Isoperistaltic versus antiperistaltic side-to-side anastomosis after right laparoscopic hemicolectomy for cancer (ISOVANTI) trial: study protocol for a randomised clinical trial.

BACKGROUND: It is believed that loosing ileocecal valve is well tolerated in patients who do not have short bowel syndrome or Crohn disease. From the hypothesis of colonic peristalsis and transit is regulated by that ileocecal valvular mechanism, we try to find out if the creation of a new pseudo-valvular mechanism as antiperistaltic anastomosis could be considered after right hemicolectomy can cause any short- or long-term changes in gastrointestinal habits. PURPOSE: The purpose of the study at primary endpoint is to compare early (occurring within 30 days of surgery) and late (occurring during the follow-up) postoperative complications between both groups The purpose of the study at secondary endpoint is to compare intraoperative and postoperative events between experimental and control groups in terms of operating time, first oral tolerance day, first flatus and faeces, length of hospital stay and orocecal transit; comparing rates of gastrointestinal life quality and comparing mortality rates between both groups. METHODS: The ISOVANTI trial is a randomized controlled single-centre trial comparing isoperistaltic versus antiperistaltic side-to-side anastomosis after right laparoscopic hemicolectomy. It is designed as a parallel group superiority trial. CONCLUSIONS: It is unknown if a pseudo-valvular mechanism as antiperistaltic anastomosis can be considered has short- or long-term consequences in gastrointestinal habit. Considering the impact that ileocolic anastomosis configuration could have on the restitution of bowel transit after right hemicolectomy, we think it is indicated and necessary a randomized trial comparing iso- and antiperistaltic modalities. TRIAL REGISTRATION: NCT02309931.

Intracorporeal ileocolic anastomosis in patients with laparoscopic right hemicolectomy.

BACKGROUND: Since the introduction of laparoscopic colorectal surgery, there has been a controversy between creating an intracorporeal or extracorporeal ileocolic anastomosis in right hemicolectomy. The purpose is to report our experience in intracorporeal anastomosis following right hemicolectomy in both malignant and benign pathologies. STUDY DESIGN: A retrospective review of a prospectively collected database was conducted at Virgen de la Arrixaca Clinical University Hospital (Murcia) between January 2000 and April 2014. The study includes all surgery patients who received a laparoscopic right hemicolectomy with an intracorporeal ileocolic anastomosis. The criteria for exclusion were conversion to open surgery during the procedure due to technical difficulties during dissect. Tumours considered T4 were not excluded, nor were stage IV patients or those with a history of previous abdominal surgery. RESULTS: There were 173 patients (63 females) aged 67 (range 14-91) years, with body mass index of 27 (17-52) kg/m(2) and ASA 1:2:3:4 of 12:78:68:15; 41% had previous abdominal surgery and 70% had a pre-existing comorbidity. Operating time was 142 (60-270) min. Specimen extraction site incision length was 8.1 (6-11.1) cm. Conversion rate was 9.2%, and there were 39 complications (22.54%) and 9 reoperations (5.2%). Readmission rate was 5.2%. Length of stay was 5.7 (1-35) days. CONCLUSION: The intracorporeal procedure is a safe and feasible alternative for creating an ileocolic anastomosis. It involves a similar rate of complications and may prevent some of the drawbacks presented by extracorporeal anastomosis.

Stimulation of the efferent limb before ileostomy closure: a randomized clinical trial.

