Can inflammatory biomarkers help in the diagnosis and prognosis of gangrenous acute cholecystitis? A prospective study.

The diagnosis of gangrenous acute cholecystitis represents a diagnostic challenge for the physician and is rarely identified preoperatively. We report a longitudinal prospective study in 180 patients who underwent cholecystectomy for acute cholecystitis. A ROC curve was obtained to determine the preoperative cut-off for various biomarkers (neutrophil to lymphocyte ratio [NLR], C-reactive protein [CRP], platelet to lymphocyte ratio [PLR], lactate and procalcitonin) and their association with both preoperative and postoperative findings. The area under the curve (AUC) for NLR, CRP, PLR, lactate and procalcitonin was 0.75, 0.8, 0.65 and 0.6, respectively. NLR > 5 and CRP > 100 are still independent factors for gangrene (adjusted odds ratio [OR], 2 and 2.1, respectively).

Gastric syphilis and its importance for a differential diagnosis in HIV patients.

A 41-year-old male, with history of HIV presented to emergency department with two months of abdominal pain and a weight loss. Radiological and endoscopic examinations where suggestive of gastric cancer. However, biopsies ruled out malignancy. The reaginic and anti-treponemal tests were positive, so the histological study was repeated with anti-Treponema pallidum monoclonal antibodies. The presence of spirochetes was confirmed. After three weeks of penicillin-based treatment, the gastric lesions and symptoms were resolved.

[The first experiences with colorectal laparoscopic surgery in Spain. Valencia, November 1991]. / Las primeras experiencias en cirugía laparoscópica de colon en España. Valencia, noviembre de 1991.

The development of laparoscopic colon surgery in Spain has spread quickly since its beginnings at the end of 1991. Colorectal Minimally Invasive Surgery is widely implemented and has changed the way we treat our patients, specially due to the short-term advantages such as lower morbidity with a better quality of life with the same oncological outcomes in the long term. A huge number of Spanish surgeons have contributed to the implementation of techniques and spreading the knowledge of these concepts by means of courses, controlled randomized studies, scientific papers, and books, and have obtained international recognition.

[Ambulatory laparoscopic cholecystectomy by minilaparoscopy versus traditional multiport ambulatory laparoscopic cholecystectomy. Prospective randomized trial]. / Colecistectomía laparoscópica ambulatoria por minilaparoscopia versus colecistectomía laparoscópica ambulatoria multipuerto tradicional. Estudio prospectivo aleatorizado.

OBJECTIVE: Difference analysis of ambulatorization rate, pain, analgesic requirements and daily activities recovery in patients undergoing laparoscopic cholecystectomy with standard multiport access (CLMP) versus a minilaparoscopic, 3mm size, technique. METHODS: Prospective randomized trial of 40 consecutive patients undergoing laparoscopic cholecystectomy. Comparison criteria included predictive ultrasound factors of difficult cholecystectomy, previous history of complicated biliary disease and demographics. Results are analyzed in terms of ambulatorization rate, pain, analgesic requirements, postoperative recovery, technical difficulty, hemorrhage intensity, overnight stay, readmission rate and total or partial conversion. RESULTS: Both procedures were similar in surgery time, technical score and hemorrhage score. MLC was associated with similar ambulatorization rate, 85%, and over-night stay 15%, with only 15% partial conversion rate. MLC showed less postoperative pain (P=.026), less analgesic consumption (P=.006) and similar DAR (P=.879). CONCLUSIONS: MLC is similar to CLMP in terms of ambulatorization with less postoperative pain and analgesic requirements without differences in postoperative recovery.

Biliary Pancreatitis. Liver Function Tests and Common Biliopancreatic Channel Kinetics--Biliopancreatic Reflux.

OBJECTIVE: To determine the prevalence of biliopancreatic reflux (BPR) in patients with biliary pancreatitis (BP) undergoing elective cholecystectomy with intraoperative cholangiography (IOC) in comparison with a control group of symptomatic cholelithiasis (CG). PATIENTS AND METHODS: Retrospective review of 107 consecutive BP cases. BPR was determined by IOC and liver function tests (LFT) were recorded at admission (A), 48hours, and preoperative examination (P). LFT analysis between A and P were analysed between groups with respect to BPR, time interval to cholecystectomy within the same group and by determination of observed value/maximum normal value ratio (OV/MNV). RESULTS: BPR incidence was 38.3% in BP in comparison with 5% in CG (p=0.0001) it was independent from interval time to cholecystectomy, in contrast with Odditis, suggesting an anatomical condition for CCBP and a functional one for Odditis. LFT analysis showed no differences in relation to BPR incidence. LFT excluding AP and GGT returned to normal values with significant differences in OV/MNV when BPR was present which points to an increased cholestasis in BPR group. US dilatation of CBD was noted in 10.3% and was associated to CCBP. CONCLUSIONS: BPR in BP increases cholestasis and contributes to confusion in the estimation of common bile duct stones increasing ERCP-EE rates. US and biochemical markers of CBDS show a low specificity due to BPR-CCBP which suggests that MRI-cholangiography is a mandatory exploration before ERCP-EE examination.

