Effect of bag extraction to prevent wound infection on umbilical port site wound on elective laparoscopic cholecystectomy: a prospective randomised clinical trial.

BACKGROUND: Laparoscopic cholecystectomy is the gold standard treatment for gallbladder stones. Complications due to laparoscopic procedure are rare, but rate of wound infection in some studies is about 8 %. From January 2007 to December 2008, 320 laparoscopic cholecystectomies were performed at our hospital, and in 4.7 % of them, wound infection of the umbilical trocar was identified. We believe that this infection rate could be lower and that it is necessary to implement a new technique to reduce the wound infection. The aim of the study was to evaluate the benefits of bag extraction of gallbladder to prevent the wound infection. METHODS: Two-arm, parallel, 1:1, randomised controlled trial (ISRCTN38095251). All patients suffering from symptomatic gallbladder stones of low risk were enrolled for this study and were divided into two groups in basics gallbladder extraction: with (80 patients) or, as usually, without bag (76 patients). All patients with cholecystitis or accidental gallbladder perforation were excluded. We compared all the results to establish whether meaningful differences were found. RESULTS: The final sample analysed (156 patients) consisted of 121 women and 35 men; there were 80 in the control group and 76 in the study group. There were 15 (9.6 %) diagnosed wound infections, eight cases in the study group and seven in the control group. There were no statistically significant differences. CONCLUSIONS: The determinant of wound infection in elective laparoscopic cholecystectomy is not the direct contact of the gallbladder with the wound; therefore, bag extraction is not necessary.

Bowel habits and fecal incontinence in patients with obesity undergoing evaluation for weight loss: the importance of stool consistency.

BACKGROUND: Fecal incontinence is highly prevalent in the general population and especially in risk groups. Obesity is also common and is associated with comorbidities that impair general health and interfere with daily activities. Identifying mutable factors for fecal incontinence, such as stool consistency, is of paramount importance to improve quality of life. OBJECTIVE: The aim of this study was to estimate the prevalence of fecal incontinence in patients with obesity undergoing evaluation for weight loss, its relationship with bowel habits, and its impact on quality of life. DESIGN: This investigation is a cross-sectional observational study. SETTINGS: This study was conducted in patients with obesity who were undergoing evaluation for weight loss. MAIN OUTCOME MEASURES: Fecal incontinence was defined as loss of flatus or liquid/solid stool occurring at least monthly. Data on comorbidities, BMI, quality of life, bowel habits including stool consistency measured with the Bristol Stool Form Scale, and symptoms of fecal incontinence were collected. RESULTS: Fifty-two patients were included, with a mean BMI of 39.6 kg/m2. Symptoms of fecal incontinence were found in 17 patients (32.7%): flatus in 9 of 17 (52.9%), liquid stool in 6 of 17 (35.2%), and solid stool in 2 of 17 (11.7%). No differences were found between patients with and without fecal incontinence in age, sex, comorbidities, or BMI. Health-related quality of life was lower in patients with fecal incontinence than in those without, but this difference was not significant, with the exception of the dimensions of role-physical (p = 0.03) and social functioning (p = 0.04). Patients with incontinence reported significantly higher percentages of altered bowel habits with nonformed stools (p = 0.004). LIMITATIONS: The cross-sectional design hampered identification of the time at which the impact of obesity occurred. CONCLUSIONS: Fecal incontinence is common in patients with obesity. Stool consistency was significantly different in these patients. This study supports the possibility of improving incontinence during weight loss by modifying stool consistency.

Prospective analysis of clinician accuracy in the diagnosis of benign anorrectal pathology: the value of clinical information.

