Enhanced Recovery After Emergency Surgery: Utopia or Reality? / Rehabilitación multimodal en cirugía de urgencias: ¿utopía o realidad?

Enhanced Recovery After Surgery (ERAS) constitutes the application of a series of perioperative measures based on the evidence, in order to achieve a better recovery of the patient and a decrease of the complications and the mortality. These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties. The main excluding factor for the application of such programs has been the urgent clinical presentation, which has caused that despite the large volume of existing literature on ERAS in elective surgery, there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies. The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery.

[Prospective study of procalcitonin as a diagnostic marker of the severity of secondary peritonitis]. / Estudio prospectivo de la procalcitonina como marcador diagnóstico de gravedad en la peritonitis secundaria.

INTRODUCTION: It has been shown that procalcitonin (PCT) is a good marker for sepsis as the more severe the infection the higher the plasma levels. The Mannheim peritonitis index (MPI) is very effective in assessing the prognosis of secondary peritonitis. The aim of this study is to find out whether there is any correlation between preoperative PCT levels and the postoperative MPI, as well as the prognostic value of preoperative PCT levels. PATIENTS AND METHOD: Prospective study of 57 patients operated on between December 2006-August 2008 for secondary peritonitis and classified into three groups (A: 23 patients, B: 24 patients and C: 10 patients) from lowest to highest severity of MPI. The preoperative values of procalcitonin were obtained with PCT-Q test (BRAHMS). RESULTS: PCT-Q was normal (<0.5ng/ml) in 19 patients in group A, in 2 patients in group B and none in group C (p<0.001). PCT-Q between 2-10ng/ml were found in one patient in group A, 13 in group B and none in group C (p<0.001). PCT-Q >10ng/ml were found in 10 cases in group C, 6 in group B and none in group A (p<0.001). Of the 19 patients admitted to the intensive care unit, the PCT-Q was >10ng/ml in 15 cases vs a PCT-Q<10mg/ml (p<0.001) in 4 cases. Seven patients died, all of them with a PCT-Q >10mg/ml (p<0.001). CONCLUSIONS: The correlation between preoperative PCT-Q and postoperative MPI is positive and significant. The values of PCT-Q are higher as the MPI severity increases. Values >10ng/ml are significant for admission to the ICU and a poor clinical prognosis.

[Laparoscopic treatment of perforated duodenal ulcer]. / Tratamiento laparoscópico de la úlcera duodenal perforada.

OBJECTIVE: To analyze the results obtained in patients undergoing laparoscopic surgery for perforated duodenal ulcer. PATIENTS AND METHOD: From January 2000 to August 2006, 15 consecutive patients with perforated duodenal ulcer underwent laparoscopic surgery after preoperative selection (ASA scores, time since onset of the perforation). RESULTS: The mean age was 44.6 +/- 15.5 years (range, 18-75). There were 10 men and five women. Fourteen patients were ASA I-II. Time since onset of perforation was more than 12 hours in only one patient. Operative time was 70.5 +/- 9.6 minutes. There were two conversions (13.3%) to the open approach and two postoperative complications (prolonged ileus in one patient and self-limiting leakage in another). There were no intra-abdominal collections or mortality in the entire series. The mean length of hospital stay was 6.5 +/- 2.1 days. CONCLUSIONS: In selected patients, laparoscopic treatment of perforated duodenal ulcer is safe and feasible. Technical standardization and appropriate patient selection are essential to define the real role of the laparoscopic approach in perforated duodenal ulcer.

[Laparoscopic gastrectomy in the treatment of gastric cancer]. / Gastrectomía laparoscópica en el tratamiento del cáncer gástrico.

OBJECTIVE: To present our initial results in the laparoscopic treatment of gastric cancer. MATERIAL AND METHOD: Between March 2002 and June 2005, 12 selected patients with resectable distal gastric cancer and oncological indication for radical treatment underwent laparoscopic gastrectomy. RESULT: There were 9 men and 3 women. The mean age was 62.6 years (range: 45-78). Ten D2 subtotal gastrectomies, with B-II reconstruction in 7 and B-III reconstruction in the remaining 3, were performed. In 6 patients, reconstruction was performed entirely by laparoscopy, while in the remaining 4 patients extracorporeal reconstruction was performed. Two total gastrectomies were performed: one was performed entirely by laparoscopy while in the other, laparoscopic-assisted gastrectomy with extracorporeal esophagojejunal anastomosis was carried out. The mean operating time was 197.6 +/- 36.9 (130-260) minutes, although mean operating time was 142.5 minutes in the subgroup that underwent subtotal gastrectomy with extracorporeal anastomosis compared with 190.8 minutes when totally laparoscopic anastomosis was performed (p < 0.002). There were no intraoperative complications or conversions. Postoperative complications occurred in 3 patients: postoperative ileus for 7 days in 1 patient, intra-abdominal abscess requiring laparotomy in 1 patient and esophagojejunal anastomotic leak that resolved without reintervention in a third patient. Oral intake was reinitiated at 72 hours in 9 patients, while a further 2 required 5 days and the patient with postoperative ileus required 8 days. The mean length of postoperative stay was 10.7 +/- 7.3 (6-28) days. The mean number of resected nodes was 21.3 +/- 5 (16-31). There was 1 locoregional recurrence at 14 months in a patient with stage IIIB tumor after a mean follow-up of 25.8 months (4-73). CONCLUSIONS: Laparoscopic gastrectomy in the treatment of gastric cancer is technically feasible and is an alternative to open surgery in terms of postoperative morbidity and mortality and oncological effectiveness when performed by teams with experience in laparoscopy and with appropriate patient selection.