulation of electrolyte transport. We therefore hypothesized that female sex hormones might impair regulated transcellular chloride transport in human intestinal epithelial cells. The T84 cell line was used for electrophysiological studies. Changes in transepithelial resistance and short-circuit current (Isc) were measured via a dual voltage/current clamp in epithelial monolayers. Short-circuit current is equivalent to chloride secretion in T84 cells. Forskolin and 8-Br-cyclic adenosine monophosphate (cAMP) were used to activate cAMP-dependent Cl− transport. Ca2+-dependent secretion was stimulated by the receptor-mediated Ca2+ agonist carbachol. Acute exposure (30 minutes) to either progesterone or estradiol did not affect monolayer viability as reflected by transepithelial resistance. Moreover, the secretory response to both cAMP and Ca2+ agonists remained unaffected. In contrast, long-term exposure (24 hours) to physiological concentrations of progesterone (100 nM), but not estradiol, dose-dependently reduced the peak Isc induced by the cAMP-agonist forskolin from 125±2.7 µA · cm−2 in the control group to 96±2.5 µA · cm−2 in monolayers exposed to progesterone (n=6 for each group; p<0.001). When the cAMP-analogue 8-Br-cAMP was used, the same behavior was observed (peak Isc=112±1.6 µA · cm−2 vs 88±1.7 µA · cm−2 for control vs. progesterone-treated monolayers; n=6 for each group; p<0.001). Taken together, our results suggest that progesterone but not estradiol inhibits cAMP-stimulated Cl− secretion in intestinal epithelial cells at a site distal to cyclic nucleotide generation.RésuméIl existe plusieurs preuves suggérant que les hormones sexuelles féminines jouent un rôle dans la régulation du transport des electrolytes. Nous avons émis l’hypothèse que les hormones sexuelles féminines pourraient entraver le transport transcellulaire de chlorure dans les cellules épithéliales intestinales d’origine humaine. La lignée cellulaire T84 a été utilisée pour les études éiectrophysioôgiques. Les changements dans la résistance transepitheliale et le courrant court-circuité ont été mesurés par un câmp à voltage/courant dans les monocouches épithéliales. Le courant court-circuité est équivalent à la sécrétion de chlorure par les cellules T84. Le forskoline et le 8-Br-cAMP ont été utilisés pour activer le transport de chlorure cAMP-dépendant. La sécrétion Ca2+-dépendante a été stimulée par l’agoniste carbachole, médiateur des récepteurs Ca2+. L’exposition aiguë (30 minutes) à la progestérone ou à l’œstradiol n’influencent pas la viabilité monocouches fait attesté par la résistance transépithéliale. Cependant, la réponse sécrétoire aux agonistes cAMP et Ca2+ n’est pas affectée. En revanche, l’exposition longue (24 h) aux concentrations physiologiques de progestérone (100 nM), mais pas d’oestradiol, réduisait Fisc maximal induit par l’agoniste cAMP, le forskoline, de 125±2.7 µA · cm−2 des contrôles à 96±2.5 µA · cm−2 dans les monocouches exposées à la progestérone (n=6 pour chaque groupe; p<0.001). Le même comportement a été observé lorsqu’on a utilisé l’analogue cAMP, le 8-Br-cAMP (Isc max=112±1.6 µA · cm−2 vs. 88±1.7 µA · cm−2 pour les contrôles vs. monocouches traitées par la progestérone; n=6 pour chaque groupe; p<0.001). Dans l’ensemble, ces résultats suggèrent que la progestérone, mais pas l’œstradiol, inhibe la sécrétion de Cl− stimulée par le cAMP dans les cellules épithéliales intestinales à un site en amont de la génération des nucleotides cycliques.ResumenDiversos trabajos han sugerido que las hormonas femeninas podrían desempeñar algún papel en la regulación del transporte de electrolitos. Nuestra hipótesis es que las hormonas femeninas podrían alterar la regulación del transporte transcelular del cloro en las células epiteliales del intestino humano. Para nuestro estudio electrofisiológico utilizamos la cepa de células T84. En monocapas epiteliales registramos, mediante un clamp dual voltage/corriente, los cambios de la resistencia transepitelial y los potenciales eléctricos de membrana. Éste equivale a la secreción de cloro en las células T84. Para activar el transporte del Cl− dependiente del AMP cíclico utilizamos forskolin y 8-Br-cAMP. La secreción Ca2+ dependiente se estimuló mediante el carbachol, un agonista de los receptores mediadores del Ca2+. La exposición breve (30 minutos) a la progesterona y al estradiol no afectó la viabilidad de la monocapa, como quedó demostrado por la resistencia transepitelial; tampoco se modificó la respuesta secretora tanto al cAMP como a los agonistas del Ca2+. Por el contrario, la exposición larga (24 horas) a concentraciones fisiológicas de progesterona (100nM) pero no del estradiol reduce, dependiendo de la dosis, la concentración máxima del Isc inducida por el forskolin cAMP agonista, desde 125±2.7 µ A · cm−2 en el grupo control hasta 96±2.5 µ A cm−2 en las monocapas expuestas a la progesterona (n=6 en cada grupo; p<0.001). Cuando se empleó el cAMP-análogo 8-Br-cAMP se constató una conducta similar (concentración máxima Isc=112±1.6 µ A · cm−2 vs 88±1.7 µA · cm−2 en el grupo control vs monocapa tratada con progesterona (n=6 en cada grupo; p<0.001). Estos hallazgos sugieren que la progesterona (no el estradiol) inhibe la secreción del Cl− estimulado por el cAMP en las células epiteliales intestinales en un punto distal a la generación del nucleotido cíclico.

