Cost-benefit analysis comparing laparoscopic and open ventral hernia repair.

OBJECTIVE: Laparoscopic surgery is a successful treatment option offering significant advantages to patients compared with open ventral hernia repair. A cost-benefit analysis was performed to compare the clinical results and economic costs of the open and laparoscopic techniques for anterior abdominal wall hernia repair, in order to determine the more efficient procedure. MATERIAL AND METHODS: We performed a prospective study of 140 patients with primary and incisional hernia, and analyzed clinical data, morbidity, costs of surgery and hospital stay costs. RESULTS: The cost of disposable surgical supplies was higher with laparoscopic repair but reduced the average length of stay (P<.001) and patient morbidity (P<.001). The total cost of the laparoscopic procedure was, therefore, less than initially estimated, yielding a savings of 1,260€ per patient (2,865€ vs. 4,125€). CONCLUSIONS: Laparoscopic ventral hernia repair is associated with a reduced complication rate, a lower average length of stay and with lower total costs. Laparoscopic repair can save 1.260€ for each patient, and so this procedure should be considered a cost-effective approach.

Esophageal resection and immediate reconstruction in esophageal perforations.

BACKGROUND: Esophageal perforation is a disease with high mortality. Treatment is controversial and should be individualized. Elapsed time, location and perforation all play a role in determining the treatment option: from conservative treatment to esophagectomy. We undertook this study to report on primary esophagectomy and reconstruction in esophageal perforations with expert surgeons and selected patients. It is worth noting the rare complication of perforated peptic ulcer on Barrett's esophagus presented in one of our patients. CLINICAL CASES: We report two patients with esophageal perforation (one spontaneous and another due to pneumatic esophageal dilation) treated by primary esophagectomy and reconstruction. The patient with spontaneous perforation had Barrett's esophagus with severe dysplasia and perforated peptic ulcer. CONCLUSIONS: Esophageal resection and immediate reconstruction is controversial. It was decided to resect the esophagus in both cases reported here due to the size of the perforation and esophageal disease in the second case. The primary reason for immediate reconstruction in selected cases is permanent resolution. Primary cervical esophagealgastric anastomosis has a lower risk of contamination and leaks than thoracic anastomosis, resulting in mediastinal drainage and parenteral nutrition. Spontaneous esophageal perforation due to perforated Barrett's ulcer is uncommon. Finally, we must consider the importance of early diagnosis and treatment. It is essential to consider the size of the perforation, location, previous esophageal disease, age and general status of the patient in order to undertake appropriate management. Emergency surgery should be individualized and depends on surgeon's experience.

Biliary cystadenoma.

The diagnosis of cystadenoma is rare, even more so when located in the extrahepatic bile duct. Unspecific clinical signs may lead this pathology to be misdiagnosed. The need for pathological anatomy in order to distinguish cystadenomas from simple biliary cysts is crucial. The most usual treatment nowadays is resection of the bile duct, together with cholecystectomy and Roux-en-Y reconstruction.

Risk of gastrojejunal anastomotic stricture with multifilament and monofilament sutures after hand-sewn laparoscopic gastric bypass: a prospective cohort study.

BACKGROUND: Gastrojejunal (GJ) stricture is one of the most common late complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) with a hand-sewn anastomosis. The object of this study was to assess the risk of stricture for two types of resorbable suture (multifilament and monofilament) in a series of LRYGBPs performed by the same surgeon. DESIGN: Prospective cohort study. The study population consisted of a series of consecutive morbidly obese patients who underwent primary hand-sewn LRYGBP between March 2004 and May 2008 at the University Hospital in Getafe, Madrid, Spain. The study comprised 242 LRYGBPs with a four-layer continuous hand-sewn anastomosis using absorbable 3/0 gauge suture. The suture material was Ethicon Vicryl multifilament in the first 105 cases and Ethicon Monocryl monofilament in the following 137 cases. All patients were followed up monthly for the first 6 months and then every 6 months after that. RESULTS: The mean BMI was 46 +/- 4 for the multifilament cohort and 48 +/- 6 for the monofilament cohort with no significant difference between the two (p = 0.567). There were no anastomotic leaks, and no cases of marginal ulcer, abscess, abdominal sepsis, deep vein thrombosis, or pulmonary embolism were recorded. No cases required conversion to open surgery, and perioperative mortality was zero. In all, 11 cases of stricture (4.4%) were recorded, 10 in the multifilament suture cohort (9.5%), and only one in the monofilament suture cohort (0.7%; p = 0.001). The odds ratio was 14.3 (95% CI = 1.8-113.4). The mean outpatient follow-up period was 30 months (range = 6-42). CONCLUSIONS: Anastomotic GJ stricture is a common and well-known complication of laparoscopic gastric bypass for morbid obesity. Hand sewing with monofilament suture significantly lowered the frequency of this complication, and hence, monofilament should be the suture material of choice for this suturing technique.

[Gastric bypass and laparoscopic biliopancreatic diversion with manual anastomosis: results in 250 morbidly obese patients]. / Bypass gástrico y derivación biliopancreática laparoscópica efectuadas con anastomosis manual. Resultados en 250 pacientes obesos móbidos.

