Inguinal hernia repair in Spain. A population-based study of 263,283 patients: factors associated with the choice of laparoscopic approach.

PURPOSE: The objective of this study is to evaluate the laparoscopic inguinal hernia repair (IHR) rate in Spain and identify the factors associated with the choice of this surgical approach. METHODS: A retrospective cohort study of 263,283 patients who underwent IHR from January 2016 to December 2018 was conducted. Data were extracted from the Spanish Minimum Basic Data Set (MBDS) of the Health Ministry database. The primary outcome was laparoscopic (LAP) rate utilization. Univariate analysis and multivariable logistic regression analysis were performed to identify factors associated with LAP-IHR. RESULTS: Only 5.7% (15,059) patients underwent LAP-IHR, whereas the remnant 94.3% (248,224 patients) underwent open repair. High variability in the LAP-IHR rate across the country was observed; ranged between provinces from 0 to 19.7%, for a unilateral hernia, and between 0 to 57.4% in the case of bilateral hernias. On multivariate logistic regression analysis, the patient place of residence was the most remarkable factor associated with the likelihood of receiving LAP-IHR (OR 4.96; p < 0.001). There were also significant differences favoring LAP-IHR for bilateral operation (OR 4.596; p < 0.001), insurance coverage (OR 4.439, p < 0.001) and self-pay patients (OR 2.317; p < 0.001), as well as a recurrent hernia (OR 1.780; p < 0.001), age younger than 65 years (OR 1.555; p < 0.001) and male sex (OR 1.162, p < 0.001). CONCLUSION: LAP-IHR remains a not frequent choice among surgeons in Spain, even when dealing with recurrent and bilateral hernias. The results suggest that the choice of LAP-IHR could depend on the surgeon's preference rather than on the indication appropriateness.

Long-term incisional hernia rate after single-incision laparoscopic cholecystectomy is significantly higher than that after standard three-port laparoscopy: a cohort study.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) is a feasible technique that provides comparable results to standard laparoscopic cholecystectomy (LC). However, despite the theoretical advantages of minor wound complications and cosmetic results, SILC usually requires a larger incision, which may increase the incidence of incisional hernias. This study evaluated SILC and standard multiport cholecystectomy with respect to perioperative outcomes, hospital stay, cosmetic results, and postoperative complications, including the 5-year incisional hernia rate. METHODS: A cohort study was performed with patients who underwent elective laparoscopic surgery for noncomplicated cholelithiasis at our hospital between July 2009 and June 2011. During the study period, there were 45 nonselected patients who underwent SILC, and these patients were compared with a control group of 140 patients who underwent LC using the standard three-trocar technique during the same period. Both patient groups were comparable in age, gender, BMI and ASA classification. RESULTS: The mean follow-up was 58.7 ± 10.9 (range 3-80) months. There were no differences between groups in terms of hospital stay, rate and severity of complications, wound infection, and patient cosmetic satisfaction. However, the operating time (57.8 versus 35.2 min) and long-term incisional hernia rate (13.3% versus 4.7%) were significantly higher in the SILC group. CONCLUSION: SILC is associated with a statistically significantly higher long-term incisional hernia rate at the umbilical port site than the standard multiport laparoscopic cholecystectomy. Our data show there was no relevant advantage regarding the postoperative course, hospital stay or cosmetic satisfaction. To date, widespread use of SILC cannot be recommended. Registration number: NCT03768661 (https://www.clinicaltrials.gov). TRIAL REGISTRATION: This study has been registered at www.clinicaltrials.gov. The clinicaltrials.gov ID number is: NCT03768661.

Long-term follow-up (at 5 years) of midline incisional hernia repairs using a primary closure and prosthetic onlay technique: recurrence and quality of life.

