Postoperative complications and predictors of mortality in patients with COVID-19.

BACKGROUND: There are limited data about the perioperative outcomes of coronavirus disease 2019 (COVID-19) patients that needed emergency general surgery. The aim of the present study was to describe the perioperative outcomes and mortality of patients with COVID-19 who underwent emergency surgery. MATERIALS AND METHODs: Retrospective study of COVID-19 patients symptomatic versus asymptomatic from March 2020 to February 2022 that needed an emergency surgery in a national referral hospital. RESULTS: Forty-four patients were included in this study. Patients with symptomatic COVID-19 have higher ICU admissions and prolonged length of stay (LOS) as compared with asymptomatic COVID-19 patients. The 90-day survival probability of the entire cohort was 70.1% (60.3-79.9) and was significantly lower in patients with COVID-19 symptomatic 63.4% (50.5-76.2). The cut-off preoperative values for the prediction of mortality: Ferritin ≥ 438.5 ng/mL (Area under the curve [AUC] = 0.908), C-reactive protein (CRP) ≥ 12.5 mg/dL (AUC = 0.715), leukocyte ≥ 13.8 × 103/mL (AUC = 0.706), and albumin ≤ 2.78 g/dL (AUC = 704). Furthermore, a cut-off value of CRP of ≥ 12.5 mg/dL yielded an accuracy of 82.9% for the prediction of postoperative complications (p < 0.001). CONCLUSION: Patients with symptomatic COVID-19 who needed emergency surgery have higher ICU admissions, prolonged LOS, and decreased 90-day survival as compared with asymptomatic COVID-19 patients. Preoperative ferritin, CRP, leukocytes, and albumin could be used as predictors of mortality.

ANTECEDENTES: Hay datos limitados sobre los pacientes con COVID-19 que necesitaron cirugía de emergencia. El objetivo del presente estudio fue describir los resultados perioperatorios y la mortalidad de pacientes con COVID-19 que se sometieron a cirugía de emergencia. MATERIAL Y MÉTODOS: Estudio retrospectivo de pacientes con COVID-19 sintomáticos vs. asintomáticos de marzo 2020 a febrero 2022 que requirieron cirugía de emergencia en un Hospital de Referencia Nacional. RESULTADOS: Se incluyeron 44 pacientes. Los pacientes con COVID-19 sintomático tienen más admisiones en la UCI y estancia hospitalaria prolongada en comparación con los pacientes con COVID-19 asintomático. La supervivencia a 90 días de la cohorte fue del 70,1% (60,3-79,9) y fue menor en los pacientes con COVID-19 sintomáticos del 63.4% (50.5-76.2). Los valores preoperatorios para la predicción de mortalidad: ferritina ≥ 438.5 ng/mL (AUC = 0.908), PCR ≥ 12.5 mg/dL (AUC = 0.715), leucocitos ≥ 13.8 × 103/mL (AUC = 0.706) y albúmina ≤ 2.78 g/dl (AUC = 704). La PCR de ≥ 12.5 mg/dL tiene una precisión del 82.9% para la predicción de complicaciones posoperatorias (p < 0.001). CONCLUSIÓN: Los pacientes con COVID-19 sintomático tienen más admisiones en la UCI, estancia hospitalaria prolongada y menor supervivencia en comparación con los pacientes con COVID-19 asintomáticos. La ferritina, PCR, leucocitos y albúmina preoperatoria pueden utilizarse como predictores de mortalidad.

Surgical treatment of acute cholecystitis in patients with confirmed COVID-19: Ten case reports and review of literature.