BACKGROUND: Gastrojejunostomy anastomosis after a gastric bypass or biliopancreatic diversion can be performed by staples or hand-sewn technique. The aim of this study is to analyze totally hand-sewn anastomosis by laparoscopy. METHODS: Morbid obese patients treated consecutively with a gastric bypass or biliopancreatic diversion in which the main anastomosis was performed with a totally hand-sewn gastrojejunostomy by laparoscopy at Hospital Universitario de Getafe from March-01 to November-07. RESULTS: 250 patients were included: 232 were gastric bypass and the remaining 18, biliopancreatic diversion. Mean BMI was 46 +/- 4. There was only one case of digestive bleeding for a marginal ulcer during immediate postoperative period (6th day). Later, there were 2 cases of complicated ulcers: due to bleeding and perforation. There were no anastomotic leaks from the hand-sewn gastrojejunostomy. A patient was re-operated on 48 hours after bypass due to a leak secondary to a thermal perforation at the lesser curvature. Radiological or endoscopic dilatation were required in 11 stenosis (4.4%) at gastrojejunostomy and none in the biliopancreatic diversion group. Mean surgical time for the anastomosis was 40+/-15 minutes. There were no deaths, sepsis, abdominal abscess, deep venous thrombosis or pulmonary embolism. Average hospital stay was 5.1+/-2.4 days. CONCLUSIONS: Even though most surgeons believe that staples anastomosis is easier, hand-sewn technique can be reproducible by surgeons with laparoscopic sutures experience. This technique has a longer operation time but continuous training provides advanced laparoscopic skills and significantly reduces operation time.

Laparoscopic hand-sewn gastrojejunal anastomoses.

BACKGROUND: Reconstruction of the digestive tract during gastric bypass (RYGBP) or biliopancreatic diversion (BPD) involves a mechanical or a hand-sewn gastrojejunal anastomosis. The object of this paper is to assess laparoscopic hand-sewn gastrojejunal anastomoses. METHODS: A series of morbidly obese patients was treated with RYGBP or BPD with a laparoscopic hand-sewn gastrojejunal anastomosis at the Hospital Universitario de Getafe-Madrid (Spain) between March 2001 and November 2007. RESULTS: The series comprised 250 patients, with 232 RYGBPs and 18 BPDs performed. The mean BMI was 46 +/- 4. Only a single case of gastrointestinal hemorrhage (0.4%) was recorded, caused by a marginal ulcer in the early postoperative period (day 6). In the late postoperative period, there were two cases of ulcer (0.8%), one complicated by hemorrhage, the other by perforation. There was no anastomotic leak. One patient (0.4%) required reintervention after 48 h because of thermal perforation of the gastric pouch. There were 11 cases of stenosis (4.4%) requiring radiologically or endoscopically guided dilatation, none in the BPD patients. Mean anastomosis time was 40 +/- 15 min. No cases of mortality or abscess, abdominal sepsis, or thromboembolism were recorded. Mean hospital stay was 5.1 +/- 2.4 days. CONCLUSIONS: Laparoscopic hand-sewn anastomoses are safe and reproducible by surgeons experienced in internal suturing and knot-tying. The technique lengthens operating time, but constant training develops the surgeon's skills, significantly shortening operating time.

[Obstructive jaundice caused by duodenal amyloidosis succesfully treated with surgery]. / Ictericia obstructiva. Inicio clínico de una amiloidosis duodenal tratada quirúrgicamente.

We present a case of obstructive jaundice due to duodenal amyloidosis presenting as a bulbar pseudotumor (amyloidoma). The duodenal and biliary obstruction were treated by double bypass, hepatojejunostomy and gastroenterostomy. Our case suggests that surgical palliative treatment may be effective, and that anastomosis is probably safe, allowing the patient a good quality of life.

[Use of pneumoperitoneum in the repair of giant abdominal hernias]. / Neumoperitoneo en el tratamiento de hernias gigantes.

The preoperative use of progressive pneumoperitoneum has been demonstrated to be safe and effective in the treatment of large hernias. The indications for this technique include massive hernias, hernias in patients with high surgical risk, and large recurrent hernias. We describe four patients in whom progressive pneumoperitoneum was carried out under local anesthesia and sedation between 1 and 3 weeks before surgery. All four hernias were closed with a preperitoneal mesh. Insufflation was performed on an inpatient basis in two patients and in the ambulatory setting in one. No postoperative complications were detected. No evidence of recurrence was found during follow-up (10 months-11 years).

[Intestinal linitis plastica: late metastasis from gastric signet ring cell adenocarcinoma]. / Linitis plástica intestinal: metástasis tardía de adenocarcinoma gástrico en anillo de sello.

Linitis plastica is a malignant disease that usually occurs in the stomach, although it can affect any segment of the alimentary tract. Typically, this entity shows slow progression and insidious clinical course. We present the case of a patient with a previous diagnosis of signet ring cell cancer of the stomach that had been treated with curative intent 12 years before the clinical onset of small and large bowel linitis plastica. The diagnosis was obtained as an incidental pathological finding after urgent surgery for intestinal obstruction. No gastric mass was found. Linitis plastica should be considered in the differential diagnosis of patients with symptoms of obstruction after resection of a gastric carcinoma, especially if there are macroscopic surgical findings of circumferential narrowing. A long interval after diagnosis and treatment of the primary disease does not allow malignancy to be ruled out.