Clinical, Anatomical, and Pathological Grading Score to Predict Technical Difficulty in Laparoscopic Splenectomy for Non-traumatic Diseases.

BACKGROUND: We aimed to develop a grading system based on preoperative parameters that would predict surgical difficulty and morbidity in elective laparoscopic splenectomy. STUDY DESIGN: We retrospectively assessed morbidity in 439 patients who underwent laparoscopic splenectomy for benign and malignant disorders between 1993 and 2013. Medical and surgical records were reviewed and analyzed. We compared preoperative data concerning demographic, clinical, pathological, anatomical, laboratory, and radiological factors with three surgical outcomes: operative time, intraoperative bleeding, and surgical conversion. Univariate and multivariate analyses were performed to identify statistically significant variables. A logistic regression model was used to identify determinant variables and to compose a predictive score. External validation of the score was performed using an independent cohort of 353 patients. RESULTS: Four preoperative parameters (age, male sex, type of pathology, and spleen size based on final spleen weight) were significantly related with operative time, operative bleeding, and conversion to open surgery. Using these results, we developed a classification system with three levels of difficulty: low (≤4 points), medium (4.5-5.5 points), and high (≥6 points), based on the four preoperative parameters. The correlation was highly significant (p = <0.001) according to Spearman's correlation. The area under the ROC curve was 0.671 (95 % CI 0.596-0.745). The external validation showed significant correlations with the present model. CONCLUSIONS: The grading score described here is simple to calculate from the physical examination, laboratory tests, and US or CT images, and we believe it could be useful to preoperatively assess the technical complexity of laparoscopic splenectomy.

Are there differences between right and left colectomies when performed by laparoscopy?

BACKGROUND: There is an extended belief that the laparoscopic approach to left colectomy (LC) is technically more demanding and associated with more postoperative complications than to right colectomy (RC). However, there is no consensus in the literature about whether the short-term outcomes of RC differ from those of LC. The aim of this paper was to compare the postoperative course of patients undergoing RC and LC. METHODS: We retrospectively analyzed 1000 consecutive patients who underwent a laparoscopic RC or LC between 1998 and 2012. Factors analyzed were intraoperative complications, surgical time, postoperative complications, and length of stay. The two groups were divided into four subgroups (neoplasia, diverticular disease, polyps, and others). RESULTS: LC was associated with more postoperative complications than RC and longer operative time both in the two main groups (postoperative complications 30 vs. 19%; operative time 139 vs. 118 min) and in the neoplasia subgroups (27 vs. 18%; 137 vs. 118 min). No differences between groups were found for rates of reintervention or death. Comparison between LC subgroups showed that the operative time was longer and the conversion rate was higher in the diverticular disease subgroup than in the neoplasia subgroup (155 vs. 137 min; 21 vs. 8%). CONCLUSIONS: In this large cohort of patients undergoing laparoscopic colectomy, LC carried a higher risk than RC of postoperative complications. These findings provide new data on the differences between the two surgeries. Our findings strengthen the notion that right and left colectomies have a different intraoperative and postoperative course and should be analyzed as two separate entities.

Differences between en bloc resection and enucleation of retroperitoneal sarcomas.

AIM: Today, free margin surgery is the gold-standard management for soft-tissue sarcoma patients and one of the most important predictors of recurrence and survival. To obtain optimal results, a multidisciplinary approach is necessary. The aim of this study was to evaluate the evolution of patients with RPS treated by «en bloc«surgical resection versus those treated with enucleation in the first surgery. METHODS: Fifty-six adult patients were divided into 2 groups. Patients in Group A underwent enucleation surgery, and patients in Group B underwent en bloc surgery. The endpoints of the study were survival time and time to recurrence, according to histological type and first surgical strategy. RESULTS: Disease-free survival was longer for en bloc surgery (P<0,05), but there was no difference in overall survival. When comparing the histology of patients who underwent enucleation surgery and en bloc resection surgery, the disease-free survival and overall survival rates were longer for liposarcoma. In the multivariate analysis, only free margins and histology of liposarcoma were significantly associated with a better survival. CONCLUSIONS: The surgical management of patients with retroperitoneal sarcoma must be very aggressive, often requiring multivisceral resection. Considering the disease-free survival and overall survival rates obtained, it is clear that it is critical to manage patients as early as possible by a radical en bloc surgery.

[Influence of the type of thoracic access on postesophagectomy respiratory complications]. / La influencia del tipo de abordaje torácico sobre el desarrollo de complicaciones respiratorias tras la esofagectomía.

INTRODUCTION: A systematic review of the literature was performed with the aim to determine differences in the rate of respiratory complications after esophagectomy for esophageal cancer using minimally invasive access vs traditional thoracic access. METHODS: A literature search was performed using Medline and Cochrane Library, identifying studies that compared the 2 types of thoracic access, regardless of the type of abdominal access (laparotomy/laparoscopy). The studies selected described respiratory complications in absolute numbers and different categories. Studies that considered minithoracotomy as a minimally invasive technique were excluded. Inclusion criteria were: studies decribing the different types of respiratory complications (9 in total), and analysing the most common complications: respiratory infection, respiratory failure and pleural effusion. RESULTS: Nine studies were selected (one prospective randomized trial and 8 case control studies) including 1,190 patients, 1,167 of which were operated on for esophageal cancer: 482 patients by thoracotomy and 708 by thoracoscopy. Three studies included definitions of respiratory complications, and one stratified them. The more frequent complications that allowed a meta-analysis were: respiratory infections, pleural effusion, and respiratory failure. No significant differences were found between the 2 types of access in the global analysis. DISCUSSION: The type of thoracic access (thoracotomy or thoracoscopy) does not seem to influence the development of respiratory complications after esophagectomy for cancer. However, the design of the studies analysed, the absence of clear definitions and stratification of the complications makes this conclusion questionable. A consensus on the definition of complications and further prospective randomized clinical trials are necessary.

[Postoperative morbidity and mortality factors after laparoscopic resection for colon cancer in octogenarians]. / Factores de morbimortalidad postoperatoria tras cirugía laparoscópica por cáncer de colon en pacientes octogenarios.

INTRODUCTION: Given the increase in the diagnosis in colon cancer and the access to treatment in patients over 80 years old, our aim is to assess whether laparoscopic surgery still has the demonstrated advantages in post-operative recovery, as well as to analyse the factors that may influence these results. MATERIAL AND METHOD: A retrospective analysis was made on a total of 593 patients subjected to elective laparoscopy surgery due to cancer of the colon between January 1999 and December 2010. They were divided into three age groups: A) less than 70 years (n = 230), B) 70-79 years (n = 209), C) 80 years or over (n=154). The independent variables were: gender, concomitant diseases, previous abdominal surgery, Karnosfky index, BMI, level of, haemoglobin, proteins and albumin, CEA, and ASA grade, location and stage of tumour. The peri-operative dependent variables were: conversion, operating time and blood loss; and post-operative: local and general complications, need for intensive care, further surgery, hospital stay, and death. RESULTS: Group C had a higher incidence (P<.001) of arterial hypertension, diabetes mellitus, heart disease, chest disease and grade 3 ASA, as well as lower values for the Karnofsky Index, body mass index (BMI), haemoglobin, albumin and total protein. A higher incidence (P>.001) of general complications (respiratory and urinary), further surgery, admission to intensive care unit, longer hospital stay and death, was also observed in the post-operative period in this group. CONCLUSION: Although laparoscopic surgery offers advantages to patients over 80 years-old, this group has a higher risk of complications than the younger population and, as a result, we must take great care in their management.