Influence of size and complexity of the hospitals in an enhanced recovery programme for colorectal resection.

PURPOSE: The aim of this study was to see whether the application of the enhanced recovery programme for colorectal resection improves the results and, in turn, the influence of complexity and size of the hospitals in applying this and its results. METHODS: A multi-centric prospective study was controlled with a retrospective group. The prospective operation group included 300 patients with elective colorectal resection due to cancer. The centres were divided depending on size and complexity in large reference centres (group 1) and area and basic general hospitals (group 2). The retrospective control group included 201 patients with the same characteristics attended before the application of the programme. Completion of categories of the protocol, complications, perioperative mortality and stay in hospital were recorded. RESULTS: The introduction of the programme achieved a reduction in mortality (1 vs. 4 %), morbidity (26 vs. 39 %) and preoperative (<24 h vs. 3 days) and postoperative (7 vs. 11 days) stays (p < 0.01). There was greater fulfilment of protocol in group 2 with the mean number of items completed at 8.46 and 60 % completed compared with the hospitals in group 1 (7.70 completed items and 55 % completion). The size of the hospital had no relation to the rate of complications (21.3 vs. 26.5 %). In smaller sized and less complex hospitals, the average length of stay was 1.88 days less than in those of greater size (6.45 vs. 8.33 days). CONCLUSION: Patients treated according to an enhanced recovery programme develop significantly fewer complications and have a shorter hospital stay. The carrying out of protocol is greater in smaller and less complex hospitals and is directly related to a shorter stay in hospital.

A calcified foreign body in the bladder due to : an unusual complication after laparoscopic incisional hernia repair.

We report a rare complication caused by a displaced tack after laparoscopic incisional hernia repair. A 41-year-old woman treated 11 months earlier for a suprapubic incisional hernia (Pfannenstiel laparotomy) received a laparoscopic repair with a bilaminar mesh fixed with tacks. Seven months later, she presented miccional irritative symptoms and chronic lower abdominal pain. Leucocyturia and microhematuria were present, and computerized tomography showed 2 calcified nodules in the bladder wall. Cystoscopy confirmed 2 calcified foreign bodies in the bladder due the tack fixation. She underwent an intra-abdominal laparoscopic exploration, which showed the protrusion of a mesh in the urinary bladder. The tacks were removed and a partial laparoscopic cystectomy including mesh protrusion was performed. The patient was discharged from hospital 4 days later without postoperative complications. At follow-up 24 months after surgery, she remains well with no pain, urinary symptoms, or hernia recurrence.

[Laparoscopic treatment of achalasia: analysis of results and reflections on the technique]. / Tratamiento laparoscópico de la acalasia. Análisis de resultados y reflexiones sobre la técnica.

INTRODUCTION: Heller myotomy using the laparoscopic approach is the best treatment that we can offer to patients with achalasia. On not acting on the cause of the disease, we can only alleviate the persistence of the symptoms, but not make them disappear. OBJECTIVE: To analyse the results of our group in the treatment of achalasia by laparoscopy. MATERIAL AND METHODS: The pre- and post-operative results are analysed of a series of 20 patients intervened prospectively by laparoscopy of achalasia during a period from May 2003 to April 2010. For this we used a modification of the grading scale of pre- and post-operative symptoms described by Velanovich for GER (a scale from 0-5). Data on the complications and the hospital stay were also collected. RESULTS: A wide Heller myotomy was performed using a Dor type antireflux mechanism. There were no oesophageal perforations or complications during the surgery. Two (10%) patients had postoperative complications. The mean hospital stay was 3.11 ± 2.13 days. After a mean follow up of 55.8 ± 14.1 months, the symptoms studied had significantly decreased after the surgery. Only 3 (15%) patients had clinical symptoms of GER after surgery. Nineteen patients (95%) said they were satisfied with the operation. CONCLUSIONS: The laparoscopic treatment of achalasia is a safe technique, reproducible and effective technique, which achieves very satisfactory control of the achalasia symptoms with a minimum of morbidity.

Laparoscopic treatment of gastric tumors.

PURPOSE: To assess the use of different laparoscopic approaches in the management of gastric tumors based on tumor type and location. MATERIALS AND METHODS: Between March 2002 and June 2005, 23 consecutive patients with gastric lesions were treated with laparoscopy procedures. Six patients presented with stromal tumors, 5 with benign lesions, and 12 with resectable gastric cancers. RESULTS: The patients were 13 men and 10 women, mean age 66.2 +/- 11.1 years (range, 29-84 years). Five laparoscopic gastric wedge resections, 6 intragastric submucosal resections, and 12 gastrectomies (10 subtotal and 2 total) were performed. Mean operative time was 49.1 +/- 18.8 minutes (range, 30-85 minutes) in the gastrointestinal stromal tumors and 64.1 +/- 19.2 minutes (range, 45-90 minutes) in benign tumors. Gastrectomy required an average of 197.6 +/- 36.9 minutes (range, 130-260 minutes). The mean times were 142.5 +/- 9.6 minutes in the subtotal gastrectomy group with extracorporeal anastomosis and 190.8 +/- 20.1 minutes when the anastomosis was totally laparoscopic (P < 0.002). All procedures were completed laparoscopically and there were no intraoperative complications. There were four postoperative complications: one wall hematoma secondary to the introduction of a trocar, one prolonged ileus, one intra-abdominal abscess, and one esophagojejunal leakage. Gastrointestinal stromal tumor patients were discharged after a mean 5.8 +/- 1.3 days; patients with benign pathology after 5.2 +/- 0.9 days, and gastric cancer patients after 10.7 +/- 7.3 days (range, 6-28 days). The mean number of dissected lymph nodes in gastric cancer was 21.3 (range, 16-31). CONCLUSION: Laparoscopic treatment of gastric lesions is technically feasible and safe. Compared to conventional surgery, it offers the advantages of low invasiveness and improved quality of life.

Recurrent inguinal hernia: a ten-year review.

BACKGROUND: This study evaluates the results obtained in recurrent inguinal hernia repair over the past ten years in a general hospital using laparoscopic (LAP) and open tension-free mesh (Lichtenstein) procedures. METHODS: A prospective controlled study with 258 recurrent inguinal hernias in 235 patients over a ten-year period. The main outcome measurements were recurrence rate, operating time, hospital stay, postoperative complications, and cost. RESULTS: There were 10 recurrences (4.3%): 7 in the Lichtenstein group (5.7%) and 3 (2.2%) in the LAP group (P = nonsignificant [NS]). There were 15 (12.2%) postoperative complications in the Lichtenstein group and 6 (4.4%) in the LAP group (P =0.04). The operating room costs were higher in the LAP group, but this difference was offset by a significantly shorter hospital stay, shorter operating time, and earlier return to work. CONCLUSION: Laparoscopic repair is an effective option for the treatment of recurrent inguinal hernia. The TEP approach combines the advantages of minimal invasive surgery and those of tension-free mesh repair, reducing operating time, postoperative morbidity, and recurrence rate.