Lactate Metabolism during Laparoscopic Cholecystectomy: Comparison between CO2 Pneumoperitoneum and Abdominal Wall Retraction

Recent reports have implicated CO2 pneumoperitoneum for laparoscopic surgery in the occurrence of postoperative mesenteric ischemia. With this kind of surgery, the increase in blood lactate levels has been attributed to anaerobic metabolism, probably due to tissue ischemia induced by high intraabdominal pressure (IAP). The aim of this study was to evaluate the metabolic repercussion of CO2 pneumoperitoneum during laparoscopic cholecystectomy (LC). This was a prospective randomized study of CO2 pneumoperitoneum (PP group, n= 19) versus abdominal wall retraction (AWR group, n= 15). Demographic data were collected preoperatively. Four-trocar LC was performed with either a CO2 pneumoperitoneum (IAP of 12 mmHg) or abdominal wall retraction (abdominal wall pressure 6–10 kp). Intraoperative and postoperative blood samples were collected and lactate levels determined by enzymatic analysis. Repeated measures analysis of variance (MANOVA) was used for statistical analysis. Significance was evaluated at p < 0.05. The groups were shown to be homogeneous. Lactate concentration, expressed as mean (SD), went from 25.4 (14.4) mg/dl at baseline to 18.9 (13.6) mg/dl 4 hours after surgery in the PP group and from 19.4 (6.1) mg/dl at baseline to 17.8 (14.7) mg/dl in the AWR group. No significant differences were found between groups intraoperatively (p= 0.116) or postoperatively (p= 0.99). Our study did not show significant differences in blood lactate levels during LC with CO2 pneumoperitoneum compared to the same procedure with abdominal wall retraction.

Gasless laparoscopic cholecystectomy is not moretime-consuming

BACKGROUND Although abdominal wall retraction is said to be advantageous in laparoscopic cholecystectomy (LC), many surgeons have found that, when this option is chosen, more time is needed to prepare for and carry out the surgical procedure. Our aim was to determine the time required for surgical preparation and operation in patients undergoing LC with carbon dioxide (CO2) pneumoperitoneum (CO2 PP) vs abdominal wall retraction (AWR). METHODS We performed a prospective randomized study of a CO2 PP LC group (n = 19) vs an AWR LC group (n = 15). Demographic data were collected preoperatively. LC was performed with either CO2 PP (12 mmHg) or AWR (6-10 kps). Two phases were considered: (a) time employed to create the surgical field (phase 1) and (b) operating time (phase 2). The chi-square test was used to compare the medians of the two groups. RESULTS The two groups were homogeneous. Phase 1 required 35 min in the CO2 PP group vs 25 min in the AWR group (p = 0.24). Phase 2 required 60 min in both groups (p = 0.76). CONCLUSION We found no statistically significant difference between the PP CO2 and AWR groups in either time spent to create the surgical field or actual operating time.