INTRODUCTION AND OBJECTIVES: The recurrence rate of incisional hernia (IH) repair is usually underestimated due to a lack of long-term follow-up. The objective of this study was to evaluate recurrence rate for patients operated on midline IH surgery, using a primary closure and prosthetic onlay technique, 5 years after the procedure. MATERIALS AND METHODS: From January 2009 to January 2011, all 92 patients operated on elective midline IH repair by primary closure and prosthetic onlay technique in a General Surgery Department were retrospectively included in the study. Exclusion criteria were absence of follow-up or death. Recurrence rate and quality of life were assessed. Demographic, surgical data and quality of life in patients with and without 5-year recurrence were compared. RESULTS: Mean follow-up was 64 months. Ultimately, 76 patients were included in the study, representing 82% of the selected patients during the study period (76/92), of whom 24 presented a recurrence (32%). Half (12) were diagnosed for recurrence more than 3 years after the surgery. Patients who developed a recurrence had more percentage of obesity (64 vs. 29%, p = 0.016), which denoted an odds ratio (OR) for recurrence of 4.4 (1.2-15.7; p = 0.01) and they punctuated lower in quality of life (6.0 ± 2.9 vs. 7.6 ± 2.6, p = 0.006). CONCLUSIONS: Recurrence rate on midline IH repair is still a concern (32% at 5 years). It is advisable to look for other strategies and more efficient surgical techniques for IH surgery, especially in obese patients.

Randomized clinical trial of mesh fixation with glue or sutures for Lichtenstein hernia repair.

BACKGROUND: Pain is the most likely reason for delay in resuming normal activities after groin hernia repair. The primary aim of this study was to determine whether the use of glue to fix the mesh instead of sutures reduced acute postoperative pain after inguinal hernia repair. Secondary objectives were to compare postoperative complications, chronic pain and early recurrence rates during 1-year follow-up. METHODS: Some 370 patients who underwent Lichtenstein hernia repair were randomized to receive either glue (Histoacryl®) or non-absorbable polypropylene sutures for fixation of lightweight polypropylene mesh. Postoperative complications, pain and recurrence were evaluated by an independent blinded observer. RESULTS: Postoperative pain at 8 h, 24 h, 7 days and 30 days was less when glue was used instead of sutures for all measures (P < 0·001). The operation was significantly quicker using glue (mean(s.d.) 35·3(8·7) min versus 39·9(11·1) min for sutures; P < 0·001). There were no significant differences between the groups in terms of postoperative complications, chronic pain and early recurrence at 1-year follow-up. CONCLUSION: Atraumatic mesh fixation with glue was quicker and resulted in less acute postoperative pain than sutures for Lichtenstein hernia repair. Registration number: NCT02632097 (http://www.clinicaltrials.gov).

Oro-facial evaluation of women with rheumatoid arthritis.

Rheumatoid arthritis (RA) is an aggressive articular autoimmune disease that causes deformities and disability. The temporomandibular joint (TMJ) might be affected by this disease. Few controlled studies have evaluated bite force (BF) and oro-facial manifestations of this disease. To characterise oro-facial alterations in patients with RA, correlate these results with clinical and disease activity parameters and correlate BF with hand strength (HS). A cross-sectional study of 150 women was performed, (75 RA patients (RA group) and 75 healthy individuals (control group). The presence of articular sounds, pain on palpation of masseter, temporal and TMJ lateral pole, changes in occlusion, range of mandibular motion, measurement of BF in the incisor and molar regions and assessment of HS were evaluated. In relation to oro-facial evaluation there were statistical differences between the groups. There was correlation between BF and HS, in the RA group, this correlation was consistent in patients with natural teeth. Patients with RA had lower scores (P < 0·05) in the HAQ, DASH and OHIP-14 questionnaires than the control group. Inverse correlations were found between BF and HAQ, but not between BF and DAS-28, DASH and OHIP-14 questionnaires in the RA group. The women with RA presented more signs and symptoms in the oro-facial region and had a lower BF than the women in the control group. BF was inversely correlated with the overall function (evaluated by the HAQ) in the patients with RA, and there were correlations between BF and HS in the RA patients and in the control group.

