Is the number of rib fractures a risk factor for delayed complications? A case-control study.

AIM: To analyse factors that may predict the appearance of rib fracture complications during the first days of evolution and determine whether the number of fractures is related to these complications. METHOD: Retrospective case-control study of patients admitted with a diagnosis of rib fractures between 2010 and 2014. Two groups were established depending on the appearance or not of pleuropulmonary complications in the first 72 h, and the following were compared: age, sex, Charlson comorbidity index (CCI), number and uni- or bilateral involvement, mechanism of trauma, days of hospital stay, haemoglobin on discharge minus haemoglobin on admission, pleuropulmonary complications during admission (pneumothorax, haemothorax or pulmonary contusion) and placement of pleural drainage. RESULTS: One hundred and forty-one cases of rib fractures were admitted in the period mentioned. There were no differences in the patients' baseline characteristics (age, sex and Charlson Comorbidity Index) between the two groups. Differences were found in the number of fractures (2.98 ± 1.19 in the group without complications vs 3.55 ± 1.33 in the group with complications, p = 0.05) and in the drop in the level of haemoglobin (0.52 ± 0.91 mg/dl vs 1.22 ± 1.29 mg/dl, p = 0.01). The length of hospital stay varied considerably in each group (5.35 ± 4.05 days vs 7.86 ± 6.96 days), but without statistical significance (p = 0.11). CONCLUSIONS: The number of fractured ribs that best predicted the appearance of complications (delayed pleuropulmonary complications and greater bleeding) was 3 or more.

[Nutritional factors associated with complications in major abdominopelvic surgery]. / Factores nutricionales asociados a complicaciones en cirugía mayor abdominopélvica.

INTRODUCTION: major abdomino-pelvic surgery includes a series of procedures that carry a high percentage of postoperative complications. Our objective is to identify the factors related to post-surgical complications, classified according to Clavien-Dindo classification, with special attention to nutritional factors in patients who undergo major abdomino-pelvic surgery. MATERIAL AND METHOD: retrospective observational study between July 2012 and December 2013. A total of 255 patients undergoing major abdomino-pelvic surgery (colorectal, gastric, obesity or total cystectomy) were selected on a scheduled basis. Four types of variables were collected: sociodemographic, baseline, diagnostic and outcome variables, including perioperative complications that were classified in 5 grades according to the Clavien-Dindo scale, and for the analysis of results, two groups of patients were separated: The group with complications grade 0 and I and group 2 with complications III to V. The statistical analysis was performed using IBM SPSS version 22.0. RESULTS: patients had a mean age of 65 years. Twenty patients (7.8%) returned in the first 30 days after surgery and 8 patients (3.1%) died. 152 cases (59.6%) were classified in group 1 and 103 cases (40.4%) in group 2. When analyzing both groups, we found significant differences in the operative variables: type of surgery and laparoscopic or open approach. Regarding the physiological and nutritional parameters, we observed significant differences in the following factors: preoperative BMI, preoperative albumin, preoperative hemoglobin and day of onset of postoperative tolerance. CONCLUSION: in our study we have identified modifiable factors, such as hemoglobin and preoperative albumin, BMI and early onset of oral tolerance, related to postoperative morbidity. Preoperative nutritional status is related to postoperative complications in major abdomino-pelvic surgery.

Introducción: la cirugía mayor abdominopélvica es un proceso que conlleva un alto porcentaje de complicaciones posquirúrgicas. Nuestro objetivo es identificar los factores relacionados con las complicaciones posquirúrgicas, catalogadas según la clasificación de Clavien-Dindo, con atención especial a los factores nutricionales en los pacientes que se intervienen de cirugía mayor abdominopélvica.Material y método: estudio observacional retrospectivo, realizado entre julio de 2012 a diciembre de 2013. Se seleccionaron a 255 pacientes sometidos a cirugía mayor abdominopélvica (cirugía colorrectal, gástrica, obesidad o cistectomía total) de forma programada. Se recogieron cuatro tipos de variables: sociodemográficas, de situación basal, de diagnóstico y de resultado, incluyendo las complicaciones perioperatorias que fueron clasificadas en 5 grados según la escala de Clavien-Dindo y, para el análisis de resultados se separaron dos grupos de pacientes: el grupo con complicaciones de grados 0 y I y el grupo 2 con complicaciones III a V. El análisis estadístico se ha realizado mediante IBM SPSS versión 22.0.Resultados: los pacientes tuvieron una edad media de 65 años. Reingresaron 20 pacientes (7,8%) en los primeros 30 días tras la cirugía y 8 pacientes (3,1%) murieron. Ciento cincuenta y dos casos (59,6%) fueron clasificados en el grupo 1 y 103 casos (40,4%) en el grupo 2. Al analizar ambos grupos, encontramos diferencias significativas en las variables operatorias: tipo de cirugía y abordaje laparoscópico o abierto. Respecto a los parámetros fisiológicos y nutricionales, observamos diferencias significativas en los siguientes factores: IMC prequirúrgico, albúmina prequirúrgica, hemoglobina prequirúrgica y día de inicio de tolerancia postoperatoria.Conclusión: en nuestro estudio hemos identificado factores modificables, como la hemoglobina y albúmina preoperatoria, el IMC y el inicio temprano de tolerancia oral, relacionadas con la morbilidad posoperatoria. El estado nutricional preoperatorio tiene relación con las complicaciones posquirúrgicas en cirugía mayor abdominopélvica.