BACKGROUND: Research concerning postoperative outcomes of confirmed coronavirus disease 2019 (COVID-19) patients revealed unfavorable postoperative results with increased morbidity, pulmonary complications and mortality. Case reports have suggested that COVID-19 is associated with more aggressive presentation of acute cholecystitis. The aim of the present study is to describe the perioperative assessment and postoperative outcomes of ten patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with concomitant acute cholecystitis who underwent cholecystectomy. CASE SUMMARY: We report a total of 10 SARS-CoV-2 positive patients with concomitant acute cholecystitis that underwent cholecystectomy. Six patients were males, the mean age was 47.1 years. Nine patients had moderate acute cholecystitis, and one patient had severe acute cholecystitis. All patients were treated with urgent/early laparoscopic cholecystectomy. Regarding the Parkland grading scale, two patients received a Parkland grade of 3, two patients received a Parkland grade of 4, and six patients received a Parkland grade of 5. Eight patients required a bail-out procedure. Four patients developed biliary leakage and required endoscopic retrograde cholangiopancreatography with biliary sphincterotomy. After surgery, five patients developed acute respiratory distress syndrome (ARDS) and required intensive care unit (ICU) admission. One patient died after cholecystectomy due to ARDS complications. The mean total length of stay (LOS) was 18.2 d. The histopathology demonstrated transmural necrosis (n = 5), vessel obliteration with ischemia (n = 3), perforation (n = 3), and acute peritonitis (n = 10). CONCLUSION: COVID-19 patients with acute cholecystitis had difficult cholecystectomies, high rates of ICU admission, and a prolonged LOS.

Laparoscopic appendectomy in complicated appendicitis with compromised appendix base: a retrospective cohort study.

BACKGROUND: Patients with compromised appendix base constitute a subgroup of patients with complicated appendicitis, and there is few available information. OBJECTIVE: To study the frequency of stump leaks and fistulae in patients with complicated appendicitis with compromised stump. METHOD: This is an observational, retrospective study of patients that underwent laparoscopic appendectomy with compromised appendix stump. RESULTS: From 2015 to 2019, 158 patients with complicated appendicitis were operated, of them 54 had compromised base or stump. There were 66.7% men, with a mean age of 38.7 years. For stump closure, a simple knot was employed in 57.4%, and in 42.6% an invaginated suture was employed. Regarding complications, 16.7% developed intraabdominal abscess, 7.4% ileus and 7.4% had wound infection. We found one stump leak and one stump fistula. The mean length of stay was 5.4 days (range: 1-20). There were 5 reoperations, 4 for abscess drainage and 1 for stump leak. CONCLUSIONS: Patients with acute complicated appendicitis with compromised appendicular base, laparoscopic surgery either with simple knot or with invaginated suture resulted in low frequency of stump leaks and fistula.

ANTECEDENTES: Los pacientes con base apendicular comprometida constituyen un subgrupo de pacientes con apendicitis complicada y existe poca información al respecto. OBJETIVO: Conocer la frecuencia de fístulas y fugas fecales en pacientes con apendicitis complicada con base apendicular comprometida. MÉTODO: Se trata de un estudio observacional, retrospectivo y transversal de pacientes operados de apendicectomía laparoscópica con base apendicular comprometida. RESULTADOS: De 2015 a 2019 se encontraron 158 casos de apendicitis complicada, de los cuales 54 tenían la base apendicular comprometida. Hubo predominio de varones (66.7%) y la edad media fue de 38.7 años. En el 57.4% de los casos se realizó un nudo simple y en el 42.6% un punto transfictivo con invaginación del muñón. En relación con las complicaciones, el 16.7% desarrollaron abscesos intraabdominales, el 7.4% íleo y el 7.4% infección de herida. Hubo un paciente con fuga del muñón y un paciente con fístula cecal. El tiempo medio de estancia hospitalaria fue de 5.4 días (rango: 1-20). Se realizaron cinco reintervenciones: cuatro para drenaje de absceso intraabdominal y una por fuga del muñón. CONCLUSIONES: En los pacientes con base apendicular comprometida, el manejo laparoscópico con ligadura simple o con punto transfictivo resulta en una baja frecuencia de fuga y fístula del muñón apendicular.

Sarcopenia predicts worse postoperative outcomes and decreased survival rates in patients with colorectal cancer: a systematic review and meta-analysis.

