Rafael Calpena

Prospective Randomized Clinical Trial Comparing Two Different Circular Staplers for Mucosectomy in the Treatment of Hemorrhoids

BackgroundThe main objections against circular stapled mucosectomy have been anal pain and rectal bleeding during the surgical procedure or in the immediate postoperative follow-up. To avoid these consequences, a new stapler (PPH33-03) has been developed. The aim of this trial was to compare the intraoperative and short-term postoperative morbidity of stapled mucosectomy with PPH33-01 versus PPH33-03 in the treatment of hemorrhoids.MethodsWe conducted a prospective randomized clinical trial comparing hemorrhoidectomy with PPH33-01 (group 1, n = 30) versus PPH33-03 (group 2, n = 30) for grade III–IV symptomatic hemorrhoids. For the follow-up, the patients underwent examination and proctoscopy at 4 weeks, 3 months, and 6 months. We recorded anal pain (linear analog scale from 0 to 10), intraoperative hemorrhage, postoperative bleeding, and continence (Wexner Continence Grading Scale).ResultsDemographic and clinical features showed no differences between the two groups. More patients required suture ligation to stop anastomotic bleeding at surgery when the PPH33-01 stapler was used (15 versus 4, P < 0.05). Rectal bleeding during the first postoperative 4 weeks was similar (P > 0.05). The postoperative pain scores during the first week were similar (P > 0.05). Patients with pain on defecation were fewer in the PPH-03 group (15 versus 2, P < 0.05). Six patients from group 1 and none from group 2 (P < 0.05) had granulomas along the line of staples at the sites of the reinforcing stitches; the granulomas were associated with postoperative anal discomfort and rectal bleeding. One patient in group 1 complained of persistent pain that resolved within 3 months. Of all the intraoperative or preoperative variables analyzed, only the presence of granuloma was associated with postoperative bleeding and anal discomfort. We have not found any recurrence or incontinence during the 6-month follow-up.ConclusionsIntraoperative bleeding along the stapled line and tenesmus or discomfort during defecation were less frequent after circular stapled mucosectomy with PPH33-03. Therefore, circular stapled mucosectomy with PPH33-03 decreases the risk of immediate complications and thus allows implantation with more safety as a day surgery procedure.

Effect of Peritoneal Lavage with Clindamycin-Gentamicin Solution on Infections after Elective Colorectal Cancer Surgery

BACKGROUND Colorectal surgery may lead to infections because despite meticulous aseptic measures, extravasation of microorganisms from the colon lumen is unavoidable. STUDY DESIGN A prospective, randomized study was performed between January 2010 and December 2010. Patient inclusion criteria were a diagnosis of colorectal neoplasms and plans to undergo an elective curative operation. Patients were divided into 2 groups: Group 1 (intra-abdominal irrigation with normal saline) and Group 2 (intraperitoneal irrigation with a solution of 240 mg gentamicin and 600 mg clindamycin). The occurrence of wound infections and intra-abdominal abscesses were investigated. After the anastomosis, a microbiologic sample of the peritoneal surface was obtained (sample 1). A second sample was collected after irrigation with normal saline (sample 2). Finally, the peritoneal cavity was irrigated with a gentamicin-clindamycin solution and a third sample was obtained (sample 3). RESULTS There were 103 patients analyzed: 51 in Group 1 and 52 in Group 2. There were no significant differences between the groups in age, sex, comorbidities, or type of colorectal surgery performed. Wound infection rates were 14% in Group 1 and 4% in Group 2 (p = 0.009; odds ratio [OR] 4.94; 95% CI 1.27 to 19.19). Intra-abdominal abscess rates were 6% in Group 1 and 0% in Group 2 (p = 0.014; OR 2.14; 95% CI 1.13 to 3.57). The culture of sample 1 was positive in 68% of the cases, sample 2 was positive in 59%, and sample 3 in 4%. CONCLUSIONS Antibiotic lavage of the peritoneum is associated with a lower incidence of intra-abdominal abscesses and wound infections.

Prophylactic Mesh vs Suture in the Closure of the Umbilical Trocar Site after Laparoscopic Cholecystectomy in High-Risk Patients for Incisional Hernia. A Randomized Clinical Trial