Tratamiento combinado endoscópico-laparoscópico de la coledocolitiasis / Treatment of choledocolithiasis combined endoscopic and laparoscopic

Objetivo. Evaluar los resultados de la colangiopancreatografía retrógrada endoscópica (CPRE), esfinterotomía endoscópica y colecistectomía por laparoscopia en el diagnóstico y tratamiento de la coledocolitiasis. Pacientes y métodos. Entre junio de 1991 y diciembre de 1998, se han estudiado de forma prospectiva 1.667 pacientes sometidos a cirugía laparoscópica. Se observaron criterios clínicos, analíticos o ecográficos de sospecha de coledocolitiasis asociada en 394 pacientes (23 por ciento) y fueron estudiados mediante CPRE preoperatoria. En caso de diagnóstico de coledocolitiasis se practicó esfinterotomía y se intentó su extracción endoscópica. Posteriormente, fueron sometidos a colecistectomía laparoscópica, excepto 25 pacientes, que fueron excluidos. Resultados. El rendimiento diagnóstico fue, para la coledocolitiasis de un 57,7 por ciento (213 pacientes), para la vía biliar dilatada sin litiasis de un 10,5 por ciento (39 pacientes) y para la exploración normal de un 28,7 por ciento (106 pacientes). Se produjo fracaso por imposibilidad de evaluación de la vía biliar principal en el 2,9 por ciento (11 pacientes). Mediante la CPRE se consiguió un tratamiento satisfactorio en el 93,4 por ciento (199/213 pacientes) y fracasó en 14 pacientes (6,6 por ciento). La tasa de complicaciones relacionadas con la CPRE fue de 7,8 por ciento y con la colecistectomía laparoscópica del 10 por ciento. La mortalidad de la serie para la totalidad del procedimiento diagnóstico-terapéutico fue del 0,5 por ciento (2 pacientes). Once pacientes (5 por ciento) presentaron coledocolitiasis residual tras CPRE-colecistectomía laparoscópica tratada con éxito en todos ellos mediante una nueva CPRE. Conclusiones. El abordaje combinado en dos tiempos de la coledocolitiasis utilizando CPRE selectiva, seguida de colecistectomía laparoscópica, es una buena alternativa terapéutica. No obstante, los criterios de sospecha de coledocolitiasis empleados clásicamente implican un considerable número de exploraciones con probabilidad innecesarias, y por tanto, parece necesario modificar la estrategia diagnóstica actual (AU)

Estadificación laparoscópica del cáncer digestivo / Laparoscopic staging of gastrointestinal cancer

Introducción. Establecer el estadio de los tumores digestivos es de gran importancia a la hora de plantear su tratamiento. La estadificación laparoscópica y la ecografía por laparoscopia, como método para explorar la cavidad abdominal, se han introducido de forma progresiva en los algoritmos diagnóstico-terapéuticos de estos pacientes. Resultados. En la experiencia de los autores, la estadificación laparoscópica en el cáncer gástrico evita la laparotomía innecesaria en el 40 por ciento de los casos, con una exactitud en la resecabilidad tumoral del 98 por ciento. En el cáncer de cardias y esófago, así como en el cáncer colorrectal, ofrece importante información en cuanto a la existencia de diseminación a distancia o metástasis hepáticas, especialmente con la ayuda de la ecografía por laparoscopia. En cirugía hepatobiliopancreática es donde se manifiesta especialmente la utilidad de la ecografía por laparoscopia, permitiendo modificar el estadio tumoral establecido preoperatoriamente y evitar un 25 por ciento de laparotomías en tumores hepáticos. En el cáncer de páncreas, la estadificación y ecografía por laparoscopia modifica la actitud inicial en el 35 por ciento de los casos y evita una laparotomía innecesaria en el 20 por ciento. Conclusión. La estadificación laparoscópica es de gran utilidad para establecer el estadio intraoperatorio de los tumores digestivos y puede ayudar a la hora de tomar decisiones intraoperatorias. En el caso de los tumores hepatobiliopancreáticos, la información adicional ofrecida por la ecografía laparoscópica permite disminuir la incidencia de laparotomías innecesarias y debe plantearse como paso previo a la cirugía (AU)

