Salvador Lledó

Efficacy and Cost-Effectiveness of the UltraCision® Harmonic Scalpel in Thyroid Surgery: An Analysis of 200 Cases in a Randomized Trial

BACKGROUND Thyroid surgery technique has undergone very few changes in the last century. The UltraCision harmonic scalpel (UHS) (Smithfield, RI) has been widely used in laparoscopic surgery and is documented to be safe and fast for cutting and coagulating tissue. We studied whether the use of the UHS could have advantages in thyroid surgery in terms of operative time, length of hospitalization, morbidity, and general costs. METHOD Our study was a prospective randomized trial of thyroidectomies and lobectomies performed for benign thyroid diseases in an endocrine surgery unit between February 2001 and July 2002. Patients were randomized in two groups: group A (n=100) underwent thyroidectomy using UHS and group B (n=100) with the conventional clamp-and-tie technique. Main outcome measures were demographics, operating time, length of hospitalization, intra- and postoperative complications, sequelae, and general costs. We used the unpaired 2-tailed Students t test and the chi2 test to compare the series. RESULTS The two groups were similar in age and sex. Mean +/- SD operative time was shorter in the UHS group compared with the conventional technique group for both lobectomy (61 +/- 06 vs. 78 +/- 10 minutes) and total thyroidectomy (86 +/- 20 vs. 101 +/- 16 minutes). Length of hospitalization was similar in both groups (1.07 vs. 1.15 days). We did not find statistical differences between the two techniques regarding transient postoperative complications. There were no deaths, no blood transfusions, no intraoperative complications, and no postoperative definitive sequelae. The global charges for every patient were significantly less in the UHS group (985.77 +/- 107.08 euro vs. 1148.40 +/- 153.25 euro). CONCLUSION The use of ultrasonically activated shears resulted in a reduction of 15-20% in operative time and was cost-effective compared to the conventional technique group.

Therapeutic Effects of Different Doses of Botulinum Toxin in Chronic Anal Fissure

PURPOSE: The aim of this study was to evaluate the clinical and manometric results of three different doses of botulinum toxin and two methods of injection for the treatment of chronic idiopathic anal fissure. METHODS: Sixty-nine patients with chronic anal fissure were included in a nonrandomized, prospective trial of intrasphincteric injection of botulinum toxin. All patients reported postdefecatory anal pain lasting more than two months. Scoring systems were developed for anal pain, bleeding, and defecatory difficulty. Maximum resting and squeeze anal pressures were determined before and one month after treatment. Twenty-three patients undergoing a 5-U injection of diluted botulinum toxin A (BOTOX®) on each side of the anal sphincter (total dose, 10 U) constituted the first group. In a second group 27 patients were injected as previously described, with an additional 5-U injection below the fissure (total dose, 15 U). The 19 patients constituting the third group received a 7-U injection on each side of the anus and below the fissure (total dose, 21 U). All patients were followed up for at least six months. RESULTS: Pain relief one month after treatment was more evident in the second and the third group (48 percent of patients in the first group, 74 percent in the second group, and 100 percent in the third group). A significant reduction of the mean resting pressure was demonstrated only in Groups II and III (P<0.05), whereas the mean squeeze pressure significantly decreased in the three groups (P<0.01 in Group I andP<0.001 in Groups II and III). Fifty-two percent of the patients in the first group, 30 percent in the second group, and 37 percent in the third group were reinjected during the follow-up period, because of persistence of symptomatology or early relapse. The need for surgery was similar in the first and the second group (17 and 19 percent, respectively) and clearly lower in the last group (5 percent). No serious complications or incontinence attributable to this therapeutic modality developed in any patient. CONCLUSIONS: Intrasphincteric injection of botulinum toxin is a reliable new option in the treatment of uncomplicated chronic anal fissure. The healing rate is related to the dose and probably to the number of puncture sites. No permanent damage to the continence mechanism was detected in these patients.

Effect of simultaneous inhibition of TNF-α production and xanthine oxidase in experimental acute pancreatitis: The role of mitogen activated protein kinases