BACKGROUND Prosthetic repair has become the standard method for hernia repair. Mesh placement for the prevention of trocar site incisional hernia (TSIH) is still a controversial issue. We tested the hypothesis that closure with an intraperitoneal prophylactic mesh of the umbilical trocar after a laparoscopic cholecystectomy can reduce the incidence of a TSIH in high-risk patients. STUDY DESIGN A randomized clinical trial was conducted among patients undergoing elective laparoscopic cholecystectomy who presented the following high-risk factors for incisional hernia, according to the literature: age 65 years and older, diabetes mellitus, chronic pulmonary disease, and obesity (ie, body mass index ≥30 kg/m(2)). Patients were assigned to have closure of the umbilical trocar site with either nonabsorbable sutures (group A) or intraperitoneal polypropylene omega-3 mesh (group B). Trocar site incisional hernia, pain, and surgical complications were evaluated at the early postoperative course and at 1, 6, and 12 months after surgery. RESULTS A total of 106 patients were randomized into the study and 92 patients were finally analyzed, including 47 in group A and 45 in group B. The TSIH rate was higher in group A (31.9%) than in group B (4.4%) (odds ratio = 10.1; 95% CI, 2.15-47.6; p < 0.001)). The wound infection rate was 4.3%; 8.5% in group A and 0% in group B (odds ratio = 2.04; 95% CI, 1.7-2.5; p = 0.045). Median postoperative pain evaluated by a visual analogue scale was 3 in group A and 2 in group B (p = 0.05). No differences were observed in complication rate, operative time, or hospital stay between the groups. CONCLUSIONS Prosthetic closure of the umbilical trocar site after laparoscopic surgery could become the standard method for preventing TSIH in high-risk patients.

Influence of type of dietary fat (olive and sunflower oil) upon gastric acid secretion and release of gastrin, somatostatin, and peptide YY in man.

The effects of adaptation to two diets differingin the type of dietary fat on the gastric acid secretoryresponse to food and on the circulating levels ofgastrin, somatostatin and peptide YY (PYY) were examined in humans. The study involved 18cholecystectomized subjects previously submitted to a30-day adaptation period to diets containing olive(group O) or sunflower oil (group S) as the fat source. During the experiments, physiologicalstimulation was achieved by ingestion of 200 ml of oleicacid- (group O) or linoleic acid-enriched (group S)liquid mixed meals. These resulted in an immediate rise in gastric pH. In group S, the return to thepremeal value was completed within 60 min, and a furtherdecline to values significantly lower than the basalones was observed at the end of the study period. In contrast, ingestion of the meal containingolive oil attenuated and prolonged the pH decrease afterthe meal, this being associated with the suppression ofpostprandial gastrin response. Food ingestion induced no significant changes in plasmasomatostatin concentration in either group, and nosignificant differences were revealed between themduring the basal or postprandial situations. Plasma PYYlevels were consistently higher in group O throughoutthe entire study period, although significance wasreached only at resting. In conclusion, our results showthat a 30-day adaptation period to diets containing olive oil as the main source of dietary fatresults, compared with those containing sunflower oil,in an attenuated gastric secretory function in responseto a liquid meal in humans. The effects of olive oil were associated with a suppression of serumgastrin and higher levels of PYY.

Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results.

Objective:To evaluate the long-term clinical and manometric results of fistulotomy and sphincter reconstruction for the treatment of complex fistula-in-ano. Background:Complex fistula-in-ano is difficult to treat due to the occurrence of postoperative anal incontinence and the high rate of recurrence. Methods:Seventy patients who were diagnosed with complex fistula-in-ano and underwent fistulotomy and sphincter reconstruction between October 2000 and October 2006 were analyzed in the present study. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Appointments were scheduled every 6 months during the first and second year of treatment and every 2 years thereafter. Recurrence and incontinence were evaluated during each visit. Continence was assessed according to the Wexner continence grading scale. Anal manometry was performed 3 and 12 months after treatment and every 2 years thereafter. Anal endosonography was conducted 6 months after treatment. Results:Fistulas were classified as medium-high trans-sphincteric in 64 patients (91.42%) and were recurrent in 22 patients (32%). Before surgery, 22 patients (32%) reported fecal incontinence, which improved after surgery in 15 cases (70%), from 6.75 to 1.88 (P < 0.005) on the Wexner Scale. Eight preoperative continent patients (16.6%) reported postoperative incontinence (Wexner Score < 3), and 6 patients (8.5%) had recurrent incontinence. Among these patients, 2 developed recurrent incontinence 6 months after treatment, 2 developed recurrent incontinence 1 year after treatment, 1 developed recurrent incontinence 2 years after treatment, and 1 developed incontinence 5 years after treatment. Conclusions:Fistulotomy with sphincter reconstruction is an effective technique for the treatment of complex fistula-in-ano. Continence and anal manometry results were improved in incontinent patients and were not jeopardized in continent ones. Fistulotomy with sphincter reconstruction is an especially suitable technique for incontinent patients with recurrent fistulas.

Tratamiento de la fisura anal crónica

Resumen La fisura anal cronica es una afeccion con una alta incidencia en nuestro medio que causa una grave incapacidad sociolaboral en el paciente, lo que nos obliga a buscar una solucion rapida y eficaz. Por ello, hemos revisado los diferentes tratamientos descritos en la bibliografia con el objetivo de establecer un protocolo terapeutico adecuado ante el paciente con fisura anal cronica que acude a la consulta. Recomendamos la esfinterotomia quirurgica (preferiblemente esfinterotomia lateral interna realizada indistintamente con una tecnica abierta o cerrada) como primera opcion terapeutica en la fisura anal cronica. Sin embargo, en pacientes > 50 anos con incontinencia previa, factores de riesgo de incontinencia (cirugia anal previa, multiples partos vaginales, diabetes, enfermedad inflamatoria intestinal, etc.) o fisura anal sin hipertonia asociada, la esfinterotomia quimica (preferiblemente con toxina botulinica) se convierte en la tecnica de eleccion ya que, a pesar de la alta tasa de recidiva en los tratamientos medicos, evita el elevado porcentaje de incontinencia residual descrito en la bibliografia con la esfinterotomia quirurgica en este grupo de pacientes.