AIM: the prevalence of anorectal disorders in general population is high. The aim of this study was to analyze the influence of clinical symptoms on diagnostic accuracy for benign anorectal pathology among different specialists and evaluate the relationship between diagnostic accuracy and years of professional experience. METHODS: seven typical cases were selected. In a first interview, participants were shown images and asked to make a diagnosis. Afterwards, images with additional information (clinical symptoms) were used. Two groups (group 1 = general surgeons and group 2 = medical specialists who attended emergency department) completed both phases of the study to analyze the influence of clinical symptoms on the final diagnosis. RESULTS: forty four specialists were interviewed. The percentage of participants making a correct diagnosis in groups 1 and 2, respectively, was as follows: case 1 (perianal abscess): 100 vs. 80.6%, (p = 0.157); case 2 (fissure): 92.3 vs. 51.6% (p = 0.015); case 3 (thrombosed hemorrhoid): 92.3 vs. 74.2% (p = 0.321); case 4 (anal condyloma): 100 vs. 87.1% (p = 0.302); case 5 (rectal prolapse): 100 vs. 83.9% (p = 0.301); case 6 (prolapsed hemorrhoid): 92.3 vs. 29% (p = 0.001), and case 7 (fistula): 100 vs. 67.7% (p = 0.021). There were significant differences in the number of correctly diagnosed cases between groups (p < 0.001). Information about clinical symptoms significantly increased overall and specific accuracy. There was no correlation between experience and accuracy. CONCLUSIONS: clinical symptoms are important for diagnostic accuracy in anorectal pathology. Training in anorectal pathology in medical specialists is warranted.

[Changes in the complaints made to a General and Gastrointestinal Surgery Department after a change in hospital structure and function]. / Variación en las reclamaciones dirigidas a un Servicio de Cirugía General y del Aparato Digestivo tras un cambio estructural y funcional hospitalario.

OBJECTIVE: The complaints to a medical service are a measure of the quality of health care perceived by the patients. The aim of this study was to analyse the differences found in the percentage of complaints made to the General and Gastrointestinal Surgery Department (GGSD) with the changes made due to moving to a new hospital. MATERIAL AND METHODS: A longitudinal study of the percentage of complaints made to the GGSD in two 6 month periods in the same year (periods A and B). The Department was moved to a new hospital between the two periods. The percentage complaints associated with the hospital and outpatient activity is compared. RESULTS: The percentage complaints made to the GGSD was 3.02% directed at the hospital service and 0.44% to outpatient care. When both periods were compared, a statistically significant difference was observed in the hospital complaints (A: 3.74% vs B: 2.20%, P=.006) and in the outpatient complaints (A: 0.53% vs. B: 0.34%, P=.005). It could also be shown that there was a continuous significant correlation in the parallel decrease in the hospital and outpatient complaints (R:0.988 P<.001). CONCLUSIONS: The structural and functional change due to moving to a new hospital showed that the percentage of complaints made to the GGSD changed significantly in the period studied. Prospective multicentre studies are required to evaluate whether these results can be extrapolated to other services.

Textbook outcome and survival after gastric cancer resection with curative intent: A population-based analysis.

BACKGROUND: The concept of textbook outcome (TO) has been proposed for analyzing quality of surgical care. This study assessed the incidence of TO among patients undergoing curative gastric cancer resection, predictors for TO achievement, and the association of TO with survival. METHOD: All patients with gastric and gastroesophageal junction cancers undergoing curative gastrectomy between January 2014-December 2017 were identified from a population-based database (Spanish EURECCA Registry). TO included: macroscopically complete resection at the time of operation, R0 resection, ≥15 lymph nodes removed and examined, no serious postoperative complications (Clavien-Dindo ≥II), no re-intervention, hospital stay ≤14 days, no 30-day readmissions and no 90-day mortality. Logistic regression was used to assess the adjusted achievement of TO. Cox survival regression was used to compare conditional adjusted survival across groups. RESULTS: In total, 1293 patients were included, and TO was achieved in 541 patients (41.1%). Among the criteria, "macroscopically complete resection" had the highest compliance (96.5%) while "no serious complications" had the lowest compliance (63.7%). Age (OR 0.53 for the 65-74 years and OR 0.34 for the ≥75 years age group), Charlson comorbidity index ≥3 (OR 0.53, 95%CI 0.34-0.82), neoadjuvant chemoradiotherapy (OR 0.24, 95%CI 0.08-0.70), multivisceral resection (OR 0.55, 95%CI 0.33-0.91), and surgery performed in a community hospital (OR 0.65, CI95% 0.46-0.91) were independently associated with not achieving TO. TO was independently associated with conditional survival (HR 0.67, 95%CI 0.55-0.83). CONCLUSION: TO was achieved in 41.1% of patients who underwent gastric cancer resection with curative intent and was associated with longer survival.

Risk factors for umbilical trocar site incisional hernia in laparoscopic cholecystectomy: a prospective 3-year follow-up study.