Objective:To assess the effects of inhibiting both tumor necrosis factor (TNF)-α production and xanthine oxidase activity on the inflammatory response, mitogen-activated protein kinase (MAPK) activation and mortality in necrotizing acute pancreatitis in rats. Summary Background Data:Pancreatic injury triggers 2 major pathways involved in the systemic effects of severe acute pancreatitis: pro-inflammatory cytokines and oxidative stress. Methods:Pancreatitis was induced by intraductal infusion of 3.5% sodium taurocholate. We examined whether treatment with oxypurinol, a specific inhibitor of xanthine oxidase, and/or pentoxifylline, an inhibitor of TNF-α production, affects pancreatic damage, ascites, lung inflammation, and MAPK phosphorylation. Results:Oxypurinol prevented p38 phosphorylation in the pancreas and partially avoided the rise in lung myeloperoxidase activity. Pentoxifylline prevented erk 1/2 and JNK phosphorylation in the pancreas, and it partially reduced ascites and the rise in lung myeloperoxidase activity. Combined treatment with oxypurinol and pentoxifylline almost completely abolished ascites, MAPK phosphorylation in the pancreas, and the increase in lung myeloperoxidase activity. Histology revealed a reduction in pancreatic and lung damage. These changes were associated with a significant improvement of survival. Conclusions:Simultaneous inhibition of TNF-α production and xanthine oxidase activity greatly reduced local and systemic inflammatory response in acute pancreatitis and decreased mortality rate. These effects were associated with blockade of the 3 major MAPKs.

A Prospective Audit of the Complications of Loop Ileostomy Construction and Takedown

Aim: A prospective review of the complications of ileostomy construction and takedown. Materials and Methods: One hundred twenty-seven consecutive patients undergoing construction of a loop ileostomy were included in a prospective nonrandomized computer database. Complications of the loop ileostomy were assessed prior to and after closure. Three closure techniques were performed [enterotomy suture (25.7%), resection and hand sewn (31.2%) or stapled anastomosis (43.1%)] and compared. Results: One hundred twenty-seven (73 male, 54 female) patients, mean age 54 years were included from 1992 to 2002. Seventy-two patients underwent anterior resection for low rectal carcinoma, 30 an ileoanal pouch for ulcerative colitis and 25 for miscellaneous conditions. Fifty-nine pre-takedown complications occurred in 50 (39.4%) patients. The most common were dermatitis (12.6%) and erythema (7.1%). The most severe were dehydration in 1 patient and stomal prolapse in 4 patients. Closure was associated with a complication rate of 33.1% and a mortality rate of 0.9%. Wound infection occurred in 18.3% and small bowel obstruction in 4.6%. Anastomotic leak requiring reanastomosis occurred in 2.8% and enterocutaneous fistula treated conservatively in 5.5%. There were no statistically significant differences in morbidity between closure techniques (p = 0.892). There were no statistically significant differences in complications (p = 0.516) between patients with ulcerative colitis and those with neoplasia (39.29% vs. 32.2%). Conclusions: Loop ileostomy construction and takedown is associated with considerable morbidity, mostly minor. No differences exist between technique used for closure or the baseline pathology of the patient.

Risk Factors for Nonhepatic Surgery in Patients with Cirrhosis

Cirrhosis of the liver appears to have an unfavorable prognosis in the surgical patient. The aim of this study was to determine risk factors for morbidity and mortality in patients with cirrhosis undergoing nonhepatic surgery. We studied 135 patients with liver cirrhosis undergoing nonhepatic procedures and 86 controls matched by age, sex, and preoperative diagnosis. Preoperative, intraoperative, and postoperative variables associated with 30-day mortality and morbidity were assessed by univariate and multivariate analyses. Patients with cirrhosis showed higher blood transfusion requirements, longer length of hospital stay, and a higher number of complications than controls. The mortality rate was 16.3% in cirrhotics and 3.5% in controls. By univariate analysis, the need for transfusions, prothrombin time, and Child-Pugh score were significantly associated with postoperative liver decompensation, whereas duration of surgery, prothrombin time, Child-Pugh score, cirrhosis-related complications, and general complications were significantly associated with mortality. In the multivariate analysis, Child-Pugh score (odds ratio [OR] 24.4; 95% confidence interval [CI] 5.5 to 106); duration of surgery (OR 5; 95% CI 1.2 to 15.6), and postoperative general complications (OR 3.7; 95% CI 3.4 to 6.4) were independent predictors of mortality. Patients with cirrhosis undergoing nonhepatic operations are at significant risk of perioperative complications leading to death. Independent variables associated with perioperative mortality include preoperative Child-Pugh score, the duration of surgery, and the presence of postoperative general complications.