BACKGROUND: Postoperative ileus is the most common complication after ileostomy closure with an increase in morbidity, hospital stay, and health care costs. OBJECTIVE: The aim of this study is to assess the utility of a new technique for reducing postoperative ileus after protective ileostomy closure. DESIGN: This is a prospective randomized study registered at ClinicalTrials.gov (NCT01881594). Patients were randomly assigned to undergo either stimulation through the efferent limb of the ileostomy before surgery or nonstimulation before surgery. SETTING: This study was conducted at the Department of Surgery of the Virgen de la Arrixaca Clinical University Hospital (Murcia). PATIENTS: Seventy patients underwent surgery for ileostomy closure. In 35 patients, during the 2 weeks before surgery, daily stimulation of the defunctionalized stomal segment was performed by using a thick solution (500 mL of physiological saline associated with 30 g of thickening agent, Nestle Resource, Vevey, Switzerland). In the other 35 patients, stimulation was not performed before surgery. MAIN OUTCOME MEASURES: The primary outcome was postoperative ileus. The secondary outcomes included time to tolerating a diet and postoperative stay. RESULTS: Both groups of patients were homogenous for demographic data, characteristics of the first rectal cancer operation, and intersurgery periods. After ileostomy closure, the stimulated group of patients had an earlier return to oral tolerance (1.06 vs 2.57 days; p = 0.007) and passage of flatus or stool (1.14 vs 2.85 days; p <0.001) than the nonstimulated group of patients. The incidence of postoperative ileus (2.85% vs 20%; p = 0.024) and hospital stay (2.49 vs 4.61 days; p = 0.002) was also lower in the stimulated patients. LIMITATIONS: Small numbers of patients means that no definitive statements can be made regarding the effectiveness of this technique. CONCLUSIONS: Stimulation of the efferent limb of the ileostomy before closure is a safe technique that reduces postoperative ileus and fosters early intestinal transit and oral tolerance with a shorter postoperative hospital stay.

Surgical treatment of endemic goiter in a nonhospital setting without general anesthesia in Africa.

BACKGROUND: Endemic goiter remains a serious public health problem and 75 % of people affected live in underdeveloped countries where treatment is difficult for various reasons. The aim of this article is to report our experience in African countries with the management and surgical treatment of endemic goiter, performed in a nonhospital setting and without general anesthesia in the context of a collaborative development project by experienced endocrine surgeons. METHODS: Fifty-six black African patients with a goiter were studied. Those in poor general health, the elderly, patients with either small goiters or clinical hyperthyroidism, and those presenting with an acute episode of malaria were excluded from the study. Cervical epidural anesthesia with spontaneous ventilation was used and a partial thyroidectomy was performed. The technique used, its immediate complications, and early and late follow-up were analyzed. RESULTS: Surgery was performed on 31 patients with grades 3 and 4 goiter without mortality and a morbidity rate of 11.9 %, with 97 % of all complications being minor. There were no instances of dysphonia or symptomatic hypocalcemia and the mean stay was 1.57 days (range 1.25-1.93). Follow-up in the first year was 71 % and no case of severe or recurrent hypothyroidism was detected. CONCLUSIONS: Surgery without general anesthesia performed in a nonhospital setting in underdeveloped countries in patients with goiter is a viable option with good results and low morbidity.

Do hernia operations in african international cooperation programmes provide good quality?

BACKGROUND: Hernia is especially prevalent in developing countries where the population is obliged to undertake strenuous work in order to survive, and International Cooperation Programmes are helping to solve this problem. However, the quality of surgical interventions is unknown. The objective of the present study was to evaluate the quality of hernia repair processes carried out by the Surgical Solidarity Charity in Central African States. MATERIALS AND METHODS: A total of 524 cases of inguinal hernia repair carried out in Cameroon and Mali during 2005 to 2009 were compared with 386 cases treated in a Multicentre Spanish Study (2003). General data (clinical, demographic, etc.), type of surgery, complications, and effectiveness and efficiency indicators were collected. RESULTS: Preoperative studies in the Spanish group were greater in number than in the African group. The use of local anesthesia was similar. Antibiotic prophylaxis was higher in the African group (100% to 75.4%). The use of mesh was similar. The incidence of hematomas was higher in the Spanish group (11.61% to 4.61%), but the incidence of infection of the wound and of hernia recurrence was similar, although follow-up was only carried out in 20.97% in the African group (70% in the Spanish group). Hospital stay of more than 24 h was higher in the Spanish group. CONCLUSIONS: The standard quality of surgery for the treatment of hernia in developing countries with few instrumental means, and in sub-optimal surgical conditions is similar to that provided in Spain.

Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer.

BACKGROUND: The laparoscopic treatment of rectal cancer is controversial. This study compared surgical outcomes after laparoscopic and open approaches for mid and low rectal cancers. METHODS: Some 204 patients with mid and low rectal adenocarcinomas were allocated randomly to open (103) or laparoscopic (101) surgery. The surgical team was the same for both procedures. Most patients had stage II or III disease, and received neoadjuvant therapy with oral capecitabine and 50-54 Gy external beam radiotherapy. RESULTS: Sphincter-preserving surgery was performed in 78.6 and 76.2 per cent of patients in the open and laparoscopic groups respectively. Blood loss was significantly greater for open surgery (P < 0.001) and operating time was significantly greater for laparoscopic surgery (P = 0.020), and return to diet and hospital stay were longer for open surgery. Complication rates, and involvement of circumferential and radial margins were similar for both procedures, but the number of isolated lymph nodes was greater in the laparoscopic group (mean 13.63 versus 11.57; P = 0.026). There were no differences in local recurrence, disease-free or overall survival. CONCLUSION: Laparoscopic surgery for rectal cancer has a similar complication rate to open surgery, with less blood loss, rapid intestinal recovery, shorter hospital stay, and no compromise of oncological outcomes.

[Cardiovascular risk factors associated to abdominal obesity in apparently healthy subjects]. / Factores de riesgo cardiovascular asociados a obesidad abdominal en adultos aparentemente sanos.

OBJECTIVE: to determine the relationship between the abdominal obesity and cardiovascular risk factors in apparently healthy subjects from Mexico City. METHODS: a total of 186 apparently healthy men and nonpregnant women from Mexico City, were enrolled in a cross-sectional study. A detailed medical history and physical examination were performed. Abdominal obesity was defined by waist circumference > or = 80 cm for women and > or = 90 cm for men. RESULTS: a total of 125 women (67.2 %) and 61 men (32.8 %) were enrolled. Of them, 151 (81.2 %) had insulin resistance and 130 (69.9 %) abdominal obesity. Among obese subjects 96 (46.2 %) showed metabolic syndrome. There were a high prevalence of hypertriglyceridemia (31 %) and low serum levels of HDL-cholesterol (58 %). CONCLUSIONS: the used cut point for abdominal obesity, despite identifying a high proportion of subjects with cardiovascular risk, did not recognize a high proportion of subjects with disorders in their lipid profile.

Failure properties of vena cava tissue due to deep penetration during filter insertion.

In this work, we use an in-vitro mechanical test to explore the resistance of biaxially stretched vena cava tissue against deep perforation and a methodology which integrates experimental and numerical modeling to identify constitutive fracture properties of the vena cava. Six sheep vena cava were harvested just after killing, and cyclic uniaxial tension tests in longitudinal and circumferential directions and biaxial deep penetration tests were performed. After that, we use a nonlinear finite element model to simulate in vitro penetration of the cava tissue in order to fit the fracture properties under penetration of the vena cava by defining a cohesive fracture zone. An iterative process was developed in order to fit the fracture properties of the vena cava using the previously obtained experimental results. The proposed solutions were obtained with fracture energy of 0.22 or 0.33 N/mm. In comparison with the experimental data, the simulation using [Formula: see text], [Formula: see text], and [Formula: see text] parameters ([Formula: see text]) is in good agreement with results from penetration experiments of cava tissue. It is noticeable that the parameter estimation process of the fracture behavior is more accurate than the estimation process of the elastic behavior for the toe region of the curve.

Stapling Versus Hand Suture for Gastroenteric Anastomosis in Roux-en-Y Gastric Bypass: a Randomized Clinical Trial.