PURPOSE: Previous studies have shown an association of sarcopenia with adverse short- and long-term outcomes in multiple gastrointestinal cancer types. We aimed to investigate the prognostic value of sarcopenia on the postoperative outcomes and survival rates of patients with colorectal cancer (CRC). METHODS: A systematic literature search was performed using the PubMed, Embase, Cochrane, Google Scholar, and Scopus databases. We included studies that compared postoperative outcomes or survival rates in sarcopenic and non-sarcopenic patients with CRC. RESULTS: A total of 44 observational studies, comprising 18,891 patients, were included. The pooled prevalence of sarcopenia was 37% (n = 7009). The pooled analysis revealed an association between sarcopenia and higher risk of total postoperative complications (23 studies, OR = 1.84; 95% CI 1.35-2.49), postoperative severe complications (OR = 1.72; 95% CI 1.10-2.68), postoperative mortality (OR = 3.21; 95% CI 2.01-5.11), postoperative infections (OR = 1.40; 95% CI 1.12-1.76), postoperative cardiopulmonary complications (OR = 2.92; 95% CI 1.96-4.37), and prolonged length of stay (MD = 0.77; 95% CI 0.44-1.11) after colorectal cancer surgery. However, anastomotic leakage showed comparable occurrence between sarcopenic and non-sarcopenic patients (OR = 0.99; 95% CI 0.72 to 1.36). Regarding survival outcomes, sarcopenic patients had significantly shorter overall survival (25 studies, HR = 1.83; 95% CI = 1.57-2.14), disease-free survival (HR = 1.55; 95% CI = 1.29-1.88), and cancer-specific survival (HR = 1.77; 95% CI 1.40-2.23) as compared with non-sarcopenic patients. CONCLUSION: Among patients with colorectal cancer, sarcopenia is a strong predictor of increased postoperative complications and worse survival outcomes.

Three-dimensional vs two-dimensional laparoscopic gastric bypass for manual gastrojejunal anastomosis: A prospective and randomized trial.

OBJECTIVE: The objective of this study was to compare the total procedure time and task-specific execution time in gastric bypass using a three-dimensional (3D) versus two-dimensional (2D) imaging system. MATERIALS AND METHODS: This study was a prospective and randomized clinical trial. Forty obese patients were randomized into two groups: gastric bypass with 3D imaging system or with conventional 2D system. The primary endpoint was operative time during manual gastrojejunal anastomosis. Data collection was carried out on demographics, comorbidities, operative time in three stages, and complications. The same surgeon performed all surgeries. Two patients were excluded because technical issues were encountered for viewing their videos during the trial. RESULTS: A total of 20 patients in the Laparoscopic Gastric Bypass (LGB) 3D group and 18 in the LGB 2D group were analyzed. There were no significant differences in the pre-operative data. The average procedure time was 16.5 min lower in the 3D group versus the 2D group. Execution time for specific tasks was not statistically significant, except for the gastrojejunal anastomosis, which is routinely performed as a manual anastomosis in our surgery group. There was no complication intra- or post-operative. CONCLUSIONS: The use of a 3D imaging system for laparoscopic gastric bypass was associated with a shorter total operative time, especially for the hand-sewn gastrojejunal anastomosis, compared with the 2D imaging system. OBJETIVO: Comparar el tiempo total del procedimiento y de tareas específicas en bypass gástrico laparoscópico (BGL) utilizando sistemas de imagen 3D y 2D.

MÉTODO: Estudio prospectivo, aleatorizado, con 40 pacientes obesos divididos en dos grupos: BGL 2D o 3D. El objetivo principal fue medir el tiempo al realizar la gastroyeyunoanastomosis manual. La recolección de datos incluyó comorbilidad, demografía, tiempo operatorio en tres fases (formación de reservorio, gastroyeyunoanastomosis y yeyunoyeyunoanastomosis) y complicaciones posoperatorias. El mismo cirujano realizó los procedimientos. Se excluyeron dos pacientes por incapacidad para abrir el video. RESULTADOS: Se analizaron 20 pacientes en el grupo 3D y 18 en el grupo 2D. No hubo diferencias significativas en los datos preoperatorios. El tiempo promedio del procedimiento fue menor en el grupo 3D que en el 2D en 16,5 minutos. El tiempo de ejecución para realizar tareas solo fue significativo al realizar la gastroyeyunoanastomosis. No hubo ninguna complicación intraoperatoria ni posoperatoria. CONCLUSIONES: El uso de un sistema de imagen 3D se asoció con un menor tiempo quirúrgico total, en especial para la gastroyeyunoanastomosis manual, en comparación con el sistema de imagen 2D.

A Four-step Technique for Effluent Diversion of Enteroatmospheric Fistulas.

