Early diverting stoma closure is feasible and safe: results from a before-and-after study on the implementation of an early closure protocol at a tertiary referral center.

BACKGROUND: Evidence on early closure (EC) of defunctioning stoma (DS) after colorectal surgery shows a favorable effect when patients are carefully selected. Therefore, a clinical pathway adapted to the implementation of an EC strategy was developed in our center. The aim of this study was to carry out a comparative analysis of time until DS closure and DS-related morbidity before and after the implementation of an EC protocol (ECP). METHODS: This study is a before-and-after comparative analysis. Patients were divided into two cohorts according to the observational period: patients from the period before the ECP implementation (January 2015-December 2019) [Period 1] and those from the period after that (January 2020-December 2022) [Period 2]. All consecutive patients subjected to elective DS closure within both periods were eligible. Early closure was defined as the reversal within 30 days from DS creation. Patients excluded from EC or those not closed within 30 days since primary surgery were analyzed as late closure (LC). Baseline characteristics and DS-related morbidity were recorded. RESULTS: A total of 145 patients were analyzed. Median time with DS was shorter in patients after ECP implementation [42 (21-193) days versus 233 (137-382) days, p < 0.001]. This reduction in time to closure did not impact the DS closure morbidity and resulted in less DS morbidity (68.8% versus 49.2%, p = 0.017) and fewer stoma nurse visits (p = 0.029). CONCLUSIONS: The ECP was able to significantly reduce intervals to restoration of bowel continuity in patients with DS, which in turn resulted in a direct impact on the reduction of DS morbidity without negatively affecting DS closure morbidity.

The SARS-CoV-2 first wave impact in the acute inflammatory surgical pathologies.

Anecdotal evidence suggests that community infection control measures during the COVID-19 outbreak have modified the number and natural history of acute surgical inflammatory processes (ASIP-appendicitis, cholecystitis, diverticulitis and perianal abscesses) admissions. This study aims to evaluate the impact of the COVID-19 pandemic on the presentation and treatment ASIP and quantify the effect of COVID-19 infection on the outcomes of ASIP patients. This was a multicentre, comparative study, whereby ASIP cases from 2019, 2020 and 2021 (March 14th to May 2nd) were analyzed. Data regarding patient and disease characteristics as well as outcomes, were collected from sixteen centres in Madrid, and one in Seville (Spain). The number of patients treated for ASIP in 2019 was 822 compared to 521 in 2020 and 835 in 2021. This 1/3rd reduction occurs mainly in patients with mild cases, while the number of severe cases was similar. Surgical standards suffered a step back during the first wave: Lower laparoscopic approach and longer length of stay. We also found a more conservative approach to the patients this year, non-justified by clinical circumstances. Luckily these standards improved again in 2021. The positive COVID-19 status itself did not have a direct impact on mortality. Strikingly, none of the 33 surgically treated COVID positive patients during both years died postoperatively. This is an interesting finding which, if confirmed through future research with a larger sample size of COVID-19 positive patients, can expedite the recovery phase of acute surgical services.

Tissucol application in dermolipectomy and incisional hernia repair.

Biological adhesives have a lot of applications in surgical procedures. Here we present a prospective study with the aim of analyzing results of the application of Tissucol between the muscle layers and subcutaneous tissue after incisional hernia repair with polypropylene mesh and associated dermolipectomy. We assess clinical and technical parameters, local morbidity, and hospital stay. Fifty-six patients were divided into two groups. Patients with whom we used fibrin glue were older, with more obesity (P < 0.005) with associated diseases, and their incisional hernias were larger and more complicated to repair. Patients in the Tissucol group developed less local morbidity (hematomas or abscesses; P < 0.01), had a shorter mean hospital stay (P < 0.01), and required less wound care. The use of Tissucol improves the results of surgical repair of large abdominal incisional hernias repaired by mesh placement and dermolipectomy, and it decreases global morbidity and hospital stay are reduced.

Liver hematoma following endoscopic retrograde cholangiopancreatography (ERCP).

