Full endoscopic minimally invasive extraperitoneal modified Sugarbaker approach for para-colostomy hernia repair: Technical aspects and 2-year follow-up results of a prospective cohort.

AIM: This study aimed to assess technical aspects and clinical results of a new minimally invasive technique in parastomal hernia (PSH) repair, full endoscopic retromuscular access, after 2 years of follow-up. METHODS: Data from consecutive patients requiring minimally invasive ventral PSH repair were collected from 2019 to 2022. The inclusion criteria were patients aged between 18 and 80 years old with symptomatic PSH. Demographics and perioperative and postoperative data were collected. Postoperative pain and functional recovery were compared with preoperative data. RESULTS: Twelve patients with symptomatic PSH were included. The mean PSH defect area was 16.2 cm2 and the mean midline defect was 8.7 cm2 . No intra-operative complications or conversion to open surgery were detected. One patient (8%) required postoperative readmission due to partial bowel obstruction symptoms that required catheterization of the stoma. Pain significantly worsened after the first postoperative day compared to preoperative data but improved after the first postoperative month compared to the first postoperative week and after the 90th postoperative day compared to the first postoperative month, with significant differences. Significant restriction improvement was identified when 30 days after surgery data were compared to preoperative data and when the 180th postoperative day results were compared to 30 days after surgery. The average follow-up was 29 months. During the follow-up no clinical or radiological recurrence was observed. CONCLUSION: This paper shows low rate of intra- and postoperative complications with significant improvement in terms of pain activities restriction compared to preoperatory. After 29 months follow-up, no recurrence was identified, confirming that this approach offers good mid-term results.

Human Omental Mesothelial Cells Impart an Immunomodulatory Landscape Impeding B- and T-Cell Activation.

Mesothelial cells form the mesothelium, a simple epithelium lining the walls of serous cavities and the surface of visceral organs. Although mesothelial cells are phenotypically well characterized, their immunoregulatory properties remain largely unknown, with only two studies reporting their capacity to inhibit T cells through TGF-ß and their consumption of L-arginine by arginase-1. Whether human mesothelial cells can suppress other immune cells and possess additional leukosuppressive mechanisms, remain to be addressed to better delineate their therapeutic potential for cell therapy. Herein, we generated secretomes from omental mesothelial cells (OMC) and assess their capacity to inhibit lymphocytes proliferation, suppress activated T and B cells, as well as to modify macrophage activation markers. The secretome from mesenchymal stromal cells (MSC) served as a control of immuno-suppression. Although OMC and MSC were phenotypically divergent, their cytokine secretion patterns as well as expression of inflammatory and immunomodulary genes were similar. As such, OMC- and MSC-derived secretomes (OMC-S and MSC-S) both polarized RAW 264.7 macrophages towards a M2-like anti-inflammatory phenotype and suppressed mouse and human lymphocytes proliferation. OMC-S displayed a strong ability to suppress mouse- and human-activated CD19+/CD25+ B cells as compared to MSC-S. The lymphosuppressive activity of the OMC-S could be significantly counteracted either by SB-431542, an inhibitor of TGFß and activin signaling pathways, or with a monoclonal antibody against the TGFß1, ß2, and ß3 isoforms. A strong blockade of the OMC-S-mediated lymphosuppressive activity was achieved using L-NMMA, a specific inhibitor of nitric oxide synthase (NOS). Taken together, our results suggest that OMC are potent immunomodulators.

The epidemiological status of osteoporotic hip fractures: A bicentric comparative and retrospective study.

BACKGROUND: Osteoporotic hip fractures have posed a significant burden to society, and more epidemiological data is required. OBJECTIVE: To compare the epidemiological differences of hip fracture patients in Spain and China. METHOD: This was a retrospective comparative study. Comparisons were made in terms of morbidity, demographic and anthropometric characteristics, length of stay, cost of hospitalization, and mortality by consulting the medical histories of osteoporotic hip fractures in two hospitals. The t test was used for measurement data, and the X2 test was used for count data. The difference is statistically significant when p< 0.05. RESULTS: A total of 757 patients were enrolled in this study, with 426 from Virgen Macarena University Hospital (HUVM) and 331 from Xi'an Daxing Hospital (XDH). The average age was 81.4 ± 9.26 and 76.0 ± 8.08 years; the proportion of women was 74.9% and 68.0%, respectively. The incidence of osteoporotic hip fractures in Seville residents over 50 years old was approximately 239 per 100,000 residents, compared to 158 per 100,000 residents in Xi'an. The timing of surgery in Spanish patients was significantly longer than in Chinese patients, 78.7 ± 48.2 vs. 60.7 ± 43.1 hours, p= 0.000. There were 81 deaths in Spain and 43 deaths in China during the one-year follow-up period (p= 0.026). CONCLUSIONS: In terms of incidence, demographics, surgical methods, and mortality, there are significant differences between hip fracture patients in Seville, Spain and Xi'an, China.

