Higher cost of single incision laparoscopic cholecystectomy due to longer operating time. A study of opportunity cost based on meta-analysis.

BACKGROUND: We aimed to calculate the opportunity cost of the operating time to demonstrate that single incision laparoscopic cholecystectomy (SILC) is more expensive than classic laparoscopic cholecystectomy (CLC). METHODS: We identified studies comparing use of both techniques during the period 2008-2016, and to calculate the opportunity cost, we performed another search in the same period of time with an economic evaluation of classic laparoscopy. We performed a meta-analysis of the items selected in the first review considering the cost of surgery and surgical time, and we analyzed their differences. We subsequently calculated the opportunity cost of these time differences based on the design of a cost/time variable using the data from the second literature review. RESULTS: Twenty-seven articles were selected from the first review: 26 for operating time (3.138 patients) and 3 for the cost of surgery (831 patients), and 3 articles from the second review. Both echniques have similar operating costs. Single incision laparoscopy surgery takes longer (16.90min) to perform (p <0.00001) and this difference represents an opportunity cost of 755.97 € (cost/time unit factor of 44.73 €/min). CONCLUSIONS: SILC costs the same as CLC, but the surgery takes longer to perform, and this difference involves an opportunity cost that increases the total cost of SILC. The value of the opportunity cost of the operating time can vary the total cost of a surgical technique and it should be included in the economic evaluation to support the decision to adopt a new surgical technique.

[Hypertonic saline solutions in resuscitation in hemorrhagic shock. An experimental study]. / Le soluzioni saline ipertoniche nel recupero dallo shock emorragico. Studio sperimentale.

The aim of the study was to evaluate the use of hypertonic solutions in restoring intravascular volume in a model of hemorrhagic shock. Eighteen pigs underwent general anesthesia and were instrumented with a carotid catheter to record mean arterial pressure (MAP), a pulmonary artery catheter for pulmonary arterial pressure (MPAP) and cardiac output (CO) monitoring and an electromagnetic flowmeter around the abdominal supraceliac aorta for aortic flow measurement (Vaor). Oxygen delivery (DO2) and oxygen consumption (VO2) data were calculated by standard formulas. The animals were hemorrhaged to a MAP of 45 mmHg, held for 1 hour. They were resuscitated during the following hour until the aortic flow regained its basal value, using three different solutions: normotonic saline (NS = NaCl 0.9%), hypertonic saline (HS = NaCl 7.5%), hypertonic saline added with dextran (HSDX = NaCl 7.5% + 6% dextran 70). An hour of autologous blood transfusion and a two hours follow-up concluded the experiment. Volumes infused were remarkably lower administering HS (13.70 +/- 1.44 ml/kg) and HSDX (9.11 +/- 1.20 ml/kg) compared to NS (90.32 +/- 24.83 ml/kg). MAP, CO and DO2 values resulted significantly higher in the HSDX animals, with lower MPAP levels. During the two hours follow-up only the animals reinfused with HSDX maintained hemodynamic and oxygen transport values at normal levels. We conclude that the administration of hypertonic saline solutions during hemorrhagic shock allows the saving of infusion volumes, thus diminishing the occurrence of interstitial edema formation. The adding of dextran to the solution prolongs the hemodynamic effects.

Pneumomediastinum: physiopathological considerations and report of six cases treated in an emergency surgery division.

Pneumomediastinum indicates the presence of air in the mediastinal space. It may be classified in three categories, based on the main causes of air dissection into the mediastinal structures: spontaneous pneumomediastinum (pnm), the most frequently encountered, post traumatic pnm and pnm secondary to non-traumatic rupture of an abdominal hollow viscus. This paper reports the experience of a major regional emergency surgery division in the management of pnm during a five years period. Physiopathologic correlations are discussed together with diagnostic and therapeutic options.

[The phantom breast syndrome]. / Síndrome del seno fantasma.