BACKGROUND: Isolation of the enteroatmospheric fistula (EAF) opening and prevention of contamination of the rest of the wound by effluent are important factors in the management of EAF. OBJECTIVE: The aim of this study is to describe an easily reproducible technique for effluent control in patients with EAF. MATERIALS AND METHODS: A retrospective analysis was conducted on all patients who underwent the present technique between 2013 and 2015. The surgical technique included condom-EAF anastomosis, fistula ring creation, negative pressure wound therapy (NPWT), and adaptation of an ostomy bag. RESULTS: A total of 7 patients with a Björck grade 4 abdomen were included. All fistulas were located in the small bowel with a median number of 2 EAFs (range, 2-3) in each patient, and the majority had moderate output volume. The mean number of NPWT changes was 10 (range, 5-18), the mean time of NPWT use was 75.7 days (range, 60-120 days), and the mean length of stay was 108.2 days (range, 103-160 days). The mean time of ostomy formation to restitution of bowel continuity was 14.3 months (range, 8-20 months). Open anterior component separation was employed in all cases for closure of the abdominal wall. No mortality, ventral herniation, or refistulization was registered in the study. The mean follow-up time was 8.5 months (range, 6-12 months). CONCLUSIONS: This is an easily reproducible and safe technique for effluent control in patients with Björk grade 4 abdomen with established EAF.

Ambulatory versus conventional laparoscopic appendectomy: a systematic review and meta-analysis.

PURPOSE: Ambulatory laparoscopic appendectomy has gained popularity due to the improved understanding of patient selection criteria, the application of enhanced recovery pathways, and the potential for improving healthcare resource utilization. The aim of the review was to compare the morbidity and readmission rates between ambulatory and conventional laparoscopic appendectomy (LA). METHODS: A systematic search was undertaken using PubMed, Embase, Cochrane, and Web of Science. Studies from 2014 to 2018, on adult patients undergoing ambulatory LA, were considered. Meta-analyses were conducted to pool the total number of complications and readmission events in the ambulatory and conventional groups. RESULTS: A total of 5 studies met our inclusion criteria accounting for 7079 total of patients with acute appendicitis treated by ambulatory LA and 6370 patients treated by conventional LA. We included four observational studies (two prospective and two retrospective) and one randomized controlled trial. Length of stay was significantly lower in the ambulatory group (mean difference = - 15.63 h, 95% CI = - 21.78 to - 9.49, P = < 0.00001). The relative risk (RR) of reoperation was 0.49 (95% CI = 0.12-1.95, P = 0.31). The results demonstrated a pooled RR of overall morbidity of 0.79 (95% CI = 0.65-0.97, P = 0.02) and a pooled RR of readmission of 0.72 (95% CI = 0.59-0.88, P = 0.002), both results favoring the ambulatory LA group. CONCLUSION: There is a lack of high-quality comparative studies making conclusive recommendations not possible at this time. Based on current data, ambulatory LA may be safe and feasible as compared with conventional LA.

Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial.

BACKGROUND: Previous observational studies have demonstrated the safety of discharging patients after laparoscopic appendectomy within the same day without hospitalization. The application of Enhanced Recovery After Surgery (ERAS) guidelines has resulted in shorter length of stay, fewer complications, and reduction in medical costs. The aim of this study was to investigate if ERAS protocol implementation in patients with acute uncomplicated appendicitis decreases the length of stay enough to allow for ambulatory laparoscopic appendectomy. METHODS: In this prospective, randomized controlled clinical trial, 108 patients were randomized into two groups: laparoscopic appendectomy with ERAS (LA-E) or laparoscopic appendectomy with conventional care (LA-C). The primary endpoint was postoperative length of stay. The secondary end points were time to resume diet, postoperative pain, postoperative complications, re-admission rate, and reoperation rate. RESULTS: From January 2016 through May 2017, 50 patients in the LA-E group and 58 in the LA-C were analyzed. There were no significant differences in preoperative data. Regarding the primary end point of the study, the ERAS protocol significantly reduced the postoperative length of stay with a mean of 9.7 h (SD: 3.1) versus 23.2 h (SD: 6.8) in the conventional group (p < 0.001). The ERAS protocol allowed ambulatory management in 90% of the patients included in this group. There was a significant reduction in time to resume diet (110 vs. 360 min, p < 0.001) and less moderate-severe postoperative pain (28 vs. 62.1%, p < 0.001) in the LA-E versus LA-C group. The rate of complications, readmissions, and reoperations were comparable in both groups (p = 0.772). CONCLUSIONS: ERAS implementation was associated with a significantly shorter length of stay, allowing for the ambulatory management of this group of patients. Ambulatory laparoscopic appendectomy is safe and feasible with similar rates of morbidity and readmissions compared with conventional care.