Opciones actuales para el diagnóstico y tratamiento de la coledocolitiasis / Existing options for the diagnosis and treatment of choledocholitiasis

La colangiografía retrógrada endoscópica y la cirugía mínimamente invasiva han modificado el protocolo clásico de tratamiento de la litiasis de la vía biliar principal. En la actualidad, existen diferentes estrategias diagnósticas y terapéuticas para abordar la coledocolitiasis, en un intento de que los pacientes con esta afección se beneficien también de un abordaje mínimamente invasivo. Sin embargo, no existe consenso respecto a cuál es el algoritmo de diagnóstico y tratamiento de la litiasis de la vía biliar principal que pueda considerarse el patrón oro o gold standard, y el manejo de esta enfermedad depende hoy día de la experiencia y las posibilidades de disponibilidad tecnológica de cada grupo de trabajo. El objetivo de este artículo es revisar las diferentes opciones técnicas de las que se dispone en la actualidad para el diagnóstico y tratamiento de la coledocolitiasis, describiendo sus resultados, ventajas e inconvenientes (AU)

Treatment options for villous adenoma of the ampulla of Vater.

INTRODUCTION: Duodenal villous adenoma arising from the ampulla of Vater has a high risk of malignant development. Excluding associated malignant disease prior to resection of an adenoma of the ampulla is not always possible. Therefore, the surgical procedure of choice to treat this rare tumour is still controversial. OBJECTIVE: To evaluate retrospectively results of treatment of villous adenoma arising from ampulla of Vater with dysplasia or associated carcinoma limited to the ampulla. PATIENTS AND METHODS: From 1985 to 1996, eight patients have been diagnosed with ampullary villous adenoma suitable for resection. We have reviewed treatment, morbidity, mortality, follow-up and final outcome. RESULTS: Pancreatoduodenectomy (PD) was performed in 4 patients. Transduodenal ampullectomy and endoscopic resection was performed in 2 patients each. There was no perioperative mortality. None of the patients had biliary, pancreatic or intestinal leakage but two patients who underwent PD had minor postoperative complications. The mean follow-up was 44 (range: 6-132) months. Villous adenoma was associated with adenocarcinoma in 50% of the cases (4/8 patients). During the follow-up both patients who underwent transduodenal ampullectomy developed recurrent disease. All patients initially treated by PD are alive without evidence of recurrent disease. CONCLUSIONS: Treatment of villous adenoma of the ampulla must be individualized within certain limits. In our series, PD achieve good results and it appears to be the procedure of choice in order to treat villous adenomas with proved presence of carcinoma, carcinoma in situ or severe dysplasia. Endoscopic or local resection may be appropriate for small benign tumours in high risk patients.

Must ERCP Be routinely performed if choledocholithiasis is suspected?

OBJECTIVE: To evaluate the results of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of those patients suspected of harboring bile duct stones before laparoscopic cholecystectomy (LC). PATIENTS AND METHODS: A total of 1,235 consecutive LCs performed between 1991 and 1997 were studied prospectively. ERCP was performed to explore the common bile duct (CBD) preoperatively when choledocholithiasis was suspected on the basis of clinical, analytical or echographical data. RESULTS: ERCPs were performed in 268 patients: unsuccessful CBD evaluation in 3%; dilated CBD without lithiasis in 13%, and normal exploration in 37% (99 patients). CBD stones were found in 46% (124 patients), and endoscopic sphincterotomy was then performed and stone extraction attempted. Endoscopic therapy achieved 92.8% successful removal of CBD stones (115 patients). There was no ERCP-related mortality and the morbidity rate was 6%. Retained CBD stones have been observed in 7 cases after ERCP-LC; all of them have been successfully treated by ERCP. CONCLUSIONS: A combined approach to bile duct stones with selective use of ERCP followed by LC is a good therapeutical alternative. Nevertheless, the usual selection criteria for ERCP may lead to unnecessary exploration. It appears to be necessary to modify the current diagnostic and therapeutic strategy.