BACKGROUND: Different anastomotic techniques have been evaluated during a laparoscopic Roux-en-Y gastric bypass (RYGB); however, no techniques have proven to be better than any other regarding complications and the percentage of weight loss (excess weight loss (%EWL)), and there are few controlled prospective studies to compare them. METHODS: A randomized, prospective study was conducted in 238 patients undergoing RYGB for morbid obesity between July 2008 and September 2012 to compare the early and late postoperative complications between the two surgical techniques: gastrojejunal hand-sutured anastomosis (HSA) and circular-stapled anastomosis (CSA). Minimum follow-up was 24 months. RESULTS: The two groups of patients were similar for demographic data and preoperative comorbidities. There were no significant differences between the surgical techniques regarding %EWL at 3, 12, and 24 months. The patients with CSA had a greater frequency of postoperative gastrointestinal bleeding (GIB) (4.2 vs. 0%, p = 0.024) and surgical wound infection (11.1 vs. 3.4%, p = 0.025) than the patients with HSA, with no significant differences in the other early complications. There were no significant differences in either group for late complications (gastrojejunal anastomosis (GJA) stricture, marginal ulcer, GJA perforation, bowel obstruction, and eventration). No significant differences were observed in operative time, rate of reoperation and postoperative length of hospital stay. CONCLUSIONS: HSA and CSA were techniques with similar safety and effectiveness in our study. HSA had a lower rate of bleeding complications and surgical wound infection, although it does require greater experience in laparoscopic hand suturing.

Life-supporting human complement regulator decay accelerating factor transgenic pig liver xenograft maintains the metabolic function and coagulation in the nonhuman primate for up to 8 days.

BACKGROUND: It is not known whether the pig liver is capable of functioning efficiently when transplanted into a primate, neither is there experience in transplanting a liver from a transgenic pigs expressing the human complement regulator human complement regulator decay accelerating factor (h-DAF) into a baboon. The objective of this study was to determine whether the porcine liver would support the metabolic functions of non-human primates and to establish the effect of hDAF expression in the prevention of hyperacute rejection of porcine livers transplanted into primates. METHODS: Five orthotopic liver xenotransplants from pig to baboon were carried out: three from unmodified pigs and two using livers from h-DAF transgenic pigs. FINDINGS: The three control animals transplanted with livers from unmodified pigs survived for less than 12 hr. Baboons transplanted with livers from h-DAF transgenic pigs survived for 4 and 8 days. Hyperacute rejection was not detected in the baboons transplanted with hDAF transgenic pig livers; however, it was demonstrated in the three transplants from unmodified pigs. Baboons transplanted with livers from h-DAF transgenic pigs were extubated at postoperative day 1 and were awake and able to eat and drink. In the recipients of hDAF transgenic pig livers the clotting parameters reached nearly normal levels at day 2 after transplantation and remained normal up to the end of the experiments. In these hDAF liver recipients, porcine fibrinogen was first detected in the baboon plasma 2 hr postreperfusion, and was present up to the end of the experiments. One animal was euthanized at day 8 after development of sepsis and coagulopathy, the other animal arrested at day 4, after an episode of vomiting and aspiration. The postmortem examination of the hDAF transgenic liver xenografts did not demonstrate rejection. INTERPRETATION: The livers from h-DAF transgenic pigs did not undergo hyperacute rejection after orthotopic xenotransplantation in baboons. When HAR is abrogated, the porcine liver maintains sufficient coagulation and protein levels in the baboon up to 8 days after OLT.

Laparoscopic gastric bypass in the treatment of morbid obesity. Preliminary results of a new technique.

INTRODUCTION: Gastric bypass is one of the most commonly used surgical techniques for the management of morbid obesity. It is usually done as an open surgery procedure, and in recent years surgeons have begun to perform it via the laparoscopic approach. The aim of this paper is to describe our surgical technique for laparoscopic gastric bypass (LGBP) and present the short-term results. MATERIALS AND METHODS: Between January 2000 and January 2002 we operated on 50 patients with morbid obesity who met criteria for bariatric surgery. The patients had a mean age of 34 years and a body mass index (BMI) of 47. RESULTS: Conversion was necessary in 4 of the 50 patients (8%). Mean operating time was 181 min, with a difference of 60 min between the first 10 and last 10 cases. There was a 26% rate of complications, 14% of which were early (%<% 30 days) and 12% late (%>%30 days). Mean hospital stay was 4.5 days. CONCLUSION: LGBP is a technique with good short-term results as far as weight loss is concerned, although it has one of the most complex learning curves in laparoscopic surgery. Surgeons who regard gastric bypass as the technique of choice for the surgical management of morbid obesity should consider performing it via the laparoscopic approach.