A New Era of Bile Duct Repair: Robotic-Assisted Versus Laparoscopic Hepaticojejunostomy.

BACKGROUND: Despite scientific evidence of the safety, efficacy, and in some cases superiority of minimally invasive surgery in hepato-pancreato-biliary procedures, there are scarce publications about bile duct repairs. The aim of this study was to compare the outcomes of robotic-assisted surgery versus laparoscopic surgery on bile duct repair in patients with post-cholecystectomy bile duct injury. METHODS: This is a retrospective comparative study of our prospectively collected database of patients with bile duct injury who underwent robotic or laparoscopic hepaticojejunostomy. RESULTS: Seventy-five bile duct repairs (40 by laparoscopic and 35 by robotic-assisted surgery) were treated from 2012 to 2018. Injury types were as follows: E1 (7.5% vs. 14.3%), E2 (22.5% vs. 14.3%), E3 (40% vs. 42.9%), E4 (22.5% vs. 28.6%), and E5 (7.5% vs. 0), for laparoscopic hepaticojejunostomy (LHJ) and robotic-assisted hepaticojejunostomy (RHJ) respectively. The overall morbidity rate was similar (LHJ 27.5% vs. RHJ 22.8%, P = 0.644), during an overall median follow-up of 28 (14-50) months. In the LHJ group, the actuarial primary patency rate was 92.5% during a median follow-up of 49 (43.2-56.8) months. While in the RHJ group, the actuarial primary patency rate was 100%, during a median follow-up of 16 (12-22) months. The overall primary patency rate was 96% (LHJ 92.5% vs. RHJ 100%, log-rank P = 0.617). CONCLUSION: Our results showed that the robotic approach is similar to the laparoscopic regarding safety and efficacy in attaining primary patency for bile duct repair.

Robotic-assisted Roux-en-Y hepaticojejunostomy after bile duct injury.

BACKGROUND: The Da Vinci Robotic Surgical System has positioned itself as a tool that improves the ergonomics of the surgeon, facilitating dissection in confined spaces and enhancing the surgeon's skills. The technical aspects for successful bile duct repair are well-vascularized ducts, tension-free anastomosis, and complete drainage of hepatic segments, and all are achievable with robotic-assisted approach. METHODS: This was a retrospective study of our prospectively collected database of patients with iatrogenic bile duct injury who underwent robotic-assisted Roux-en-Y hepaticojejunostomy. Pre-, intra-, and short-term postoperative data were analyzed. RESULTS: A total of 30 consecutive patients were included. The median age was 46.5 years and 76.7% were female. Neo-confluences with section of hepatic segment IV were performed in 7 patients (those classified as Strasberg E4). In the remaining 23, a Hepp-Couinaud anastomosis was built. There were no intraoperative complications, the median estimated blood loss was 100 mL, and the median operative time was 245 min. No conversion was needed. The median length of stay was 6 days and the median length of follow-up was 8 months. The overall morbidity rate was 23.3%. Two patients presented hepaticojejunostomy leak. No mortality was registered. CONCLUSION: Robotic surgery is feasible and can be safely performed, with acceptable short-term results, in bile duct injury repair providing the advantages of minimally invasive surgery. Further studies with larger number of cases and longer follow-up are needed to establish the role of robotic assisted approaches in the reconstruction of BDI.

Minimally invasive approach (robotic and laparoscopic) to biliary-enteric fistula secondary to cholecystectomy bile duct injury.