[Survival after resection of lung metastasis from colorectal cancer]. / Supervivencia tras resección de metástasis pulmonares de cáncer colorrectal.

OBJECTIVE: To analyze the results of resection of lung metastases from colorectal adenocarcinoma in selected patients, evaluating type of resection, morbidity and mortality associated with the procedure, and overall actuarial survival rates after surgery. PATIENTS AND METHODS: Between 1988 and 1996, 811 patients were treated surgically for colorectal adenocarcinoma. Recurrent chronic lung metastases were resected, presumably with the intention to cure, in 15 patients in the series. One patient underwent surgery for pelvic recurrence and another seven for liver metastases, before resection of the lung metastases. RESULTS: Twenty-seven wedge resections were performed, two being non-malignant and one patient requiring re-resection of new lung metastases. Unsuspected locations of lung metastasis were found in three patients during surgery. Perioperative mortality was zero. Mean follow-up was 50 months (range 28 to 99). Seven patients presented new occurrences of metastasis or tumor recurrence and died as a result. The actuarial survival rate was 48% at 5 years. CONCLUSIONS: In selected patients, surgical resection of lung metastasis from colorectal cancer, with the assumed intention of cure, has yielded a good survival rate and zero perioperative mortality. It appears advisable to use an approach that permits exhaustive palpation of the pulmonary parenchyma, due to the risk of finding unsuspected metastases.

Laparoscopic ultrasound guidance for laparoscopic resection of benign gastric tumors.

Laparoscopic excision of gastric leiomyoma is technically feasible and safe, but it may fail to localize the exact placement of the lesion because of the lack of tactile sensitivity. The authors present two cases of small gastric leiomyomas that were resected by a totally laparoscopic approach, assisted with intraoperative laparoscopic ultrasonography because the lesions could not be palpated. A gastric wedge resection with tumor-free margins was performed with an endostapler device. Use of a harmonic scalpel to divide the gastroepiploic vessels facilitated the laparoscopic procedure.

How, when, and why bile duct injury occurs. A comparison between open and laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury (BDI) is a severe complication of laparoscopic cholecystectomy (LC). There is general agreement about the increase of this complication after LC vs open cholecystectomy (OC), but comparative studies are scarce. The aim of this paper has been to compare the incidence and clinical features of BDI after LC vs open procedures. MATERIALS AND METHODS: 3,051 OC, performed from June 1977 to December 1988 were retrospectively analyzed and compared with 1,630 LCs performed from June 91 to August 96, for which data were prospectively recorded. Age, sex, type of BDI, performance of intraoperative cholangiography (IOC), underlying biliary pathology, morbidity, mortality, and late morbidity were all analyzed. RESULTS: BDI incidence was higher in group II (LC) (N: 16, 0.95%) than in group I, (OC, N: 19. 0.6%). BDI incidence was also higher in the group of patients in which it was necessary to convert to an open procedure (3/109, 2.7%, p < 0.05). BDIs were more frequently diagnosed intraoperatively in group I (OC, 18/19) than in group II (LC, 12/16). In both groups, BDI was more prevalent in cases operated by staff surgeons than residents, mainly in complicated gallbladder patients, with a bile duct of less than 7-mm diameter. Morbidity, postoperative stay, mortality, and late morbidity were similar after a BDI in both types of approach. CONCLUSIONS: (1) BDI increases with LC. (2) BDI after LC carries a similar postoperative morbidity and mortality to those after OC. (3) Incidence of BDI in converted cases increases significantly and this constitutes a high-risk group.

[Malignant rhabdoid tumor of the kidney in the adult]. / Tumor rabdoide maligno de riñón en el adulto.

Presentation of a malignant rhabdoid renal tumour. This type of sarcoma which occurs commonly during the paediatric age is exceptional in the adult, this being the reason for reviewing this clinical case and its management. The term rhabdoid includes several types of morphologically similar tumours which make analysis and pathological categorization difficult. A description of the classification criteria and likely origin of the tumour is included.