Real-Time Quantification in Plasma of Human Telomerase Reverse Transcriptase (hTERT) mRNA: A Simple Blood Test to Monitor Disease in Cancer Patients

Real-Time Quantification in Plasma of Human Telomerase Reverse Transcriptase (hTERT) mRNA: A Simple Blood Test to Monitor Disease in Cancer Patients

Bile duct injury during laparoscopic cholecystectomy Myth or reality of the learning curve

AbstractBackground: Bile duct injury (BDI) is a severe complication of laparoscopic cholecystectomy (LC) that is probably related to the effects of the learning curve. The aim of this prospective, institutional, and longitudinal study is to compare the incidence of BDI during LC in relation to the progressive experience of surgeons. Methods: A total of 784 LC were examined during a 6-year period. They were divided into the following three consecutive groups: group A (1993–94), group B (1995–96), and group C (1997–98). Incidence and type of BDI, experience of the surgeon, intra- or postoperative diagnosis, treatment performed to repair the injury, and early and late morbidity and mortality were evaluated. Results: The overall incidence of BDI was 1.4%. There were three cases of transection of the common bile duct, four partial lesions of the bile duct, and four cystic leakages. The number of BDI was maintained over the three different time periods; there were no statistical differences in the proportion of injuries among groups. Most BDI were incurred by experienced surgeons. In all, 36% of BDI were recognized intraoperatively. Hepaticojejunostomy, direct suture over a T-tube, and closure of the cystic stump were done to repair BDI. There was no additional morbidity or mortality in the patients with BDI. Conclusions: No relation was found between the experience of the surgeon and the number of BDI over the different periods of time. Therefore, BDI during LC cannot be attributed solely to the learning curve.

Outcome of Esophageal Function and 24-hour Esophageal pH Monitoring after Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass

Background: One of the co-morbidities frequently associated with morbid obesity is gastro-esophageal reflux disease (GERD), present in >50 % of morbidly obese individuals. We compared the anti-reflux effect of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP), and their effect on esophageal function. Methods: 10 patients underwent VBG and 40 patients underwent RYGBP. Anthropometric parameters, symptomatology of GERD, esophageal manometry (EM), isotopic esophageal emptying (IEE) and 24hr esophageal pH monitoring were recorded in all patients preoperatively, and at 3 months and 1 year postoperatively. Results: Preoperatively, there was a high prevalence of GERD, symptomatic and pH-metric in both groups (57% and 80% respectively). The preoperative values of EM and IEE parameters were within the normal range in most patients. After surgery, there was an improvement at 3 months postoperatively in both groups. 1 year after surgery, the VBG group presented symptomatic GERD in 30% and pH-metric reflux in 60% of patients while the RYGBP group presented symptomatic GERD and pH-metric reflux in 12.5% and 15% of patients, respectively. There was an increase in postoperative sensation of dysphagia in both groups (70% VBG, 30% RYGBP) one year after operation. After surgery, differences in all EM parameters were minimal, and never reached statistical significance for any group (VBG and RYGBP). The IEE showed a significantly higher percentage of esophageal retention after surgery, but this retention was always within the normal range. Both groups had an improvement in anthropometric parameters, but 1 year after surgery the results were significantly better in RYGBP patients (70% excess weight loss) than in VBG patients (46% excess weight loss). Conclusion: >50% of morbidly obese individuals suffer from GERD. We did not find changes in esophageal function of morbidly obese patients to explain their gastroesophageal reflux preoperatively and postoperatively. EM and IEE studies are not indicated as standard preoperative tests, except in patients with significant symptoms of gastroesophageal reflux. RYGBP is significantly better than VBG as an anti-reflux procedure, and had better weight loss.

Real time quantification in plasma of human telomerase reverse transcriptase (hTERT) mRNA in patients with colorectal cancer

Background  Increased telomerase activity can be found in almost 90% of colorectal tumours. We aim to describe the preliminary results for quantification in plasma of hTERT mRNA in colorectal cancer patients.

Early Prediction of Anastomotic Leak in Colorectal Cancer Surgery by Intramucosal pH

PurposeAdequate oxygenation is necessary for anastomotic healing, and ischemia has been found to be one of the most important factors in anastomotic leakage. This study was designed to assess the value of early postoperative intramucosal pH measurements for the prediction of anastomotic leakage in patients with colorectal anastomosis.MethodsA prospective study of 90 patients with rectal or sigmoid cancer with primary anastomosis was conducted. In all patients intramucosal pH was determined by using tonometry at the anastomotic and gastric levels during the first 24 and 48 hours postoperatively. Seven other variables also were tested by univariate and multivariate analysis for any association with anastomotic leakage.ResultsThe rate of clinical anastomotic leakage was 6.6 percent. Multivariate analysis showed that only the intramucosal pH at the anastomosis was an independent factor for the development of anastomotic leakage. The risk of leakage was 22 times higher in patients with an anastomotic intramucosal pH < 7.28 in the first 24 hours after surgery.ConclusionsMeasurement of anastomotic intramucosal pH in the early postoperative period can more accurately predict the risk of anastomotic leakage and benefit those patients who would need additional measures to improve the viability of the anastomosis.