Role of liver transplantation in the management of metastatic neuroendocrine tumors.

INTRODUCTION: In the majority of patients transplanted for unresectable liver metastases, long-term results are disappointing because of early tumor recurrence. Due to its biologically less aggressive nature, neuroendocrine metastases (NM) may represent a good indication for liver transplantation (LT). PATIENTS AND METHODS: Between January 1996 and May 2000, five patients with NM were transplanted. The primary tumors were located in the pancreas (n=4) and the small bowel (n=1). In three cases there were symptoms related to hormone production: two carcinoids, and one gastrinoma. The management of primary tumors was sequential in three patients with the tumor being resected before LT (one Whipple procedure and two left pancreatectomies). In two patients the resections of the primary tumors and the LT were simultaneous namely one bowel resection and one left pancreatectomy. All patients were treated with chemotherapy. RESULTS: Two patients developed recurrent disease succumbing at 15 months (nonfunctioning NE pancreatic head tumor) and 17 months (carcinoid of the pancreatic tail) post-LT. Another patient died at 3 months post-LT due to technical complications. The other two patients are alive and free of recurrence. CONCLUSION: Despite the promising results obtained with LT for NM, our experience indicates that patients must be carefully selected. Perhaps the use of more aggressive chemotherapeutic protocols combined with an individualized approach will improve the results.

Fulminant hepatic failure and liver transplantation: experience of Virgen de la Arrixaca Hospital.

INTRODUCTION: For patients with fulminant hepatic failure who show a poor evolution despite medical treatment, liver transplantation is an option, with survival rates of greater than 50%. The ideal time to perform the transplant is controversial, as it must not be done too soon (when the liver disease is still reversible) or too late (when the patient is in an irreversible clinical situation). PATIENTS AND METHODS: Retrospective review of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure included 26 who underwent transplantation. The most frequent cause was viral (n=10, 38%); with no etiology established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of AB0/DR compatibility, 13 cases were identical (40%), 17 compatible (51%), and the other three incompatible (9%). RESULTS: Thirty-three transplants were performed in 26 patients: four were retransplants due to chronic rejection, two for primary graft failure, and one for hyperacute rejection. The overall mortality rate was 46% (12 patients). The most frequent cause of death was infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years, and 59% at 5 years. The factors associated with a poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the last being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the last being the only prognostic factor identified in the multivariate analysis. CONCLUSION: Good results of transplantation for the management of fulminant hepatic failure depends on optimal selection of transplant candidates, which means identifying them early, reducing the waiting time, and excluding factors associated with a poor prognosis.

Eversion thromboendovenectomy for organized portal vein thrombosis encountered during liver transplantation.

INTRODUCTION: Due to the technical experience acquired in the field of liver transplantation portal vein thrombosis is no longer considered a contraindication for transplantation. Nevertheless, the results obtained in patients with portal vein thrombosis are at times suboptimal, and there is no consensus on the appropriate surgical technique. PATIENTS AND METHODS: Among the 455 liver transplants performed between May 1988 and December 2001, 32 (7%) presented with portal vein thrombosis. Twenty (62%) were type Ib, seven (22%) type II/III, and five (16%) type IV. Twenty-two were men (69%), with a mean age of 50 years (range: 30-70 years); the thrombosis in all cases developed in a cirrhotic liver. The surgical method in all cases consisted of an eversion thromboendovenectomy under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. RESULTS: Among the 32 cases undergoing thrombectomy, 31 (96%) were successful with a failure in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis rethrombosed. The 5-year survival rate of the patients in the series was 69%. Only two patients died from causes related to the thrombosis, both showing type IV thrombosis. CONCLUSION: The ideal treatment for portal thrombosis during liver transplantation depends on its extension and on the experience of the surgeon. In our experience, eversion thromboendovenectomy resolves most thromboses (types I, II, and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal hemitransposition.