[Evaluation of the gastrointestinal quality of life index as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy]. / Evaluación del gastrointestinal quality of life index como sistema de selección para la priorización de pacientes en lista de espera de colecistectomía laparoscópica.

INTRODUCTION: We prospectively evaluated health-related quality of life (HRQoL) through the gastrointestinal quality of life index (GIQLI) as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy (LC) and its correlation with a linear prioritization system developed in the General and Gastrointestinal Surgery Institute of Clínica Quirón in Valencia. MATERIAL AND METHODS: There were 100 consecutive patients who underwent elective outpatient LC. The main outcome measures consisted of: 1) assessment of the impact of the disease, measured through the GIQLI; 2) evaluation of an objective system based on technical scientific criteria; 3) evaluation of the utility of LC in improving HRQoL through the GIQLI by analyzing expected and obtained utility through the change ratio, and 4) analysis of the correlation between the objective linear system, HRQoL and utility. RESULTS: The GIQLI was useful in evaluating the impact of the disease. LC significantly improved HRQoL in both oligosymptomatic and symptomatic patients. The objective or clinical factors did not allow perceptions of the process to be evaluated or the impact on HRQoL to be measured or inferred. A prioritization system based on GIQLI scores allows patients to be selected according to the expected utility (worsening of HRQoL) and obtained utility (improvement in HRQoL) of CL. CONCLUSIONS: Prioritization systems should include utility to guarantee equity. The GIQLI shows the impact of the disease on the patient while the clinical/objective factors are unrelated to the expectation of prioritization. Prioritization systems should include both elements to maintain the balance between impact and appropriate indication.

[Ambulatory laparoscopic cholecystectomy. A cohort study of 1,600 consecutive cases]. / Colecistectomía laparoscópica ambulatoria. Estudio de cohortes de 1.600 casos consecutivos.

OBJECTIVE: A descriptive analysis of day-case laparoscopic cholecystectomy (ALC) in a cohort of 1,600 consecutive patients performed in Instituto de Cirugía y Aparato Digestivo (ICAD), Clínica Quirón de Valencia in the period 1997-2010. PATIENTS AND METHODS: Prospective observational study of 1,601 consecutive patients undergoing elective laparoscopic cholecystectomy (LC) provided by the regional health service and private health companies. MAIN MEASURES: Conversion rate, non-planned admissions, readmissions, surgery duration and demographics. RESULTS: ALC was successfully performed in 80.8% of cases. LC with over-night (ON) stay accounted for 13.4% of patients. Admission was necessary in 4.6%. Mortality was 0.13%, 0.08 in ALC and 0.5% in ON LC. Readmissions occurred in 2.1%, 1.6% in ALC group, 5.4% in ON stay and 4.2% in admission group. CONCLUSIONS: ALC is a reliable and safe procedure. Minimization of admission rates is the key for cost-effective optimization in the management of cholelithiasis. ALC should be considered as the reference standard in gallbladder stone disease treatment.

Calidad asistencial y percibida en colecistectomía laparoscópica ambulatoria. Consideraciones metodológicas y cuestionarios / Quality of perception and quality of care in ambulatory laparoscopic cholecystectomy. Methodological considerations and questionnaires

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Las primeras experiencias en cirugía laparoscópica de colon en España. Valencia, noviembre de 1991 / The first experiences with colorectal laparoscopic surgery in Spain. Valencia, November 1991

El desarrollo de la cirugía laparoscópica de colon en nuestro país ha sido muy rápida desde su comienzo a finales de 1991. La resección de colon y recto por cirugía mínimamente invasiva ha cambiado desde sus inicios la manera de tratar a nuestros enfermos, debido esencialmente a las ventajas a corto plazo sobre la cirugía abierta, por su menor morbimortalidad y mejor calidad de vida con igualdad a largo plazo en los resultados oncológicos. En la enseñanza y difusión de estos conceptos en forma de cursos, estudios aleatorizados, artículos científicos y libros han participado y participan un ingente número de cirujanos españoles que gozan del reconocimiento internacional