Uso inadecuado de la hospitalización en cirugía general. Magnitud, factores asociados y causas

OBJECTIVE To determine the proportion of inappropriate days of hospitalization in the general surgery wards of three university hospitals, its causes, and associated factors. MATERIAL AND METHOD We concurrently reviewed 596 days of hospitalisation during a 1-week period in 2000, using the Appropriateness Evaluation Protocol (AEP). The association among inappropriate days of hospital stay and independent variables was evaluated using bivariable and multivariable methods. Finally, the causes for inappropriate hospitalization use were analyzed. RESULTS The percentage of inappropriate days was 17.6%, with no significant differences among the hospitals (21.5%, 12.5% and 17.5%). Inappropriate days were associated with the weekend (odds ratio [OR] = 2.1, scheduled admissions (OR = 2.9), hospital stay of more than 1 week (OR:2.3), the last third of the hospital stay (OR: 3.7), and inappropriate admission (OR: 2.1). The main causes of inappropriate hospital stays were organizational problems in the hospital or in the clinical management of discharge. CONCLUSIONS Inappropriate days of hospitalization represent a considerable percentage of hospitalization in surgery wards. The main reasons for inappropriate days are problems with surgical and discharge planning and factors that depend on the organization of the surgery departments and other related departments in the hospital.

Pancreatic enzyme secretion in response to test meals differing in the quality of dietary fat (olive and sunflowerseed oils) in human subjects

The aim of the present study was to investigate in human subjects whether or not the ingestion of two liquid meals that differed only in their fatty acid composition (due to the addition of olive oil (group O) or sunflowerseed oil (group S) as the source of dietary fat) would lead to differences in the pancreatic enzyme activities secreted into the duodenum. The experiments were performed in eighteen cholecystectomized subjects who, during the 30 d period immediately before surgery, modified their habitual diets in such a way that their fat composition would reflect, as far as possible, that of the experimental meals. Lipase (EC 3.1.1.3), colipase, amylase (EC 3.2.1.1), chymotrypsin (EC 3.4.21.1) and trypsin (EC 3.4.21.4) activities were measured in duodenal contents aspirated before and after the ingestion of the test meals. The plasma levels of secretin and cholecystokinin (CCK) were also examined. Duodenal enzyme activities were similar in resting conditions. No significant differences were revealed in postprandial enzyme activities, except for lipase activity, which was higher in group O, probably in relation to the greater plasma CCK concentrations observed in this group. In the absence of enzyme output data, we should not exclude the possibility that the type of dietary fat will affect human pancreatic enzyme secretion to a greater extent than is evident from the present study, for instance through a flow-mediated effect, as we previously observed in dogs.

Hematoma subcapsular hepático tras CPRE

La colangiopancreatografía retrógrada endoscópica (CPRE) es una técnica mínimamente invasiva de gran utilidad para el diagnóstico y tratamiento de patología biliar y pancreática (1). La aparición de un hematoma hepático tras la realización de una CPRE es un hecho extremadamente infrecuente, existiendo sólo 5 casos descritos en la literatura desde el año 2000, en el que se describió el primer caso (2). Presentamos un caso clínico de hematoma subcapsular hepático que precisó de intervención quirúrgica para control de la hemorragia.

Effect of exogenous insulin and glucagon on exocrine pancreatic secretion in rats in vivo

SummaryBackground. The physiological roles of the islet hormones insulin and glucagon in the control of exocrine pancreatic secretion is not clear. It is still unknown whether these hormones have a stimulatory or an inhibitory effect on the basal exocrine pancreatic secretion.Methods. Thirty anesthetized rats were stimulated with doses of insulin and glucagon administered by continuous intravenous infusion. Doses varying from physiological to supraphysiological were used. Different groups of 5 rats were given each of these doses. The volume of pancreatic juice and amylase, lipase and trypsin activity, as well as enzyme output, were measured 0, 20, 40, and 60 min after starting infusion. The insulin, glucagon, and glucose levels were determined in serum at 0, 10, 30, and 60 min.Results. In the insulin group, the secreted volume of pancreatic juice increases with the maximum dose. All insulin doses results in amylase and lipase decreased activity. When submaximum and maximum insulin doses are administered, the trypsin activity also decreases. In the glucagon group, the activity of lipase and trypsin decreases regardless the dose, whereas the amylase activity decreases with submaximum and supramaximum doses.Conclusion. Both insulin and glucagon affect the basal exocrine pancreatic secretion in vivo when physiological doses are administered.