We report the case of an 81-year-old man who presented with abdominal pain following endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. A diagnosis of infected hematoma was made. A CT-guided puncture produced bloody matter that grew Citrobacter freundii. A catheter was left in place for 3 weeks before the patient could be discharged from hospital. We hypothesize that the hepatic parenchyma had been torn by the guide used during the ERCP. This case represents the first report of this type of iatrogenic injury.

Un caso de paraganglioma del arco aórtico / A case of paraganglioma of the aortic arch

Se presenta el caso de una mujer de 20 años con un paraganglioma secretor de localización infrecuente en el arco aórtico. Su presentación clínica tuvo lugar tras una cesárea, precisando de tratamiento previo a la cirugía para normalizar la tensión arterial. Su tratamiento quirúrgico fue la escisión completa, con buena evolución clínica de la paciente. Se comentan las peculiaridades de dicha presentación anatómica y su frecuencia. (AU)

Morbilidad atribuible a los cálculos abandonados en la cavidad abdominal tras la colecistectomía laparoscópica / Morbidity attributable to calculi left in the abdominal cavity after laparoscopic cholecystectomy

Objetivo. Analizar la morbilidad postoperatoria atribuible a los cálculos abandonados en la cavidad abdominal tras colecistectomía laparoscópica. Diseño. Estudio retrospectivo de cohortes. Pacientes y métodos. Se revisaron las colecistectomías laparoscópicas realizadas en el Hospital Universitario de Getafe entre 1991 y 1997. Se excluyeron los pacientes con signos de colecistitis aguda, hidropesía vesicular o vesícula escleroatrófica. En 22 casos hubo rotura de la pared vesicular con abandono de uno o más cálculos en la cavidad peritoneal al finalizar la intervención (cohorte de cálculos libres), mientras que en 277 casos la vesícula biliar tenía la pared íntegra. Entre estos últimos, se extrajo una muestra de 22 casos operados por los mismos cirujanos (cohorte control). El seguimiento ambulatorio fue de 42 meses. El análisis estadístico se realizó con el programa SPSS. Resultados. No se registró ninguna complicación pulmonar o intraabdominal, ni tampoco hubo reintervenciones. En la cohorte de cálculos libres, la duración de la cirugía fue 25 min más larga (p < 0,02) y la estancia media postoperatoria fue 0,6 días mayor (p < 0,04). Conclusiones. En ausencia de enfermedad inflamatoria, el abandono de cálculos en la cavidad peritoneal prolonga el tiempo quirúrgico y la estancia hospitalaria, pero no aumenta la morbilidad postoperatoria (AU)

Tratamiento laparoscópico del dolor abdominal de origen adherencial / Laparoscopic treatment of abdominal pain due to adhesions

Objetivo. Analizar la eficacia a medio-largo plazo de la adhesiólisis laparoscópica en el tratamiento del dolor abdominal de origen adherencial. Pacientes y métodos. Estudio experimental sin asignación aleatoria antes-después. Se incluyeron aquellos pacientes con antecedentes de una laparotomía que referían dolor abdominal crónico durante más de 6 meses, sin evidencia de una enfermedad orgánica de origen ginecológico, urológico o digestivo. Se excluyeron los pacientes con episodios de suboclusión intestinal o cuando el seguimiento fue inferior a 6 meses. La evaluación del dolor se realizó según la Escala Verbal Analógica de la Organización Mundial del Dolor. Resultados. Se incluyeron 30 pacientes. La intensidad de dolor preoperatorio fue de 8,3 (rango, 6-10), y tras la adhesiólisis de 3,9 (rango, 0-10), con un decremento medio de la intensidad del dolor de 4,7 (IC del 95 por ciento, 3-6); (p < 0,0001). Un 64 por ciento estaban muy satisfechos con el procedimiento. El seguimiento ambulatorio medio fue de 32 meses. Conclusión. Dos de cada tres pacientes con dolor abdominal crónico y con antecedentes de laparotomía mejoran clínicamente tras la adhesiólisis laparoscópica. Esta técnica disminuye la intensidad del dolor y reduce la tasa de recurrencias a medio-largo plazo, aunque sólo se debe indicar tras una exhaustiva evaluación preoperatoria (AU)