The use of coffee, chewing-gum and gastrograffin in the management of postoperative ileus: A review of current evidence. / Uso de café, chicle y gastrografín en el manejo del íleo postoperatorio: revisión de la evidencia actual.

Postoperative ileus is one of the main complications in the postoperative period. New measures appeared with the introduction of «fast-track surgery¼ to accelerate recovery: coffee, chewing gum and gastrograffin. We performed a summary of current evidence, reviewing articles from MEDLINE, Cochrane Database of Systematic Reviews, ISI Web of Science, and SCOPUS databases. Employed search terms were «postoperative ileus¼ AND («definition¼ OR «epidemiology¼ OR «risk factors¼ OR «Management¼). We selected 44 articles: 9 systematic reviews 11 narrative reviews, 13 randomized clinical trials, 6 observational studies, and the remaining 5 scientific letters, assumptions, etc. There is little literature about this topic, studies are heterogeneous, with disparity in the results. In addition, they only focus on colorectal and gynecological surgery. New high-quality studies are needed, preferably randomized clinical trials, in order to clarify the usefulness of these measures.

Does Abdominoplasty Add Morbidity to Incisional Hernia Repair? A Randomized Controlled Trial.

Background Abdominoplasty is considered an operation linked to a considerable rate of morbidity. The convenience of simultaneously performing an incisional hernia repair and an abdominoplasty remains controversial. Methods A total of 111 patients were randomized prospectively to compare isolated incisional hernia repair and hernia repair when combined with abdominoplasty. Primary end points were in-hospital stay and early morbidity. Secondary end points were late morbidity, recurrences, and quality of life. Patients were followed-up for 24 months. Results Duration of the surgical procedure differed significantly between both groups (39 vs 85 minutes, P < .001) and postoperative hospital stay (2.5 vs 3.5 days; P < .001). No statistically significant differences in early or late morbidity between both groups were detected. The perceived quality of life for patients was higher in the combined surgery group (P < .001) that in the isolated hernia repair group. Conclusions Postoperative in-hospital stay and early and late morbidity do not differ significantly between isolated incisional hernia repair and simultaneous hernia repair with abdominoplasty, but associated abdominoplasty provides a higher quality of life when indicated.

[Marjolin's ulcer. A 10 year experience in a diabetic foot unit]. / Úlcera de Marjolin: experiencia de 10 años en una unidad de pie diabético.

BACKGROUND: Marjolin's ulcer is defined as the appearance of a neoplasm within a chronic wound. The most common histological type is squamous. A total of 2 cases treated in our hospital are presented. CLINICAL CASE: Case 1. A 71 year old man who presented with redness and suppuration from the wounds he had in his right foot after an electric shock 40 years earlier. The radiology showed involvement of the 4° and 5° metatarsal. Supracondylar amputation was performed, showing a well-differentiated invasive squamous cell carcinoma. CASE 2: A 56 year old male, paraplegic for 20 years. He was treated due to an infected right heel ulcer, with partial improvement, but the ulcers persisted. Biopsy was performed, reporting as epidermoid carcinoma. Infracondylar amputation was performed. The diagnosis was a well-differentiated squamous cell carcinoma infiltrating the dermis. CONCLUSION: The prevalence of Marjolin's ulcer is 1.3-2.2% of all ulcers. Diagnosis is difficult, so biopsy is recommended on any suspicious lesion or ulcer that has received conservative treatment for one month without improvement, although this time limit is not clear. The treatment is the surgery. Local excision with a margin of an inch is enough. If the ulcer is extensive, amputation is required. Survival is estimated between 66 and 80% at 2 years, with recurrence rates of 23%. Unfavourable factors are poor tumour differentiation and metástasis, appearing in 20% of cases.