Feasibility of quantitative analysis of colonic perfusion using indocyanine green to prevent anastomotic leak in colorectal surgery.

BACKGROUND: The aim of this study was to quantify Fluorescence angiography with indocyanine green (ICG) in colorectal cancer anastomosis, determine influential factors in its temporary intensity and pattern, assessing the ability to predict the AL, and setting the cut-off levels to establish high- or low-risk groups. METHODS: Retrospective analysis of prospectively managed database, including 70 patients who underwent elective surgery for colorectal cancer in which performing a primary anastomosis was in primary plan. In all of them, ICG fluorescence angiography was performed as usual clinical practice with VisionSense™ VS Iridium (Medtronic, Mansfield, MA, USA), in Elevision™ IR Platform (Medtronic, Mansfield, MA, USA). Parameters measured at real time or calculated were T0, Tmax, ∆T, Fmax, %pos, Fpos, and Slope. RESULTS: 70 patients were included, 69 anastomosis were performed and one end colostomy. Arterial hypertension demonstrated higher Fmax, as well as the location of the anastomosis (the nearest to rectum, the most intensity detected). A statistical relationship was found between AL and the lower Fpos and Slope. The decision of changing the subjectively decided point of division did not demonstrate statistical difference on the further development of AL. All parameters were analyzed to detect the cut-off related with AL. Only in case of Fpos lower than 158.3 U and Slope lower than 13.1 U/s p-value were significant. The most valuable diagnostic parameter after risk stratification was the Negative Predictive Value. CONCLUSION: Quantitative analysis of ICG fluorescence in colorectal surgery is safe and feasible to stratify risk of AL. Hypertension and location of anastomosis influence the intensity of fluorescence at the point of section. A change of division place should be considered to avoid AL related to vascular reasons when intensities of fluorescence at the point of section is lower than 169 U or slopes lower than 14.4 U/s.

Analysis of frequency, type of complications and economic costs of outlying patients in general and digestive surgery. / Análisis de la frecuencia, tipos de complicación y costes económicos en los pacientes ectópicos de cirugía general y digestiva.

INTRODUCTION: The shortage of available beds and the increase in Emergency Department pressure can cause some patients to be admitted in wards with available beds assigned to other services (outlying patients). The aim of this study is to assess the frequency, types of complications and costs of outlying patients. METHODS: Using a retrospective cohort model, we analysed the 2015 general and digestive surgery records (source: Minimum Basic Data Set and economic database). After selecting all outlying patients, we compared the complications, length of stay, costs and consequences of complications against a randomized sample of non-outlying patients with the same DRG and date of episode for every outlying patient, obtaining one non-outlying patient for each selected outlying patient. Thirteen outlying patients with no non-outlying patient pair were excluded from the study. RESULTS: From a total of 2,915 patients, 363 (12.45%) were outlying patients. A total of 350 outlying patients were analysed versus 350 non-outlying patients. There were no significant differences in complications (9.4 vs. 8.3%), length of stay (4.33 vs. 4.65 days) or costs (€3,034.12 vs. €3,223.27). Outlying patients men presented a significantly higher risk of complications compared to women (RR=2.10). Outlying patients presented complications after 2.5 or more days. CONCLUSIONS: When outlying admissions become necessary, the selection of patients with less complex pathologies does not increase complications or their consequences (ICU admissions, readmissions, reoperations or mortality), hospital stays or costs. Only in cases of prolonged outlying stays of more than 2.5 days, or in males, may more complications appear. Therefore, male outliers should be avoided in general, and patients should be transferred to the proper ward if a length of stay beyond 2.5 days is foreseen.

Prevention of parastomal hernia with a preperitoneal polypropelene mesh.