BACKGROUND: The phantom breast syndrome (PBS) is a complication of mastectomy which consists of a sensation of breast persistence after mastectomy. MATERIALS, PATIENTS AND METHODS: The incidence, clinical course and location of PBS in 97 operated women were studied for a 15-year period. All women were interviewed in postoperative follow-up controls after mastectomy. RESULTS: The incidence of PBS was 29 patients out of the 97 total. The syndrome was present for more than 48 months in eleven of these patients. In most cases the location of "phantom sensations" was the nipple (15 cases) and the entire breast in five patients. In only three patients was phantom breast pain (PBP) reported whereas some discomfort was reported by the other patients. CONCLUSIONS: The incidence of PBS in our series was similar to that reported by other authors, but PBP was less common. Neither postoperative sequelae nor the antitumoral specific therapy seemed to have influence on the emergence of PBS.

[Imaging-guided therapy of primary tumors of the liver]. / Terapia imaging-guided dei tumori primitivi del fegato.

Primitive tumor of the liver, associated with cirrhosis with 40-80% of incidence, isn't one of the most common malignant neoplasms in the western area but it holds low survival and diminished possibilities of radical exeresis. A few years ago it has enrolled several non-invasive imaging-guided techniques, alternative or complementary to surgery, for the treatment of hepatic carcinoma. The authors carried out a review of the literature of the past years referring to no invasive imaging guided techniques for the treatment of liver neoplasms and they describe the therapeutical indications, advantages and disadvantages of their application and the complications reported. Although this is a controversial subject, with several lines of actuation, the present report demonstrate that the intraoperative echography, chemoembolization, radiochemoembolization and percutaneous alcoholization are more feasible because definite indications and acceptable results.

[Gasless laparoscopic cholecystectomy using retractor of the abdominal wall]. / Colecistectomia laparoscopica "gasless" mediante elevatore della parete addominale.

The Authors present a new gasless laparoscopic cholecystectomy method using an abdominal wall elevator with subcutaneous traction ("laparotenser"). Fifty patients between May 1994 and March 1995 were operated by videolaparoscopy using this new gasless method. Twenty of them were operated with Nagai's method while the laparotenser was used in the remaining thirty. The results obtained are similar to those using pneumoperitoneum. It has been observed a global reduction of costs, less postoperative pain, no influence in cardiovascular and metabolic indexes. No complications were reported during the postoperative period but two cases of conversion to laparotomy not related to the method used were needed. Laparoscopic cholecystectomy without pneumoperitoneum using the subcutaneous elevator of the abdominal wall ("laparotenser") has demonstrated that it's possible to operate in a working space similar to that created by the pneumoperitoneum. After an initial period of distrust towards the laparoscopic methods without pneumoperitoneum it has been accepted that gasless methods multiply the indications to minimally invasive surgery in patients with cardiorespiratory problems considered no ideal candidates to laparoscopic cholecystectomy with pneumoperitoneum.

[The reappearance of gastrointestinal tuberculosis in general surgery]. / La ricomparsa della tubercolosi gastrointestinale in chirurgia generale.

Gastro-intestinal tuberculosis (TB) continues to give rise to diagnostic and therapeutic challenges. Its increasing incidence and multiple and non-specificity of symptoms and signs require special attention to establish a prompt diagnosis and not to delay treatment. The authors describe on case of colonic TB presenting with multiple episodes of subocclusion suggesting a stenosing neoplasm of the caecum.

[Pancreatic endocrine F-cell tumor]. / Tumor pancreático endocrino de células F.

Two cases of pancreatic F-cell malignant tumors, producing only pancreatic polypeptide (PP) with clinical, biochemical and immunohistochemical features are described. No PP-associated endocrine symptoms were present. In both tumors, definitive diagnosis was immunohistochemical, and surgical treatment was carried out. Clinical evolution in the two patients was different: one of them died within the postoperative period with upper gastrointestinal bleeding by multiple duodenal ulcers, whereas the other--with lymph node metastasis at intraoperative diagnosis--is alive six years after treatment. F-cell tumors can be classified among the group of silent endocrine tumors of the pancreas. The reason for their discrepancy in the clinical behavior is unknown.