Which should be the gold standard laparoscopic technique for handling Spigelian hernias?

BACKGROUND: The advantages and disadvantages of both extraperitoneal and intra-abdominal laparoscopic Spigelian hernia repair are still being discussed. To our knowledge, no study has compared both techniques in terms of safety, feasibility, and cost-effectiveness. METHOD: Prospective data were collected to compare the results of the extraperitoneal approach with the intra-abdominal approach in laparoscopic Spigelian hernia repair, between 2000 and 2012 (n = 16). Diagnosis was confirmed preoperatively by ultrasonography and/or tomography. RESULTS: Spigelian hernias occur mostly in women (69 %), on the left side (56 %) and at a median age of 62 (range: 38-83). In our study, the extraperitoneal technique was performed in seven patients, while the intra-abdominal approach was indicated in nine. No complications, re-admissions, or recurrences were detected in either during a mean follow-up of 48 months (range: 18 months-9 years). The statistical study showed that there was no difference in either morbidity or the recurrence rate between a totally extraperitoneal (TEP) and an intraperitoneal onlay mesh (IPOM) repair. The mean duration of an IPOM repair was, though, shorter than that of a TEP repair (30 vs. 48 min, P = 0.06). The combined fixation technique (tacks + glue) did not modify the results but did reduce the costs, as shown in the cost-effectiveness study where the intra-abdominal approach was cheaper (1260 vs. 2200 euros, P < 0.001). CONCLUSION: Laparoscopy seems to be a safe and feasible technique whichever the approach chosen, be it intra or extraperitoneal. Our experience shows that intra-abdominal laparoscopic Spigelian hernia repair should be recommended as the gold standard because of its technical and economic advantages. The IPOM procedure with a lightweight titanium-coated mesh fixed using a combined technique is a highly effective option for Spigelian hernia repair.

Gastrojejunal anastomotic stenosis after laparoscopic gastric bypass. Experience in 280 cases in 8 years.

OBJECTIVE: Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass, but its frequency is about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass. PATIENTS AND METHOD: From January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis is performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation. RESULTS: Twenty cases (7.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and all case were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up has not been detected re-stricture. CONCLUSION: Structure at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.

[Complications and level of satisfaction after dermolipectomy and abdominoplasty post-bariatric surgery]. / Complicaciones y nivel de satisfacción tras la realización de una dermolipectomía y abdominoplastia después de efectuar una cirugía bariátrica.

BACKGROUND: Body contouring surgery is in high demand following the increase in bariatric surgery. But these types of procedures are associated with high complication rates that cause long hospital stays and have a negative effect on patient satisfaction. The purpose of this study is to identify predictors of complications in order to optimize outcomes in these patients and find a relationship between complication rate and satisfaction. MATERIAL AND METHODS: Out of a group of 175 post-bariatric patients, 72 patients underwent body contouring surgery following massive weight loss from 2003-2008. They were reviewed retrospectively for demographic data, pre- and postoperative weight status, co-morbidities and complications and reoperation rate. Patient satisfaction was evaluated. RESULTS: a) COMPLICATIONS: The overall complication rate was 45.8%. The most frequent were seromas (23.6%); infection (13.9%), bleeding (11.1%), hematoma (6.9%) (needing transfusions [6.9%]), skin necrosis (6.9%) and umbilical necrosis (4.2%). A total of 8 patients required reoperation (11.1%). b) Satisfaction rating: 1) very satisfied: 51.4%, 2) satisfied: 31.9%, 3) dissatisfied: 8.3%, 4) very dissatisfied: 8.3%. c) The presence of complications was significantly associated with patients' satisfaction, reoperation rate and longer hospital stays (P<.001). CONCLUSIONS: Post operative complications were frequent. No predictors could be found to prevent these complications and optimize patient selection and appropriate timing of surgery. Patients with complications had a significantly higher reoperation rate, longer hospital stay and more dissatisfaction. The patients' satisfaction was negatively influenced by complication occurrence and not by the aesthetic results.

[Low-cost laparoscopic training: necessary time for acquiring expertise]. / Entrenamiento laparoscópico de bajo costo: tiempo de entrenamiento necesario para adquirir habilidades laparoscópicas básicas similares a las de un experto.