OBJECTIVE: To show our results with the use of a polypropylene mesh at the stoma site, as prophylaxis of parastomal hernias in patients with rectal cancer when a terminal colostomy is performed. METHODS: From January 2010 until March 2014, 45 consecutive patients with rectal cancer, underwent surgical treatment with the need of a terminal colostomy. A prophylactic mesh was placed in a sublay position at the stoma site in all cases. We analyze Demographics, technical issues and effectiveness of the procedure, as well as subsequent complications. RESULTS: A prophylactic mesh was placed in 45 patients, 35 male and 10 females, mean age of 66.2 (47-88) and Body Mass Index 29.19 (20.4-40.6). A total of 7 middle rectal carcinoma, 36 low rectal carcinoma, one rectal melanoma and one squamous cell anal carcinoma were electively treated with identical protocol. Abdominoperineal resection was performed in 38 patients, and low anterior resection with terminal colostomy in 7. An open approach was elected in 39 patients and laparoscopy in 6, with 2 conversions to open surgery. Medium follow up was 22 months (2.1-53). Overall, 3 parastomal hernias (6.66%) were found, one of which was a radiological finding with no clinical significance. No complications related to the mesh or the colostomy were found. CONCLUSIONS: The use of a prophylactic polypropylene mesh placed in a sublay position at the stoma site is a safe and feasible technique. It lowers the incidence of parastomal hernias with no increased morbidity.

[Importance of the quality of the discharge report in the management of a surgical clinical unit]. / Importancia de la calidad del informe de alta en la gestión de una unidad clínica quirúrgica.

BACKGROUND: The discharge report is a basic document at the end of a care process, and is a key element in the coding process, since its correct wording, reliability and completeness are factors used to determine the hospital production. MATERIAL AND METHODS: From a hypothesis based on the analysis of the consistency between the discharge report and data collected from the routine clinical notes during admission, we should be able to re-code all those mis-coded, thus placing them in a more appropriate diagnosis-related group (DRG). A total of 24 patient outliers were analysed for the correct filling in of the type and reason for admission, personal history, medication, anamnesis, primary and secondary diagnosis, sugical procedure, outcome, number of diagnostic and procedures cited, concordance between discharge report and history and recoding of the DRG. RESULTS: From a total of 24 episodes, 6 had precise and valid reports, 4 were valid but not precise enough, 9 were insufficient, and 5 were clearly invalid. The recoded DRG after the documentation review was not significantly different, according to the Wilcoxon test, being changed in only 5 cases (P = .680). CONCLUSION: Quality in discharge reports depends on an adequate minimum data set (MDS) in concordance with the source documentation during admission. Discordance can change the DRG, despite it not being significantly different in our series. Self-audit of discharge reports allows quality improvements to be developed along with a reduction in information mistakes.

[One year follow-up after doppler-guided haemorrhoidal artery ligation]. / Resultados a un año tras desarterialización hemorroidal guiada por doppler.

INTRODUCTION: The Doppler-guided haemorrhoidal artery ligation (DG-HAL) is a non-exeresis technique for the treatment of haemorrhoids, consisting in the ligature of the distal branches of the upper rectal artery. The aim of this work is to evaluate the safety and efficacy of this technique after one year of follow-up. MATERIAL AND METHOD: A total of 30 patients were operated on using DG-HAL for grade II or III haemorrhoids. The mean age was 49.9 years (30-70 years). The THD® (Transanal Haemorrhoidal Dearterialisation) device was employed in all cases. The procedures were performed under intradural anaesthesia in a short-stay surgery unit. The operating time, pain, bleeding, postoperative stay, and complications and symptoms after 3-6 months and 12 months were recorded. RESULTS: The mean operating time was 23minutes (15-50). The pain according to a visual analogue scale (VAS) was 5.5 during the first day (90% required analgesia). Only 2 patients required analgesia after the second day. One patient described persistent pain up to 3 months, and 2 slight bleeding. A further operation was performed due to a haemorrhoidal thrombosis on the 10(th) day. There were no other complications and no re-admissions. The mean hospital stay was 1.4 days (0-2), and normal daily activity re-established at 7-8 days. A large majority (87%) of patients described having tenesmus, which disappeared in 3 months. After one year, two patients had had further operations, 3 had recurrences (2 slight prolapses and 1 occasional bleeding). The success rate was 80%. CONCLUSIONS: Haemorrhoidal dearterialisation using Doppler-guided arterial ligation seems to be effective after one year, with a low percentage of complications.