The development of laparoscopic colon surgery in Spain has spread quickly since its beginnings at the end of 1991. Colorectal Minimally Invasive Surgery is widely implemented and has changed the way we treat our patients, specially due to the short-term advantages such as lower morbidity with a better quality of life with the same oncological outcomes in the long term. A huge number of Spanish surgeons have contributed to the implementation of techniques and spreading the knowledge of these concepts by means of courses, controlled randomized studies, scientific papers, and books, and have obtained international recognition

Colecistectomía laparoscópica ambulatoria por minilaparoscopia versus colecistectomía laparoscópica ambulatoria multipuerto tradicional. Estudio prospectivo aleatorizado / Ambulatory laparoscopic cholecystectomy by minilaparoscopy versus traditional multiport ambulatory laparoscopic cholecystectomy. Prospective randomized trial

OBJETIVO: Determinar la existencia de diferencias en tasa de ambulatorización, dolor percibido, consumo de analgésicos y recuperación de las actividades de la vida diaria (AVD) en pacientes tratados mediante colecistectomía laparoscópica multipuerto (CLMP) y colecistectomía por minilaparoscopia con material de 3 mm (MLC). MÉTODO: Estudio prospectivo aleatorizado de 40 pacientes consecutivos tratados mediante colecistectomía laparoscópica. Los criterios de pareamiento incluyeron factores ecográficos predictivos de colecistectomía técnicamente dificultosa, historia previa de enfermedad biliar complicada y factores demográficos. Se analizan los resultados en términos de tasa de ambulatorización, dolor percibido, consumo de analgésicos, recuperación de las AVD, grado de dificultad técnica, grado de hemorragia asociada, tasa de ambulatorización, porcentaje de estancia over-night, reingresos y conversión parcial o total. RESULTADOS: Ambos procedimientos mostraron similar duración de intervención, puntuación de dificultad técnica y de hemorragia. La MLC mostró porcentaje similar de ambulatorización (85%) y de estancia over-night(15%), con solo un 15% de conversiones parciales y 0% de conversión a CLMP. La MLC mostró menor dolor postoperatorio (p = 0,026), menor consumo de analgésicos (p = 0,006) con similar recuperación de las AVD (p = 0,879). CONCLUSIONES: La MLC no es inferior a la CLMP en términos de ambulatorización, resultando en menor dolor postoperatorio y menor consumo de analgésicos, con similar resultado en cuanto a reincorporación a las AVD

OBJECTIVE: Difference analysis of ambulatorization rate, pain, analgesic requirements and daily activities recovery in patients undergoing laparoscopic cholecystectomy with standard multiport access (CLMP) versus a minilaparoscopic, 3 mm size, technique. METHODS: Prospective randomized trial of 40 consecutive patients undergoing laparoscopic cholecystectomy. Comparison criteria included predictive ultrasound factors of difficult cholecystectomy, previous history of complicated biliary disease and demographics. Results are analyzed in terms of ambulatorization rate, pain, analgesic requirements, postoperative recovery, technical difficulty, hemorrhage intensity, overnight stay, readmission rate and total or partial conversion. RESULTS: Both procedures were similar in surgery time, technical score and hemorrhage score. MLC was associated with similar ambulatorization rate, 85%, and over-night stay 15%, with only 15% partial conversion rate. MLC showed less postoperative pain (P=.026), less analgesic consumption (P=.006) and similar DAR (P=.879). CONCLUSIONS: MLC is similar to CLMP in terms of ambulatorization with less postoperative pain and analgesic requirements without differences in postoperative recovery

¿Pueden los biomarcadores inflamatorios ayudar al diagnóstico y predecir el pronóstico de la colecistitis aguda gangrenosa? Un estudio prospectivo / No disponible

INTRODUCCIÓN: el diagnóstico de la colecistitis aguda gangrenosa constituye un reto diagnóstico para el médico y en pocas ocasiones se realiza de manera preoperatoria. MATERIAL Y MÉTODOS: presentamos un estudio longitudinal prospectivo de 180 pacientes a los que se les realiza colecistectomía secundaria a colecistitis aguda. Se realiza curva ROC para determinar el punto de corte preoperatorio de diferentes biomarcadores (ratio neutrófilo-linfocito [RNL], proteína C reactiva [PCR], ratio plaqueta-linfocito [RPL], lactato y procalcitonina) y asociación con hallazgos perioperatorios y postoperatorios. RESULTADOS: el área bajo la curva para RNL, PCR, RPL, lactato y procalcitonina fue de 0,75, 0,8, 0,65 y 0,6, respectivamente. CONCLUSIÓN: RNL > 5 y PCR > 100 permanecen como factores independientes de gangrena (odds ratio [OR] ajustada de 2 y 2,1, respectivamente)

