Laparoscopic staged colon-first resection for metastatic colorectal cancer: Perioperative and midterm outcomes from a single-center experience.

INTRODUCTION: The present study aimed to evaluate the short- and mid-term outcomes of laparoscopic colon-first staged resection for colorectal cancer (CRC) and colorectal cancer liver metastases (CRCLM). METHODS: This study included patients with metastatic CRC who underwent laparoscopic surgical staged resection for the primary tumor and CRCLM between June 2013 and December 2018. Data collection included the baseline patient's and tumor features, the perioperative and histopathologic outcomes from both surgical procedures, and the oncologic follow-up. RESULTS: Twenty-five patients were eligible for the study. Three major and 22 minor laparoscopic liver resections were performed following laparoscopic CRC surgery. Five patients required conversion to laparotomy during CRCLM resection, but no conversion was needed for the colorectal procedures. The rate of severe intraoperative complications (CLASSIC grade III-IV) was 8% and 16% during CRC and CRCLM resection, respectively. Three patients (12%) developed major postoperative complications (Clavien-Dindo grade > III) after both interventions, including one death due to intraoperative bleeding. During a median follow-up of 30 months, 15 patients were diagnosed with disease recurrence. The 3-year disease-free survival and overall survival were 33.3% and 73.9%, respectively. CONCLUSIONS: Laparoscopic staged resection for CRC and CRCLM is safe, feasible, and offers acceptable midterm oncological outcomes in patients with metastatic colorectal cancer.

Laparoscopic approach of the left side of the pancreas. / Abordaje laparoscópico del páncreas izquierdo.

INTRODUCTION: Laparoscopic left-sided pancreatectomy (LLP) is an increasingly used surgical technique for the treatment of benign and malignant lesions of the left side of the pancreas. The results of LLP as a treatment for primary pancreatic lesions of the head and tail of the pancreas were evaluated. METHODS: From November 2011 to November 2017, 18 patients underwent surgery for primary lesions of the pancreas by means of a laparoscopic distal pancreatectomy. An intra-abdominal drain tube was used in all cases, and the recommendations of the International Study Group for Pancreatic Fistula (ISGPF) were followed. RESULTS: The mean age was 66.5years (IQR 46-74). Among the 18 left pancreatectomies performed, four were with splenic preservation, and one was a central pancreatectomy. There were two conversions. The median surgical time was 247.5minutes (IQR 242-275). The median postoperative hospital stay was 7days (IQR 6-8). After 90days, complications were detected in five patients: three gradeII, one gradeIII and one gradeV according to the modified Clavien-Dindo classification. There was one gradeB pancreatic fistula, and four patients had to be readmitted to hospital because of peripancreatic collections. The anatomic pathology diagnosis was malignant neoplasm in 38.9% of cases, all of them with negative resection margins. CONCLUSIONS: LLP can be considered the technique of choice in the treatment of primary benign pancreatic lesions and an alternative to the open approach in selected patients diagnosed with malignant pancreatic lesions.

Accuracy of malignancy criteria for an intraductal papillary mucinous neoplasm. Should we have blind faith in consensus guidelines?

Based on a recent review about intraductal papillary mucinous neoplasm (IPMN), we want to reflect some important issues referring to the different consensus guidelines, criteria anda algorithms that are a starting point to manage this neoplasm as well as their limitations.

Mirizzi syndrome: a new insight provided by a novel classification.

BACKGROUNDS/AIMS: Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis. The aim of this study is to evaluate our 15-year experience in this challenging entity and to propose a new classification for this disease. METHODS: A retrospective study including patients diagnosed with Mirizzi syndrome and undergoing surgical procedures for Mirizzi syndrome between January 2000 and October 2015 was conducted. Data collected included clinical, surgical procedure, postoperative morbidity. Patients were evaluated according to the Csendes classification and the proposed system, in which patients were divided into three types and three subtypes. RESULTS: 28 patients were included for analysis. They accounted as the 0.5% of a total of 4853 cholecystectomies performed in the study period. There were 21 women and 7 men. Initial laparotomic approach was performed in 12 patients and in 16 patients laparoscopic procedures were attempted. The procedure was completed in only 6 patients, 5 presenting type I and 1 type II Mirizzi syndrome. Mean postoperative stay was 15±9 days. Postoperative morbidity rate was 28%. Postoperative mortality was none. CONCLUSIONS: Laparoscopic surgery for Mirizzi syndrome has been shown succesful only in early stages. A novel classification is proposed, based on the types of common bile duct injuries and in the presence cholecystoenteric fistula.

[Transanal endoscopic surgery with conventional laparoscopy materials: is it feasible?]. / Cirugía endoscópica transanal con material convencional de laparoscopia, ¿es factible?