Spontaneous biliary-enteric fistula after laparoscopic cholecystectomy bile duct injury is an extremely rare entity. Y-en-Roux hepaticojejunostomy has been demonstrated to be an effective surgical technique to repair iatrogenic bile duct injuries. Seven consecutive patients underwent robotic-assisted (n = 5) and laparoscopic (n = 2) biliary-enteric fistula resection and bile duct repair at our hospital from January 2012 to May 2017. We reported our technique and described post-procedural outcomes. The mean age was 52.4 years, mostly females (n = 5). The mean operative time was 240 min for laparoscopic cases and 322 min for robotic surgery, and the mean estimated blood loss was 300 mL for laparoscopic and 204 mL for robotic cases. In both groups, oral feeding was resumed between day 2 or 3 and hospital length of stay was 4-8 days. Immediate postoperative outcomes were uneventful in all patients. With a median of 9 months of follow-up (3-52 months), no patients developed anastomosis-related complications. We observed in this series an adequate identification and dissection of the fistulous biliary-enteric tract, a safe closure of the fistulous orifice in the gastrointestinal tract and a successful bile duct repair, providing the benefits of minimally invasive surgery.

Intraoperative endoscopy prevents technical defect related leaks in laparoscopic Roux-en-Y gastric bypass: A randomized control trial.

BACKGROUND: Postoperative anastomotic leaks, bleeding and stenosis are major causes of morbidity after laparoscopic Roux-en-Y gastric bypass (LRYGB). Retrospective studies suggest that intraoperative endoscopy reduces the incidence of these complications. METHODS: We conducted a prospective randomized controlled trial in a single institution between March 2013 and January 2016. Patients were assigned to one of two groups: LRYGB with Intraoperative Endoscopy (IOE) or LRYGB without IOE. Patient selection criteria were morbidly obese patients, 18 years or older who were candidates to LRYGB. The primary outcome was the frequency of technical defect related anastomotic leaks. Secondary outcomes were operative time, length of hospital stay, anastomotic related complications, reoperations and 30-day mortality. RESULTS: 50 patients were randomly assigned in the IOE group and 50 in the control group. The IOE group had statistically significant lower rate of anastomotic leak (0 vs. 8%, p = .0412), and lower need for reoperation (0 vs. 8%, p = .0412). The IOE group had longer operative time (194.10 vs. 159 min, p < .001), and shorter mean length of hospital stay (2.44 vs. 3.46 days, p = .025). No differences were found in the rate of bleeding of the anastomosis, narrow anastomosis and 30-day mortality. CONCLUSION: This study specifically provides evidence that air leak test performed by intraoperative endoscopy is superior to simple visual inspection in preventing technical defect related leaks after laparoscopic Roux-en-Y gastric bypass.

Adipocyte Size and Leptin Receptor Expression in Human Subcutaneous Adipose Tissue After Roux-en-Y Gastric Bypass.

The molecular mechanisms implicated in pronounced weight loss and metabolic benefits after bariatric surgery are still unknown. Adipocyte phenotype and metabolism have not been entirely explored. However, some features of adipocyte function have been studied, such as adipocyte size and inflammation, which are both reduced after bariatric surgery. Adipocyte fat metabolism, which is partly regulated by leptin, is likely modified, since adipocyte area is decreased. Here, we show that leptin receptor expression is increased, while adipocyte size is decreased 8 months after Roux-en-Y gastric bypass. Thus, adipocyte function is possibly modified by improved leptin signaling after bariatric surgery.

Colédoco-duodeno anastomosis laparoscópica / Laparoscopic Choledochoduodenostomy

Introducción: Las opciones actuales para realizar procedimientos permanentes de derivación biliodigestiva, secundarios a coledocolitiasis compleja, van desde la cirugía abierta hasta el empleo de procedimientos híbridos laparoendoscópicos. El objetivo del estudio fue realizar un análisis de los resultados obtenidos en pacientes con coledocolitiasis compleja tratados con colédoco-duodeno anastomosis laparoscópica. Métodos: Se realizó un estudio observacional longitudinal en el período comprendido de marzo de 2011 a junio de 2016. Se incluyeron pacientes con coledocolitiasis compleja no resuelta por CPRE o resueltas por CPRE pero con dilatación masiva de vía biliar y evidencia de colestasis persistente, los cuales fueron seleccionados para procedimiento quirúrgico con colédoco-duodeno anastomosis. Resultados: Se incluyeron un total de 19 pacientes. La mayoría mujeres (78,9%), con edad media avanzada (72,4 ± 12 años) y con múltiples comorbilidades. Todos con al menos un episodio (mín-máx: 1-7) de coledocolitiasis o colangitis previos. El diámetro del colédoco fue de 24,9 ± 7mm. El tiempo quirúrgico fue de 218,5 ± 74 min, sangrado de 150 (30-600) mL, inicio de dieta en 3,2 ± 1 días y estancia hospitalaria postoperatoria de 4,9 ± 2 días. Se encontró una mediana de 18 (12-32) meses de seguimiento. Posterior al procedimiento se observó normalización de las pruebas de funcionamiento hepático. Un paciente presentó síndrome del sumidero y un paciente falleció por neumonía nosocomial. Conclusiones: La colédoco-duodeno anastomosis laparoscópica asistida con coledocoscopia representa una técnica segura y eficaz para el tratamiento de pacientes con coledocolitiasis compleja con indicación de derivación biliodigestiva, ofreciendo los beneficios de la cirugía de mínima invasión (AU)