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Pancreatitis biliar. Cinética de pruebas funcionales hepáticas y canal común biliopancreático - reflujo biliopancreático / Biliary pancreatitis. Liver function tests and common biliopancreatic channel kinetics - biliopancreatic reflux

OBJETIVO: Estudio de la prevalencia de reflujo biliopancreático (RBP)/canal común biliopancreático (CCBP) en pacientes con pancreatitis biliar (PB) sometidos a colecistetomía (CST) y colangiografía intraoperatoria (CIO) y análisis de la cinética de pruebas funcionales hepáticas (PFH) en comparación con un grupo control (GC) de colelitiasis sintomática. MATERIAL Y MÉTODOS: Estudio retrospectivo de 107 pacientes consecutivos con PB. Se determinó la existencia de RBP-CCBP en la CIO y se analizaron las PFH al ingreso (AI), a las 48 horas y en el examen preoperatorio (AP). La variación analítica se analizó entre grupos según existencia de RBP-CCBP y entre el AI y AP, según intervalo ingreso-intervención (III) y dentro del mismo grupo mediante determinación de la ratio valor observado-valor máximo normal (VO/VMN). RESULTADOS: La incidencia de CCBP fue de 38,3% en PB vs 5,0 en GC (p = 0,0001) y fue independiente del III a diferencia de la odditis apuntando a una alteración anatómica para la primera y funcional para la segunda. Las variaciones analíticas no muestran diferencias entre grupos en función de la existencia de CCBP, pero con ausencia de diferencias al analizar la ratio VO/VMN en FA y GGT, lo que indica un mayor grado de colestasis en los pacientes con RBP-CCBP. La incidencia de dilatación de vía biliar US fue del 10,3% asociándose a CCBP. CONCLUSIONES: El RBP-CCBP en PB genera un mayor grado de colestasis e incertidumbre en la estimación de coledocolitiasis asociada y excesiva sobreindicación de ERCP-EE. Los marcadores US y bioquímicos de coledocolitiasis tienen una baja especificidad en PB por la existencia de CCBP lo que obliga a incluir a la colangiografía por RMN como exploración previa a la ERCP-EE

OBJECTIVE: To determine the prevalence of biliopancreatic reflux (BPR) in patients with biliary pancreatitis (BP) undergoing elective cholecystectomy with intraoperative cholangiography (IOC) in comparison with a control group of symptomatic cholelithiasis (CG). PATIENTS AND METHODS: Retrospective review of 107 consecutive BP cases. BPR was determined by IOC and liver function tests (LFT) were recorded at admission (A), 48hours, and preoperative examination (P). LFT analysis between A and P were analysed between groups with respect to BPR, time interval to cholecystectomy within the same group and by determination of observed value/maximum normal value ratio (OV/MNV). RESULTS: BPR incidence was 38.3% in BP in comparison with 5% in CG (p = 0.0001) it was independent from interval time to cholecystectomy, in contrast with Odditis, suggesting an anatomical condition for CCBP and a functional one for Odditis. LFT analysis showed no differences in relation to BPR incidence. LFT excluding AP and GGT returned to normal values with significant differences in OV/MNV when BPR was present which points to an increased cholestasis in BPR group. US dilatation of CBD was noted in 10.3% and was associated to CCBP. CONCLUSIONS: BPR in BP increases cholestasis and contributes to confusion in the estimation of common bile duct stones increasing ERCP-EE rates. US and biochemical markers of CBDS show a low specificity due to BPR-CCBP which suggests that MRI-cholangiography is a mandatory exploration before ERCP-EE examination

[Surgical Complexity Classification Index (SCCI): a new patient classification system for clinical management of laparoscopic cholecystectomy]. / Indice de clasificación de complejidad quirúrgica (ICCQ): un nuevo sistema de clasificación de pacientes para la gestión clínica de la colecistectomía laparoscópica.