BACKGROUND: Trocar site incisional hernia (TSIH) is a common complication after laparoscopic cholecystectomy. The aim of this study was to evaluate the prevalence of TSIH and analyze the influence of several risk factors for this complication in a prospective series. METHODS: From 2007 to 2008, a prospective observational study with 3 years of follow-up was performed including all consecutive patients with cholelithiasis who underwent elective laparoscopic cholecystectomy. A multivariate analysis was performed to identify risk factors for TSIH. RESULTS: Overall, 241 patients were included. During a median follow-up period of 46.8 months, 57 patients (25.9%) were diagnosed with umbilical TSIH by physical exam or ultrasound. The multivariate analysis revealed that incision enlargement (odds ratio [OR], 14.17; 95% confidence interval [CI], 3.61 to 55.51; P < .001), wound infection (OR, 5.62; 95% CI, 2.35 to 13.42; P < .001), diabetes mellitus (OR, 2.79; 95% CI, 1.05 to 7.37; P = .0038), and obesity (OR, 2.71; 95% CI, 1.28 to 5.75; P = .009) contributed to the risk for developing a TSIH. CONCLUSIONS: Umbilical TSIH is highly prevalent. This study identified several factors that could be useful to introduce preventive measures in high-risk patients.

Intra-abdominal pressure as a prognostic factor for tolerance of enteral nutrition in critical patients.

BACKGROUND: The purpose of this study is to establish a relationship between tolerance of enteral nutrition (EN) and intra-abdominal pressure (IAP) in critical patients, establish an objective measure for monitoring tolerance, and determine a threshold value for IAP. MATERIALS AND METHODS: Prospective and observational study at the critical care unit. Seventy-two patients were recruited with an expected stay of more than 72 hours and scheduled to receive EN. We recorded IAP and clinical and laboratory variables to describe predictive ones for tolerance of EN at the start of nutrition. RESULTS: The largest group was polytrauma patients (41.7%). Of the patients, 40.3% had undergone surgery prior to inclusion in the study. Most patients (87.5%) were fed via nasogastric tube. Physiological POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) on admission was 26.4 ± 7.6, and surgical POSSUM was 22.4 ± 8.0. The mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 13.6 ± 6.0. Mortality was 31.9%. In all, 70.8% tolerated EN. The univariate analysis revealed a statistically significant relation between tolerance of EN and surgical POSSUM, APACHE II, and baseline IAP. The multivariate analysis showed a relationship between APACHE II score, baseline IAP, and the tolerance of EN. So, on the basis of these 2 variables, logistic regression analysis can predict whether a patient will tolerate the diet with an overall precision of 80.3%. CONCLUSIONS: In critically ill patients, there is a relation between IAP values and the tolerance of EN. The baseline IAP with the APACHE II score can predict the tolerance of EN.

[A prospective study on the incidence of missed injuries in trauma patients]. / Estudio prospectivo de la incidencia de las lesiones inadvertidas en el paciente politraumatizado.

INTRODUCTION: Missed injuries in trauma patients are injuries not identified during a primary and secondary trauma survey (Advanced Trauma Life Support, ATLS). These injuries are important because of the delay in correct treatment. There is a particularly important sub-group consisting of clinically significant missed injuries, which may cause serious complications in the patient or even death. MATERIAL AND METHOD: A prospective study on missed injuries and clinically significant missed injuries. The study includes all trauma patients older than 16 years admitted to the resuscitation area or who had died during the first 24 hours. We collected injuries, time of their diagnosis and their treatment for each patient. For injuries detected later than 24 hours (i.e. missed injuries) we specified whether it was a clinically significant missed injury and its possible cause. RESULTS: From March of 2006 to January of 2007, 122 trauma patients were recorded with a mean Injury Severity Store of 20 +/- 15.8. Of those, 40.3% had some missed injury, fractures being the most frequent miss (42.7%), followed by chest and abdominal injuries. A clinically significant injury (38.7% of all missed injuries) were found in 17% of trauma patients, the most frequent being spine, abdominal and chest injuries. There is a statistically significant relationship between the presence of missed injuries, high ISS and intubation before or after admission to hospital. CONCLUSIONS: The rate of missed injuries and clinically significant missed injuries is high. Severe trauma patients and intubated patients have higher rates of missed injuries.