María Luisa García-García

Protective ileostomy: complications and mortality associated with its closure

INTRODUCTION diverting loop ileostomies are widely used in colorectal surgery to protect low rectal anastomoses. However, they may have various complications, among which are those associated with the subsequent stoma closure. The present study analyses our experience in a series of patients undergoing closure of loop ileostomies. METHOD retrospective study of all the patients undergoing ileostomy closure at our hospital between 2006-2010. There were 89 patients: 56 males (63%) and 33 females (37%) with a mean age of 55 (38-71) years. The most common indication for ileostomy was protection of a low rectal anastomosis, 81 patients (91%). The waiting time until stoma closure, type and frequency of the complications, length of hospital stay and mortality rate are analysed. RESULTS waiting time before surgery was 8 (1-25) months. Forty-one patients (45,9%) developed some type of complication, three were reoperated (3.37%) and one patient died (1.12%). The most important complications were intestinal obstruction (32.6%), diarrhoea(6%), surgical wound infection (6%), enterocutaneous fistula (4.5%), rectorrhagia (3.4%) and anastomotic leak (1.12%). The mean length of patient stay was 7.54 (2-23) days. CONCLUSIONS protective ostomies in low rectal anastomoses have proved to be the only preventive measure for reducing the morbidity and mortality rates for anastomotic leakage. However, creation means subsequent closure, which must not be considered a minor procedure but an operation with possibly significant complications, including death, as has been shown in publications on the subject and in our own series.

Endoscopia urgente por hemorragia digestiva tras cirugía bariátrica. Algoritmo terapéutico

OBJECTIVE Gastrointestinal bleeding (GB) is a potential complication after bariatric surgery and its frequency is around 2-4% according to the literature. The aim of this study is to present our experience with GB after bariatric surgery, its presentation and possible treatment options by means of an algorithm. PATIENTS AND METHOD From January 2004 to December 2012, we performed 300 consecutive laparoscopic bariatric surgeries. A total of 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of a gastrojejunal anastomosis using a circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. Demographics, clinical presentation, diagnostic evaluation and treatment were reviewed. A total of 20 patients underwent a sleeve gastrectomy. RESULTS Twenty-seven cases (9%) developed GB. Diagnosis and therapeutic endoscopy was required in 13 patients. The onset of bleeding occurred between the 1(st)-6(th) postop days in 10 patients, and the origin was at the gastrojejunostomy staple-lines, and 3 patients had bleeding from an anastomotic ulcer 15-20 days after surgery. All other patients were managed non-operatively. CONCLUSION Conservative management of gastrointestinal bleeding is effective in most cases, but endoscopy with therapeutic intent should be considered in patients with severe or recurrent bleeding. Multidisciplinary postoperative follow- up is very important for early detention and treatment of this complication.

Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Experiencia en una serie de 280 casos en 8 años

OBJECTIVE Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass, but its frequency is about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass. PATIENTS AND METHOD From January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis is performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation. RESULTS Twenty cases (7.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and all case were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up has not been detected re-stricture. CONCLUSION Structure at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.

Failure of the Obesity Surgery Mortality Risk Score (OS-MRS) to Predict Postoperative Complications After Bariatric Surgery. A Single-Center Series and Systematic Review

BackgroundThe obesity surgery mortality risk score (OS-MRS) was developed to determine the risk of postoperative mortality in patients undergoing bariatric surgery. The aim of the present study is to assess the utility of this score for preventing the risk of postoperative complications from bariatric surgery.MethodsProspective study of 321 patients undergoing bariatric surgery to whom the OS-MRS was applied. Postoperative complications were classified according to the Clavien-Dindo system. The relation between the OS-MRS and the appearance of complications and mortality was analyzed. A Medline/Embase search was conducted using bariatric surgery, mortality, and complications as key words. Studies using the OS-MRS to predict morbidity and mortality were included.ResultsOf the 321 patients, 303 (94.3%) underwent gastric bypass and the remaining 18 (5.6%) a sleeve gastrectomy. The OS-MRS classified 178 patients as class A (55.5%), 129 as class B (40.2%), and 14 as class C (4.4%). According to the Clavien-Dindo system, 10.4% of the complications were ≥III. There was one death (class B). No significant association was found between the OS-MRS and the rate of complications.ConclusionsIn our study, the OS-MRS is not correlated with the appearance of early complications or mortality. Future studies must focus on systems for predicting the appearance and severity of postoperative complications classified according to the Clavien-Dindo system, and not only on mortality.