OBJECTIVE: To devise a classification system of patients subjected to elective laparoscopic cholecystectomy (LC) which will enable the degree of surgical difficulty and possible time in surgery to be correlated with clinical, ultrasound, associated comorbidity and age group variables. MATERIAL AND METHOD: A prospective observational study of 110 patients subjected to LC in which the SCCI (Surgical Complexity Classification Index) had been calculated. The SCCI was worked out from previous studies published on patient classification systems and complication predictive factors in patients subjected to LC. MAIN OUTCOME MEASURES: surgical technique difficulty score, length of surgical time, post-operative stay (ambulatory). RESULTS: The cut-off value that obtained a better classification of the patients was an SCCI > in whom the technique difficulty score was 13.2 +/- 3.6 and the duration of the surgery 51.9 +/- 31 compared with the SCCI < 5 subgroup, technical difficulty score 10.5 +/- 2.8 and the duration of the surgery 6.9 +/- 11.4 (p < 0.05). CONCLUSIONS: The SCCI enables the technical complexity of LC to be estimated and therefore appropriate risk management in the LC process together with improved clinical management of that process.

[Intraoperative factors predictive of failure of the ambulatory regimen after laparoscopic cholecystectomy]. / Factores intraoperatorios predictivos del fracaso del régimen ambulatorio tras colecistectomía laparoscópica.

OBJECTIVES: To determine which intraoperative factors during ambulatory laparoscopic cholecystectomy predict postoperative admission. MATERIAL AND METHOD: Between January 1999 and August 2003, we attempted 410 consecutive laparoscopic cholecystectomies. Intraoperative variables were analyzed using univariate and multivariate methods. An intraoperative score was applied to determine the probability of successful ambulatory surgery in each patient. RESULTS: A total of 88.5% of the patients were strictly ambulatory. Forty-two patients required overnight admission, mostly due to social factors, and five patients required admission after 24-48 hours. Intraoperative variables predictive of postoperative admission were an operating time of more than 60 minutes (p = 0.011), gallbladder dissection with anatomic difficulty (p = 0.001), and cystic artery hemorrhage (p = 0.041). Surgical access to the abdominal cavity, gallbladder perforation, trocar wound or hepatic bed bleeding, intensity or grade of hemorrhage, and gallbladder extraction were not predictive variables. CONCLUSIONS: Ambulatory laparoscopic cholecystectomy is a safe and effective procedure. Operating time, correct dissection of gallbladder structures and hemorrhage of the gallbladder hilus, especially of the cystic artery, play a major role in the success or failure of ambulatory laparoscopic cholecystectomy.

Evaluación del gastrointestinal quality of life index como sistema de selección para la priorización de pacientes en lista de espera de colecistectomía laparoscópica / Evaluation of the gastrointestinal quality of life index as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy

Introducción Evaluación prospectiva de la calidad de vida relacionada con la salud (CVRS) mediante el gastrointestinal quality of life index (GIQLI) como sistema de priorización de pacientes en lista de espera para el proceso colecistectomía laparoscópica (CL) y su correlación con un sistema lineal de priorización (SP) desarrollado en el Instituto de Cirugía General y Aparato Digestivo (ICAD) de la Clínica Quirón de Valencia. Material y métodos Un total de 100 pacientes consecutivos a los que se les realizó CL electiva ambulatoria. Principales medidas de resultados 1) repercusión de la enfermedad mediante el GIQLI; 2) evaluación de un sistema objetivo basado en criterios científico-técnicos; 3) evaluación del valor de la CL en términos de CVRS mediante el GIQLI analizando la utilidad esperable y la obtenida en términos de change ratio (CR) y 4) análisis de la correlación entre el sistema objetivo lineal, la CVRS y la utilidad. Resultados El GIQLI es útil en la evaluación de la repercusión. La CL obtiene un beneficio en CVRS significativo en pacientes tanto oligosintomáticos como sintomáticos. Los factores objetivos o clínicos no permiten evaluar la percepción sobre el proceso ni medir o inferir la repercusión en CVRS. Un SP basado en tramos de puntuación del GIQLI permite una selección en función de la utilidad de la CL esperable (deterioro en CVRS) y obtenida (ganancia en CVRS).Conclusiones Un SP debe incluir la utilidad para garantizar la equidad. El GIQLI objetiva la repercusión sobre el paciente mientras que los factores clínicos-objetivos no tienen relación con las expectativas de priorización. Un SP debe incluir ambos a fin de mantener el equilibrio repercusión/adecuada indicación (AU)