Introduction: Today's options for biliary bypass procedures, for difficult choledocholithiasis, range from open surgery to laparo-endoscopic hybrid procedures. The aim of this study was to analyze the outcomes of patients with difficult choledocholithiasis treated with laparoscopic choledochoduodenostomy. Methods: We performed a prospective observational study from March 2011 to June 2016. We included patients with difficult common bile duct stones (recurrent or unresolved by ERCP) in which a biliary bypass procedure was required. We performed a laparoscopic bile duct exploration with choledochoduodenostomy and intraoperative cholangioscopy. Results: A total of 19 patients were included. We found female predominance (78.9%), advanced mean age (72.4 ± 12 years) and multiple comorbidities. Most patients with previous episodes of choledocholitiasis or cholangitis, mode 1 (min-max: 1-7). Mean common bile duct diameter 24.9 ± 7mm. Mean operative time 218.5 ± 74min, estimated blood loss 150 (30-600) mL, resume of oral intake 3.2±1 days, postoperative length of stay 4.9 ± 2 days. We found a median of 18 (12-32) months of follow-up. All patients with normalization of liver enzymes during follow-up. One patient presented with sump syndrome and one patient died due to nosocomial pneumonia. Conclusions: Laparoscopic choledochoduodenostomy with intraoperative cholangioscopy seems to be safe and effective treatment for patients with difficult common bile duct stones no resolved by endoscopic procedures. This procedure is a good option for patients with advanced age and multiple comorbidities. We offer all the advantages of minimally invasive surgery to these patients (AU)

Laparoscopic Choledochoduodenostomy. / Colédoco-duodeno anastomosis laparoscópica.

INTRODUCTION: Today's options for biliary bypass procedures, for difficult choledocholithiasis, range from open surgery to laparo-endoscopic hybrid procedures. The aim of this study was to analyze the outcomes of patients with difficult choledocholithiasis treated with laparoscopic choledochoduodenostomy. METHODS: We performed a prospective observational study from March 2011 to June 2016. We included patients with difficult common bile duct stones (recurrent or unresolved by ERCP) in which a biliary bypass procedure was required. We performed a laparoscopic bile duct exploration with choledochoduodenostomy and intraoperative cholangioscopy. RESULTS: A total of 19 patients were included. We found female predominance (78.9%), advanced mean age (72.4±12 years) and multiple comorbidities. Most patients with previous episodes of choledocholitiasis or cholangitis, mode 1 (min-max: 1-7). Mean common bile duct diameter 24.9±7mm. Mean operative time 218.5±74min, estimated blood loss 150 (30-600)mL, resume of oral intake 3.2±1 days, postoperative length of stay 4.9±2 days. We found a median of 18 (12-32) months of follow-up. All patients with normalization of liver enzymes during follow-up. One patient presented with sump syndrome and one patient died due to nosocomial pneumonia. CONCLUSIONS: Laparoscopic choledochoduodenostomy with intraoperative cholangioscopy seems to be safe and effective treatment for patients with difficult common bile duct stones no resolved by endoscopic procedures. This procedure is a good option for patients with advanced age and multiple comorbidities. We offer all the advantages of minimally invasive surgery to these patients.

Laparoscopic Versus Open Surgery for Abdominal Trauma: A Case-Matched Study.