BACKGROUND: Today laparoscopic approach is essential, but learning is usually expensive and very limited. Homemade and low equipment costs are required. We undertook this study to quantify how many hours of training are necessary for a surgeon without laparoscopic experience in order to acquire the abilities to carry out procedures as a staff member with laparoscopic experience. METHODS: A low-cost laparoscopic trainer was constructed. Four exercises of increasing difficulty have been developed. Five residents without laparoscopic experience and four experts developed the study. A satisfaction questionnaire was completed. Data were analyzed comparing the average times for the accomplishment of each exercise between groups. RESULTS: Data showed that the more difficult an exercise is, the more training is required. The average time needed to acquire similar skills as experts was almost 7 h of training spread over 4 months. The level of confidence for approaching a laparoscopic procedure for residents after completing the training was increased by 70%. CONCLUSION: Laparoscopic training is essential in the formation of all surgeons and a reason why this low-cost and easily accessible method could become a basic tool for learning the first steps of the laparoscopic procedure.

Preoperative very low-calorie diet and operative outcome after laparoscopic gastric bypass: a randomized multicenter study.

HYPOTHESIS: A 14-day very low-calorie diet (VLCD) regimen before a laparoscopic gastric bypass procedure will improve perioperative and postoperative outcomes. DESIGN: Multicenter, randomized, single-blind study. SETTING: Five high-volume bariatric centers in Sweden, the Netherlands, Lithuania, Spain, and Belgium. PATIENTS: Two hundred ninety-eight morbidly obese patients undergoing laparoscopic gastric bypass from March 1, 2009, through December 5, 2010. INTERVENTION: Patients were randomly allocated to a 2-week preoperative VLCD regimen or no preoperative dietary restriction (control group). MAIN OUTCOME MEASURES: Operating time, surgeon's perceived difficulty of the operation, liver lacerations, intraoperative bleeding and complications, 30-day weight loss, and morbidity. RESULTS: Mean (SD) preoperative weight change was -4.9 (3.6) kg in the VLCD group vs -0.4 (3.2) kg in the control group (P < .001). Although the surgeon's perceived difficulty of the procedure was lower in the VLCD group (median [interquartile range], 26 [15-42] vs 35 [18-50] mm on a visual analog scale; P = .04), no differences were found regarding mean (SD) operating time (81 [21] vs 80 [23] min; P = .53), estimated blood loss (P = .62), or intraoperative complications (P = .88). At the 30-day follow-up, the number of complications was greater in the control compared with the VLCD group (18 vs 8; P = .04). CONCLUSIONS: Although weight reduction with a 14-day VLCD regimen before laparoscopic gastric bypass performed in high-volume centers seems to reduce the perceived difficulty of the procedure, only minor effects on operating time, intraoperative complications, and short-term weight loss could be expected. However, the finding of reduced postoperative complication rates suggests that such a regimen should be recommended before bariatric surgery.

Evaluation of a clinical pathway to improve colorectal cancer outcomes.

The aims of this preintervention and postintervention study were to monitor and evaluate the clinical pathway (CP) for colorectal cancer (CRC) over a 5-year period and to compare 2 groups of patients (before and after the intervention) with regard to different variables of effectiveness. Group I comprised 68 patients who underwent planned surgery between January 2002 and January 2003. Group II comprised a sample of 202 patients who underwent surgery between January 2004 and December 2008. No significant differences were found in the majority of the parameters measured: postoperative stay, compliance with antibiotic prophylaxis, compliance with the staging study, mortality, rate of infection, and reoperations. The mean length of stay (±standard deviation) for patients without complications was reduced significantly (9.2 ± 3.6 in group I versus 7.7 ± 1.7 in group II, P = .031). The CP for CRC did not achieve most of the objectives for which it was designed.

[One-step nucleic acid amplification (OSNA) assay for sentinel lymph node metastases as an alternative to conventional postoperative histology in breast cancer: A cost-benefit analysis]. / El análisis molecular intraoperatorio (one-step nucleic acid amplification) del ganglio centinela como alternativa al estudio histopatológico diferido en el cáncer de mama: análisis coste-beneficio.