Schwannoma en colon descendente: presentación de una neoplasia en rara localización

Presentamos un varón de 67 años en el que la colonoscopia de cribado evidenció, a 35 cm del margen anal, una lesión polipoidea ulcerada. La biopsia fue inespecífica. La TC y la colonografía virtual mostraron una masa polipoidea en colon izquierdo de 4,5x3,6x3,7 cm con adenopatías regionales, sin metástasis a distancia. El paciente acudió a urgencias por rectorragia y dolor abdominal. La ecografía mostró una invaginación cólico-cólica originada por la masa polipoidea. Se intervino mediante laparotomía media objetivándose una invaginación en colon descendente, sin observar infiltración ni diseminación a distancia. Se realizó una colectomía segmentaria con anastomosis latero-lateral mecánica. El paciente evolucionó favorablemente. El estudio anatomopatológico informó de una tumoración blanco-amarillenta submucosa bien delimitada constituida por células fusiformes que formaban empalizadas, un infiltrado linfoide intratumoral con nódulos periféricos y escasa actividad mitótica. La inmunohistoquímica dio positividad para S-100 y CD68, no habiendo reactividad para CD117, CD34, actina y CD10 (Fig. 1). El diagnóstico definitivo fue de schwannoma de colon. En 3 años de seguimiento no se ha evidenciado recidiva.

Reflexiones sobre los fines de semana y festivos en los hospitales

It is a well-known fact that the medical care the hospitalized patients receive is not the same on weekdays as on weekends and holidays. The quality of health care on weekends has been studied with regard to emergencies and critical care in particular. In general, greater mortality, complications and length of hospital stay have been observed in patients admitted or operated on during the weekend compared to other days of the week. This is attributed to the fewer resources available as well as the more limited experience and skills of weekend staff. A recent study gives adds new data by analyzing the differences in mortality of elective surgery performed on different days of the week. Aylin et al.have studied the 30-day mortality rate of 4 133 346 patients who had undergone elective surgical procedures while hospitalized at English hospitals over the course of 3 years; they later correlated these data with the day of surgery. Emergency and ambulatory surgeries were excluded. Among their findings, they observed how the risk of mortality significantly rises over the course of the successive days of the week (Table 1). It is striking that a surgical patient has a 44% higher risk of death if surgery is performed on a Friday than on a Monday. The study is serious, and among the explanations proposed for these differences is the varying level of health care (diagnostic and therapeutic) that is provided in the immediate postoperative period at the end of the week. The situation in Spanish hospitals may be different from that of English hospitals but, in any event, the medical care provided between 3 pm on Friday afternoons and 8 am on Monday mornings (65 h, 38.69% of the week) has always been a concern. And that is without mentioning long-weekends, holidays or vacations. We should admit that during these time periods, the resources and capabilities available are reduced. Holidays and Sundays can be particularly problematic. Barba et al., at the Hospital de Alcorcón in Madrid, reported a higher risk of mortality in patients who had been hospitalized on the weekend. Meanwhile, we ourselves have brought attention to the importance of systematic hospital rounds on Sundays for early detection of clinical problems, while reducing unnecessary hospital stays and costs. We cannot be certain whether the findings of Aylin would be reproducible in Spanish hospitals, but our intuition tells us that the answer would be ‘yes’. During the 65 h that transpire after 3 pm on Fridays, the same capability for response on weekends does not exist when compared with normal working conditions. Surgical teams are probably not much of an influencing factor, as they distribute work in a cyclical timeframe, but there is a reduction in the accessibility to diagnostic procedures and intensive care support. We general surgeons are dependent on these services and responsible for surgical emergencies, and among these are the serious postoperative complications. We should be able to provide continuous, attentive care to surgical patients, which would enable us to detect and quickly treat any deviations from the c i r e s p . 2 0 1 4 ; 9 2 ( 2 ) : 1 4 2 – 1 4 4

Perioperative complications following bariatric surgery according to the clavien-dindo classification. Score validation, literature review and results in a single-centre series

BACKGROUND There is no unified system for reporting surgical complications after bariatric surgery. One increasingly used system for notifying postoperative complications is the Clavien-Dindo classification, which focuses on their therapeutic implications. OBJECTIVE The aim of this study is to validate and apply the Clavien-Dindo scale to a series of cases of bariatric surgery and systematically review its use worldwide. SETTING University hospital. METHODS A cohort of 321 patients with morbid obesity (Mean BMI: 45.4±5.5 kg/m2) underwent surgery by the same team of surgeons, fundamentally using a laparoscopic gastric bypass. Initially, the Clavien-Dindo scale was translated and validated for its acceptability and reproducibility using the Kappa index. The scale was then applied to the whole of the bariatric series. A systematic review was also conducted in the literature regarding the use of the Clavien-Dindo classification after bariatric surgery. Lastly, a comparison was made with our results. RESULTS The classification was validated without any difficulty. Most of the postoperative complications are grades I (8.4%) and III (7.8%). We found it used in 15 series (including our own), which accounts for 10,347 patients. The overall results are analogous to our series. CONCLUSIONS The Clavien-Dindo scale has been validated and translated into Spanish. Application is quick and simple and enables comparisons to be made between centers and series. Our results are similar to those reported by other authors.