BACKGROUND: The use of laparoscopic surgery in abdominal emergencies, such as in trauma, has had a slow acceptance. The advantages described with this approach include less postoperative pain, faster recovery, quicker return to everyday activities, and fewer wound complications. The aim of this retrospective study was to compare outcomes following laparoscopic versus open surgery for abdominal trauma (either blunt or penetrating). MATERIALS AND METHODS: Nineteen patients with abdominal trauma who underwent laparoscopic surgery from January 2013 to May 2016 were compared with 19 patients undergoing open surgery during the same time period. Patients were matched (1:1) for age, gender, body-mass index, American Society of Anesthesiologists score, hemodynamic stability, and injury mechanism. Intra- and postoperative variables were compared between groups. RESULTS: Laparoscopic group displayed a significantly shorter operative time (93.3 versus 134.2 minutes; P < .009), lower estimated blood loss (100 versus 600 mL; P < .019), faster return to normal diet (1.6 versus 2.4 days; P < .039), and shorter hospital length of stay (LOS) (3.8 versus. 5.6 days; P < .042). There were no statistical significant differences in 30-day mortality between both groups. CONCLUSIONS: Laparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. We found in our study that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss, faster return to normal diet, and shorter hospital LOS.

[Skills comparison using a 2D vs. 3D laparoscopic simulator]. / Comparación de destrezas en simulador de laparoscopia: imagen en 2D vs. 3D.

BACKGROUND: The development and application of 3D images in laparoscopic surgery has brought the benefit of in-depth perception that traditional laparoscopic surgery lacked. Previous studies in surgical populations have demonstrated the advantages of 3D technology. To limit bias of the previous experiences of participants, this study was performed in a population without any experience in this area. MATERIAL AND METHODS: An experimental, open, cross-sectional, comparative study between surgical skills achievements using 2D and a 3D laparoscopy equipment, using each subject as their own control. Six skills were evaluated in 2D and 3D modalities. RESULTS: Of the 40 participants included, 20 began the skills in the 2D modality and then performed them in 3D, and the other 20 began in 3D. Of the 118 skills evaluated there was a time improvement in 72% in the 3D group compared to 37% in the 2D modality (P=.000). The accomplishment percentage using the 3D laparoscopy was greater for both groups. There was a statistically significant difference in the better time for the 3D performed tasks. Just over half (52.5%) of participants preferred 3D laparoscopy, 15% preferred 2D, and 32.5% had no preferences. DISCUSSION: As other studies have demonstrated, there was improvement in the overall performance using the 3D laparoscope. Bias was limited by using a population without surgical experience. CONCLUSIONS: 3D laparoscopic surgical skills showed superior to 2D, with higher percentages of tasks completion, less time in performing them, and a shorter learning curve.

Laparoscopic hepaticojejunostomy after bile duct injury.

BACKGROUND: The incidence of bile duct injuries (BDI) after cholecystectomy, which is a life-threatening condition that has several medical and legal implications, currently stands at about 0.6%. The aim of this study is to describe our experience as the first center to use a laparoscopic approach for BDI repair. METHODS: A prospective study between June 2012 and September 2014 was developed. Twenty-nine consecutive patients with BDI secondary to cholecystectomy were included. Demographics, comorbidities, presenting symptoms, details of index surgery, type of lesion, preoperative and postoperative diagnostic work-up, and therapeutic interventions were registered. Videos and details of laparoscopic hepaticojejunostomy (LHJ) were recorded. Injuries were staged using Strasberg classification. A side-to-side anastomosis with Roux-en-Y reconstruction was always used. In patients with E4 and some E3 injuries, a segment 4b or 5 section was done to build a wide anastomosis. In E4 injuries, a neo-confluence was performed. Complications, mortality, and long-term evolution were recorded. RESULTS: Twenty-nine patients with BDI were operated. Women represented 82.7% of the cases. The median age was 42 years (range 21-74). Injuries at or above the confluence occurred in 62%, and primary repair at our institution was performed at 93.1% of the cases. Eight neo-confluences were performed in all E4 injuries (27.5%). The median operative time was 240 min (range 120-585) and bleeding 200 mL (range 50-1100). Oral intake was started in the first 48 h. Bile leak occurred in 5 cases (17.2%). Two patients required re-intervention (6.8%). No mortality was recorded. The maximum follow-up was 36 months (range 2-36). One patient with E4 injury developed a hepaticojejunostomy (HJ) stenosis after 15 months. This was solved with endoscopic dilatation. CONCLUSIONS: The benefits of minimally invasive approaches in BDI seem to be feasible and safe, even when this is a complex and catastrophic scenario.