Introduction We prospectively evaluated health-related quality of life (HRQoL) through the gastrointestinal quality of life index (GIQLI) as a system to prioritize patients on the waiting list for laparoscopic cholecystectomy (LC) and its correlation with a linear prioritization system developed in the General and Gastrointestinal Surgery Institute of Clínica Quirón in Valencia. Material and methods There were 100 consecutive patients who underwent elective outpatient LC. The main outcome measures consisted of: 1) assessment of the impact of the disease, measured through the GIQLI; 2) evaluation of an objective system based on technical scientific criteria; 3) evaluation of the utility of LC in improving HRQoL through the GIQLI by analyzing expected and obtained utility through the change ratio, and 4) analysis of the correlation between the objective linear system, HRQoL and utility. Results The GIQLI was useful in evaluating the impact of the disease. LC significantly improved HRQoL in both oligosymptomatic and symptomatic patients. The objective or clinical factors did not allow perceptions of the process to be evaluated or the impact on HRQoL to be measured or inferred. A prioritization system based on GIQLI scores allows patients to be selected according to the expected utility (worsening of HRQoL) and obtained utility (improvement in HRQoL) of CL.Conclusions Prioritization systems should include utility to guarantee equity. The GIQLI shows the impact of the disease on the patient while the clinical/objective factors are unrelated to the expectation of prioritization. Prioritization systems should include both elements to maintain the balance between impact and appropriate indication (AU)

Colecistectomía laparoscópica ambulatoria. Estudio de cohortes de 1.600 casos consecutivos / Ambulatory laparoscopic cholecystectomy. A cohort study of 1, 600 consecutive cases

Objetivo Describir la experiencia de nuestro grupo en colecistectomía laparoscópica ambulatoria en una cohorte de 1.600 casos consecutivos realizados en el Instituto de Cirugía y Aparato (CLA) Digestivo (ICAD) en la Clínica Quirón de Valencia durante el período 1997-2010.Pacientes y método Estudio prospectivo, observacional de 1.601 pacientes consecutivos remitidos para colecistectomía laparoscópica, procedentes de la Agencia Valenciana de Salud (AVS) y compañías aseguradoras privadas (CAP).Principales medidas de resultados: se evalúan los resultados con el análisis de índice de sustitución, tasa de ingresos no planeados, reingresos, estancia postoperatoria, duración de intervención y factores demográficos. Resultados El índice de sustitución de la serie fue de 80,8% con un porcentaje de pacientes intervenidos en régimen de estancia over-night (EON) de 13,4% y un porcentaje de ingresos en hospitalización convencional de 4,6%. La mortalidad de la serie fue de 0,13%, 0,08 en el grupo de CLA y 0,5% en el grupo de CL con EON. El índice de reingresos fue de 2,1% en la serie global, 1,6% en los pacientes ambulatorios, 5,4% en los pacientes con EON y 4,2% en los pacientes ingresados. Conclusiones La CLA es un procedimiento seguro y fiable. La reducción en la necesidad de ingreso de los pacientes es fundamental en la optimización coste efectividad del procedimiento de colecistectomía. La CLA debería ser considerada como el patrón oro del tratamiento de la colelitiasis sintomática (AU)

Objective A descriptive analysis of day-case laparoscopic cholecystectomy (ALC) in a cohort of 1,600 consecutive patients performed in Instituto de Cirugía y Aparato Digestivo (ICAD), Clínica Quirón de Valencia in the period 1997-2010.Patients and methods Prospective observational study of 1,601 consecutive patients undergoing elective laparoscopic cholecystectomy (LC) provided by the regional health service and private health companies. Main measures Conversion rate, non-planned admissions, readmissions, surgery duration and demographics. Results ALC was successfully performed in 80.8% of cases. LC with over-night (ON) stay accounted for 13.4% of patients. Admission was necessary in 4.6%. Mortality was 0.13%, 0.08 in ALC and 0.5% in ON LC. Readmissions occurred in 2.1%, 1.6% in ALC group, 5.4% in ON stay and 4.2% in admission group. Conclusions ALC is a reliable and safe procedure. Minimization of admission rates is the key for cost-effective optimization in the management of cholelithiasis. ALC should be considered as the reference standard in gallbladder stone disease treatment (AU)

Dolor percibido, consumo de analgésicos y recuperación de las actividades de la vida diaria en pacientes sometidos a hernioplastia inguinal ambulatoria laparoscópica tipo TEP versus hernioplastia Lichtenstein en régimen ambulatorio / Pain, analgesic consumption and daily life activities recovery in patients undergoing ambulatory totally extra-peritoneal laparoscopic inguinal hernioplasty versus ambulatory Lichtenstein hernioplasty