INTRODUCTION: Transanal endoscopic surgery with conventional laparotomy materials may be an alternative to transanal endoscopic microsurgery (TEM) for the excision of rectal lesions susceptible to local resection. MATERIAL AND METHOD: We prospectively analysed 27 patients included consecutively between 1999 and 2009, on whom a Transanal endoscopic operation (TEO) was performed by total resection of the rectal wall. All procedures were performed with a 40mm rectoscope, initially designed by us and later with the Storz rectoscope, using conventional laparoscopic tools and material. RESULTS: We operated on 27 patients with a mean age of 69.4 years: 23 due to benign lesions and 4 malignant. The medium distance of the tumour to the anal margins was 8.2cm (range 5-15) and a mean tumour diameter of 3.38 ± 1.2cm. There were 4 postoperative complications, 3 due to bleeding and one case of perforation. The mean hospital stay was 6 ± 3.75 days. There was no perioperative mortality or recurrences.. CONCLUSION: Performing transanal endoscopic surgery with conventional laparoscopy material is feasible, with a reduction in costs and accessible to laparoscopy surgeons.

[Impact of endorectal advancement flaps in fecal incontinence]. / Impacto de los colgajos transanales de avance en la continencia fecal.

OBJECTIVE: The aim of this study was the prospective evaluation of the functional results of a series endorectal advancement flaps in the treatment of complex anal fistulas. MATERIAL AND METHODS: A total of 90 patients were operated on for a complex anal fistula by means of fistulectomy and endorectal advancement flap. The functional results were evaluated using the Wexner continence scale and an anorectal manometry study before and after surgery. RESULTS: There were seven patients with fistula recurrence (7.7%) and the same surgical procedure was performed on five of them, resulting in healing in all cases. Significant reductions in maximum resting pressure (83.85+/-30.96 vs 46.51+/-18.67; p<0.001) and maximum squeeze pressure (220.97+/-100.21 vs 183.06+/-75.36; p<0.001) were seen 3 months after surgery. On the continence scale, 80% of patients had a normal continence with a value of 0 on the postoperative Wexner scale, while 20% recorded changes in continence values, most of them lower than 3 points. CONCLUSIONS: Endorectal advancement flap is an effective surgical procedure in complex anal fistulas treatment, with a low recurrence rate. Only 20% of the patients showed changes in the continence value.

[Results of a medication reconciliation project in routine medical treatment after surgical discharge]. / Resultados de un proyecto de control y adecuación del tratamiento médico habitual tras el alta quirúrgica.

OBJECTIVE: To reduce the number of medication-related problems by ensuring reconciliation between ambulatory treatment and surgical prescription and to increase patients' understanding of drug therapy and treatment adherence. MATERIAL AND METHOD: Information on ambulatory medication was obtained through a personal interview and a review of the patient's personal and pharmacotherapeutic history. A dossier was created that included detailed information on each medication and a chronopictogram with all doses. On the day of discharge, a second interview with the patient was performed in which information was obtained orally and in writing about all treatment. The process was evaluated through a satisfaction questionnaire. Two weeks after discharge a telephone interview was carried out to detect post-discharge medication-related problems. RESULTS: During the study period (April-December 2006) 544 patients were included. There were 658 pharmaceutical interventions: 87% educational, 8% safety, 5% efficiency. A total of 346 satisfaction questionnaires were properly completed (63% of those distributed). Responses to questionnaires were evaluated from 0 (completely dissatisfied) to 5 (highly satisfied). Interest in the information received was scored 4.75, understanding of the information 4.67, and satisfaction with the intervention 4.59. CONCLUSIONS: Including the pharmacist in the surgical team ensures reconciliation between ambulatory treatment and surgical prescription and reduces medication errors. Providing information to patients about their medication at discharge increases their understanding of drug treatment and adherence.

Secretory immunoglobulin A (sIgA) deficiency in serum of patients with GALTectomy (appendectomy and tonsillectomy).

INTRODUCTION: In adult human beings, 80-85% of the immune cells are located in the digestive tract mucosa; hence the importance of the Gut Associated Lymphoid Tissue (GALT) in host defence. We studied the influence of the surgical removal of two important parts of the gut associated with lymphoid tissue (tonsillectomy and appendectomy) on immune parameters. METHODS: One hundred and sixty patients were enrolled in this study. They were divided into four groups of forty patients each and matched for gender and age: group 1, appendectomized and tonsillectomized; group 2, only appendectomized; group 3, only tonsillectomized; and group 4, control group, neither tonsillectomized nor appendectomized. We analysed in blood: hemogram, protein electrophoresis, lymphocytic populations (T4 cells, T8 cells, NK cells), IgG, IgM, IgA immunoglobulin, and their fractions IgA1, IgA2, and secretory IgA. RESULTS: Levels of secretory IgA in serum of patients in group 1 were significantly lower than in the other three groups (1.89 mg/dl, group 1; 2.32 mg/dl, group 2; 2.19 mg/dl, group 3 and 4.97 mg/dl, group 4; p<0.0001). Also, the values found in the two groups that had undergone only one of the operations were clearly lower than in control patients (p<0.0001). In this study, the reduction was sustained for a period of between 3 months and 3 years in appendectomized patients, and more than 20 years in tonsillectomized patients. IN SUMMARY: GALTectomy (appendectomy and tonsillectomy) significantly decreases secretory IgA levels in serum. The decrease is more intense when both operations have been done.