Complications and Level of Satisfaction After Abdominoplasty Post-bariatric Surgery

With the worldwide increase of obesity, bariatric surgery is expanding proportionally. Surgery is the only treatment resulting in long-term, sustained weight loss and decrease in comorbidities but also comes along with unsightly excessive and lax skin. Following bariatric procedures an increasing number of patients are seeking body contouring surgery. The goal of post-bariatric body contouring is to optimize the results obtained from bariatric surgery with surgical removal of the excess tissue.

Controversias sobre el manejo de la fluidoterapia en cirugía abdominal

In the August issue, CIRUGÍA ESPAÑOLA published an Editorial about fluid therapy, concept and use. Along with the authors, we also believe that there is undesirable variability in the administration of fluids among hospitals, anesthesiologists and even surgeons at the same medical center. The general perioperative management of patients undergoing elective surgery is experiencing a process of change. Until a few years ago, the approach was based on what was taught in medical school and the experience attained during medical practice instead of on scientifically demonstrated facts. It fundamentally involved waiting for the recovery of physiological functions that had been modified by the aggressions of surgery and pharmacological agents, according to the organic reserve, with minimal intervention throughout the entire perioperative process. Enhanced Recovery After Surgery (ERAS) programs arose in the 1990s, when Kehlet coined the term ‘‘fast-track’’ and presented several proposals to improve postoperative progress in patients who had undergone elective surgery. The ERAS protocol was initially used only for patients undergoing colorectal surgery, and its use has later been extended to other surgical subspecialties. A well-known complication after gastrointestinal surgery is postoperative ileus. The multifactorial etiology of prolonged ileus means that all patients are different, and studies about risk factors have calculated theoretical probabilities. Based on these principles, traditional measures in anesthetic and surgical practices (prolonged preoperative fasting, mechanical bowel preparation and the use of nasogastric tubes for decompression) are not currently recommended. On the other hand, it has been demonstrated that practices like intravenous analgesia for pain control (especially with opiates), the delay in the initiation of oral intake until the appearance of peristalsis evaluated subjectively and bedrest are risk factors that favor longer hospitalization and increased healthcare costs. A key point would be the optimized use of fluid therapy. Fluid overload is associated with cardiorespiratory complications, reduced tissue oxygenation, predisposition for thromboembolisms and slowing down of gastrointestinal function, all of which lead to reduced survival. Although it is well known that ileus is caused by multiple factors, and there are numerous publications about the associated risk factors, the management of perioperative fluid therapy has not been widely studied or related with postoperative ileus. Traditionally, large quantities of fluids have been used to replace perioperative deficit. This deficit includes replacing losses due to fasting, insensible water loss, third-space sequestration and blood loss, resulting in an excessive input of intraoperative fluids. In a multi-center study, Brandstrup et al. researched the impact of fluid restriction on colorectal surgery, and they observed a reduction in complications of almost 20% in the group with fluid restriction (1000 mL the day of surgery). Lung complication rates were 7% vs 24%, and tissue healing complications were 16% vs 31%, when they compared the group with fluid restriction with the classic fluid therapy group. Nevertheless, this study does not refer to postoperative ileus. Along this line, clinical guidelines have recently been published for intraoperative hemodynamic optimization in non-cardiac surgery. It has currently been demonstrated that prolonged fasting (8–10 h) does not entail a clinically relevant reduction in intravascular volume and, therefore, does not require perioperative replacement. To this situation, we should add that fasting of clear liquids has been reduced to 2 h prior to surgery, which reduces even more the possibilities c i r e s p . 2 0 1 6 ; 9 4 ( 1 0 ) : 6 1 4 – 6 1 6

USO DEL PLASMA RICO EN PLAQUETAS AUTÓLOGO EN ABDOMINOPLASTÍAS

Resumen es: Objetivo: Evaluacion de la eficacia del plasma rico en plaquetas autologo administrado de forma topica en la cicatrizacion y prevencion de las complicaci...