Introducción Aunque el patrón de comparación de la reparación de la hernia inguinal primaria es la técnica de Lichtenstein (LICH), la Hernioplastia inguinal laparoscópica totalmente extraperitoneal (TEP) muestra claras ventajas no sistemáticamente demostradas en cuanto a dolor percibido, consumo de analgésicos y recuperación de las actividades de la vida diaria. Objetivo Demostrar la existencia de diferencias en dolor percibido, consumo de analgésicos y recuperación de las actividades de la vida diaria entre la hernioplastia Lichtenstein versus la laparoscopia TEP. Material y métodos Estudio prospectivo, observacional no aleatorizado de 169 pacientes consecutivos sometidos a LICH vs. TEP. El LICH se realizó mediante anestesia local y sedación y el TEP con anestesia general, siendo ambos practicados en forma ambulatoria. Los puntos de análisis incluyeron: consumo de analgésicos, grado de dolor percibido y grado de recuperación de las actividades de la vida diaria. Resultados El consumo de analgésicos fue menor en el grupo TEP para los días 4 y 5 postoperatorio, al igual que el dolor percibido. En referencia a la recuperación de las actividades de la vida diaria se alcanzaron mínimas diferencias significativas en el 7.° día postoperatorio a favor del TEP. Conclusiones Nuestro estudio muestra una diferencia significativa en cuanto a dolor percibido y consumo de analgésicos, así como en el grado de recuperación de las actividades de la vida diaria al comparar ambos grupos. La hernioplastia tipo TEP debe ser también considerada en la hernia inguinal unilateral primaria no complicada (AU)

Introduction: Although the unique comparison standard of primary inguinal hernia repair is the Lichtenstein technique (LICH), totally extra-peritoneal (TEP) laparoscopic inguinalhernioplasty shows, although not systematically demonstrated, clear advantages as regards, perceived pain, analgesic use, and recovery of daily life activities. Objective: To demonstrate the differences in perceived pain, analgesic use, and recovery of daily life activities between Lichtenstein hernioplasty and TEP laparoscopy. Material and methods: A prospective, non-randomised observational study was conducted on 169 consecutive patients subjected to LICH vs TEP. The LICH was performed using local anaesthesia and sedation, and the TEP with general anaesthesia, both being performed as ambulatory surgery. The points of analysis included: analgesic use, level of perceived pain, and recovery of daily life activities. Results: Analgesic use was less in the TEP group for post-operative day 4 and 5, similar to the perceived pain. As regards recovery of daily life activities, the significantly minimum differences were achieved on post-operative day 7 in favour of TEP. Conclusions: Our study shows a significant difference as regards perceived pain and analgesicuse, as well as in the level of recovery of daily life activities, when comparing both groups.TEP hernioplasty should also be considered in the non-complicated primary unilateralinguinal hernia (AU)

Índice de clasificación de complejidad quirúrgica (ICCQ): un nuevo sistema de clasificación de pacientes para la gestión clínica de la colecistectomía laparoscópica / Surgical Complexity Classification Index (SCCI): a new patient classification system for clinical management of laparoscopic cholecystectomy

Objetivo. Elaborar un sistema de clasificación de pacientes sometidos a colecistectomía laparoscópica (CL) electiva que permita correlacionar el grado de dificultad quirúrgica y la posible duración de la cirugía en relación con variables clínicas y ecográficas, comorbilidades y segmentos de edad. Material y método. Estudio observacional prospectivo de 110 pacientes consecutivos sometidos a CL de quienes se ha calculado el índice de clasificación de complejidad quirúrgica (ICCQ), que se elaboró a partir de estudios previos publicados sobre sistemas de clasificación de pacientes y factores predictivos de complicaciones en pacientes sometidos a CL. Las principales medidas de resultados fueron score de dificultad técnica intraoperatoria, tiempo quirúrgico y estancia postoperatoria (ambulatorización). Resultados. El valor de corte que obtuvo una mejor clasificación de los pacientes fue ICCQ > 5, en cuyo subgrupo el score de dificultad técnica fue 13,2 ± 3,6 y la duración de la intervención, 51,9 ± 31 en comparación con el subgrupo de ICCQ < 5: score de dificultad técnica, 10,5 ± 2,8 y duración de la intervención, 36,9 ± 11,4 (p < 0,05). Conclusiones. El ICCQ permite estimar la complejidad técnica de la CL y, por lo tanto, la adecuada gestión de riesgos en el proceso de la CL junto con una mejora en la gestión clínica de dicho proceso (AU)