INTRODUCTION: Intraoperative molecular analysis for sentinel lymph node (SLN) metastases using the OSNA (one-step nucleic acid amplification) method has been already validated in breast cancer. The authors compared the cost of OSNA versus the conventional postoperative histopathologic evaluation in patients with breast cancer. METHODOLOGY: Patients with operable breast cancer and clinically and sonographic negative evaluation of the axilla, and who subsequently were operated on between the 15th of October 2008 and the 15th of December 2009 were included in this retrospective cost-benefit analysis. The SLN was assessed by conventional postoperative histological evaluation in Group 1 (45 patients), and by OSNA in Group 2 (35 patients). The following variables were analysed: age, tumour size, histological type, number of SLNs, biopsy result, duration of surgery, days in hospital, postoperative complications, positive lymph nodes in the case of axillary lymphadectomy, cost per patient, hospitalisation cost, and cost per operation. RESULTS: The duration of surgery of the first operation in Group 1 was significantly shorter, but the total time was also higher in this group. The mean hospital stay was longer in Group 1 (P<.001). The mean cost of the hospital stay was higher in Group 1 compared to Group 2 (P<.001), with a mean difference of 199.69 €. The mean cost of the surgery was higher in Group 1 (P<.001), with a mean difference of 157.49 €. The mean cost per SLN analysis was significantly higher in Group 1, with a mean difference of 162.5 €. The cost per patient was significantly higher in Group 1 (P<.005). A mean saving of 439.67 € per patient was achieved by using the OSNA method. CONCLUSION: Intraoperative molecular analysis for SLN metastases using the OSNA method reduces the number of admission days, duration of surgery, and achieves a saving of 439.67 € per patient.

[Frozen section doesn't reduce the number of reoperations for cancer after hemithyroidectomy]. / La biopsia intraoperatoria no reduce la tasa de reintervenciones por cáncer tras hemitiroidectomía.

UNLABELLED: FUNDAMENTALS AND OBJECTIVES: Frozen section (FS) constitutes a diagnostic procedure in patients following hemithyroidectomy. It is used to diagnose malignant lesions and to avoid reoperations. Our objective is to confirm this test as useless to rule out cancer. PATIENTS AND METHODS: Retrospective and comparative trial between two series of patients following hemithyroidectomy. G I: 179 patients operated in 1995-2002. In this period we performed systematic FS. Sensitivity (S), specificity (E) and predictive values (PPV, NPV) are analyzed. G II: 126 patients were operated between 2003-2008. Selective FS was performed (23 patients). Both groups are compared: hospital stay, number of FS, percentage of cancer, definitive biopsy and reoperations. RESULTS: Data analyzed in the first period: S: 48%, E: 100%, PPV: 100%, NPV: 90%, positive likelihood ratio>10, negative likelihood ratio 0.52. When both periods are compared no significant differences between reoperations are found. CONCLUSION: FS during hemithyroidectomy does not reduce reoperations for cancer.

Vascular injury by tacks during totally extraperitoneal endoscopic inguinal hernioplasty.

Totally extraperitoneal laparoscopic hernioplasty is a consolidated approach for treating recurrent and bilateral inguinal hernias. However, it may be associated, albeit very rarely, with vascular lesions that can endanger the patient's life. A proper anatomic knowledge of the posterior aspect of the inguinal region and a perfect command of the laparoscopic technique are essential for avoiding and, if necessary, treating these lesions. We present an unusual case of an arterial lesion of the aberrant obturator artery of the corona mortis during fixation of the mesh with a tacker.

Gastrojejunal anastomosis stricture after laparoscopic gastric bypass. Our experience with 62 patients.

OBJECTIVE: Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass (LGBP), but its frequency is about 15% according to bibliography. Our aim is to present our experience after 62 LGBP. PATIENTS AND METHOD: From January 2004 to September-2006, we performed 62 consecutive laparoscopic gastric bypass (Wittgrove's technique). The gastrojejunal anastomosis is performed with auto suture material type CEAA No 21 termino-lateral (ILS, Ethicon). In 4 cases (6.45%) was converted to laparotomy, perform the anastomosis in the same way. Monitoring has a range of 3-35 months, conducted in 61 patients because one patient died of pulmonary thromboembolism in the immediate postoperative period after reoperation, after two weeks of gastric bypass, by necrosis of a small fragment of the remnant gastric. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation (recommending dilate the anastomosis to a maximum 1.5 cm). RESULTS: Five cases (8.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and in 1 case by endoscopy. Two patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion (circumferentially sclerosis within 48 hours of surgery and sclerosis of bleeding points). All cases were resolved by endoscopic dilatation. At follow-up has not been detected re-stricture. CONCLUSION: Clinically, gastrojejunal stricture results in a progressive oral intolerance, revealing stenosis between 1 and 3 months postoperatively. The situations of sclerosis of the bleeding lesions favor, especially in cases of extensive sclerosis. In cases of suspected barium transit offers us a high diagnostic yield. Endoscopic dilatation resolved, so far, all cases.