Substernal goiter: clinical experience of 72 cases.

The aim of this work was to study the clinical management and surgical approach of substernal goiters. We studied the clinical data, preoperative evaluation, surgical treatment, histopathologic data, complications, and follow-up of 72 patients found to have substernal goiter over a period of 15 years, from a total of 780 patients with goiter who underwent surgery. In this group, 83% were women, and the mean age was 61 years. The most common symptoms were the existence of a palpable cervical mass (93% of cases) and dyspnea (40%). The most successful study to diagnose substernal goiter was computed tomography (100%), followed by chest radiography (75%), gammagraphy (19%), and ultrasound (15%). All but 7 patients received a Kocher cervicotomy, and 49% of the cases underwent a total thyroidectomy. The histologic study revealed 3 carcinomas (4%). There was 1 permanent unilateral recurrent laryngeal nerve injury (1.4%) and 1 instance of permanent hypoparathyroidism (1.4%). We regard surgery as the most successful treatment for patients with substernal goiter, even in those without compressive symptoms. We base our choice on the low morbidity and zero mortality obtained.

Distribución nerviosa interna del músculo temporal humano: consideraciones anatómicas y quirúrgicas / Internal nervous distribution of the human temporal muscle: anatomical and surgical considerations

Resumen Introducción: Conocer en detalle la inervación interna del músculo temporal humano permite realizar múltiples técnicas quirúrgicas y tratamientos de patologías que involucran al territorio craneofacial. Si bien en la literatura se ha descrito la inervación interna del músculo temporal humano basado en micro-disección directa, la técnica de tinción de Sihler es una herramienta ventajosa para el estudio anatómico ya que permite observar ramos nerviosos pequeños sin perder su relación tridimensional con las fibras musculares. Objetivo: Describir la distribución nerviosa al interior del músculo temporal humano en cadáveres al aplicar el método de Sihler y analizar su asociación anátomo quirúrgica. Materiales y Método: Ocho músculos temporales humanos previamente disecados fueron sometidos al método de tinción de Sihler. Cada una de las muestras se observó bajo lupa estereoscópica y transiluminación; finalmente para su descripción se dividió al músculo en tres regiones. Resultados: Se determinó la presencia de tres troncos nerviosos principales: el temporal profundo anterior, el temporal profundo medio y temporal profundo posterior, los que discurren de profundo a superficial. Además, se observaron ramos colaterales de menor calibre del nervio temporal profundo posterior que en forma de arco comunican las tres regiones del músculo. Conclusión: Se describió una distribución nerviosa interna común para los músculos estudiados en las tres dimensiones del espacio, conocimiento útil para innovar en terapias clínico-quirúrgicas del territorio craneofacial.

Introduction: Knowing in detail the inner innervation of the human temporal muscle allows to perform multiple surgical techniques and treatments of pathologies that involve the craniofacial territory. Although the internal innervation of the human temporal muscle based on direct microdissection has been described in the literature, the Sihler staining technique is an advantageous tool for anatomical study since it allows observing small nerve branches without losing its three-dimensional relationship with muscle fibers. Aim: To describe the nervous distribution within the human temporal muscle in cadavers by applying the Sihler method and analyzing its surgical anatomical association. Materials and Method: Eight previously dissected human temporal muscles were subjected to the Sihler staining method. Each one of the samples was observed under stereoscopic magnification and transillumination, finally for its description the muscle was divided into three regions. Results: The presence of three main nervous trunks was determined: the anterior deep temporal, the deep medium temporal and the posterior deep temporal, those that run from deep to superficial. In addition, collateral branches of lesser caliber of the posterior deep temporal nerve that in the form of an arc communicate the three regions of the muscle were observed. Conclusion: A common internal nervous distribution was described for the muscles studied in the three dimensions of space, useful knowledge to innovate in clinical-surgical therapies of the craniofacial territory.