Objective. To devise a classification system of patients subjected to elective laparoscopic cholecystectomy (LC) which will enable the degree of surgical difficulty and possible time in surgery to be correlated with clinical, ultrasound, associated comorbidity and age group variables. Material and method. A prospective observational study of 110 patients subjected to LC in which the SCCI (Surgical Complexity Classification Index) had been calculated. The SCCI was worked out from previous studies published on patient classification systems and complication predictive factors in patients subjected to LC. Main outcome measures: surgical technique difficulty score, length of surgical time, post-operative stay (ambulatory). Results. The cut-off value that obtained a better classification of the patients was an SCCI > in whom the technique difficulty score was 13.2 ± 3.6 and the duration of the surgery 51.9 ± 31 compared with the SCCI < 5 subgroup, technical difficulty score 10.5 ± 2.8 and the duration of the surgery 6.9 ± 11.4 (p < 0.05). Conclusions. The SCCI enables the technical complexity of LC to be estimated and therefore appropriate risk management in the LC process together with improved clinical management of that process (AU)

Factores intraoperatorios predictivos del fracaso del régimen ambulatorio tras colecistectomía laparoscópica / Introsperative factors pedictive of failure of the ambulatory regimen after laparoscopic cholecysteroctomy

Objetivos. Establecer qué hechos intraoperatorios durante una colecistectomía laparoscópica con pretensión ambulatoria determinan su conversión en una operación con ingreso hospitalario. Material y método. Entre enero de 1999 y agosto de 2003 se realizaron 410 colecistectomías laparoscópicas consecutivas con pretensión de régimen ambulatorio. Se aplicaron análisis univariante y multivariante de variables intraoperatorias de los pacientes. Se aplicó un score intraoperatorio para determinar la probabilidad de régimen ambulatorio tras la colecistectomía laparoscópica en cada paciente. Resultados. El índice de sustitución de la serie global fue del 88,5%. Cuarenta y dos pacientes requirieron estancia nocturna en el hospital, la mayoría por causas sociales, y 5 precisaron ingreso después de 24-48 h. Los hechos intraoperatorios relacionados con el fracaso del pretendido régimen ambulatorio para la colecistectomía laparoscópica fueron el tiempo quirúrgico superior a 60 min (p = 0,011), la existencia de dificultad anatómica en la disección intraoperatoria de la vesícula biliar (p = 0,001) y la hemorragia de la arteria cística (p = 0,041). Variables como el acceso a la cavidad abdominal, la perforación vesicular, la hemorragia de las puertas de entrada o del lecho hepático, la intensidad o el grado de hemorragia, o la extracción vesicular no se comportaron como factores predictores. Conclusiones. La colecistectomía laparoscópica en régimen ambulatorio se puede realizar de manera segura y fiable. El tiempo operatorio, la correcta disección de estructuras hiliares y la hemorragia del hilio vesicular, especialmente de la arteria cística, desempeñan un papel importante en el éxito o el fracaso de la colecistectomía laparoscópica con pretensión ambulatoria (AU)

Objectives. To determine which intraoperative factors during ambulatory laparoscopic cholecystectomy predict postoperative admission. Material and method. Between January 1999 and August 2003, we attempted 410 consecutive laparoscopic cholecystectomies. Intraoperative variables were analyzed using univariate and multivariate methods. An intraoperative score was applied to determine the probability of successful ambulatory surgery in each patient. Results. A total of 88.5% of the patients were strictly ambulatory. Forty-two patients required overnight admission, mostly due to social factors, and five patients required admission after 24-48 hours. Intraoperative variables predictive of postoperative admission were an operating time of more than 60 minutes (p = 0.011), gallbladder dissection with anatomic difficulty (p = 0.001), and cystic artery hemorrhage (p = 0.041). Surgical access to the abdominal cavity, gallbladder perforation, trocar wound or hepatic bed bleeding, intensity or grade of hemorrhage, and gallbladder extraction were not predictive variables. Conclusions. Ambulatory laparoscopic cholecystectomy is a safe and effective procedure. Operating time, correct dissection of gallbladder structures and hemorrhage of the gallbladder hilus, especially of the cystic artery, play a major role in the success or failure of ambulatory laparoscopic cholecystectomy (AU)