Determining the need for a thoracoscopic approach to treat a giant hiatal hernia when abdominal access is poor.

BACKGROUND: Giant hernias present a significant challenge for digestive surgeons. The approach taken (laparoscopic vs thoracoscopic) depends largely on the preferences and skills of each surgeon, although in most cases today the laparoscopic approach is preferred. AIM: To determine whether patients presenting inadequate laparoscopic access to the intrathoracic hernial sac obtain poorer postoperative results than those with no such problem, in order to assess the need for a thoracoscopic approach. METHODS: For the retrospective series of patients treated in our hospital for hiatal hernia (n = 112), we calculated the laparoscopic field of view and the working area accessible to surgical instruments, by means of preoperative imaging tests, to assess the likely outcome for cases inaccessible to laparoscopy. RESULTS: Patients with giant hiatal hernias for whom a preoperative calculation suggested that the laparoscopic route would not access all areas of the intrathoracic sac presented higher rates of perioperative complications and recurrence during follow-up than those for whom laparoscopy was unimpeded. The difference was statistically significant. Moreover, the insertion of mesh did not improve results for the non-accessible group. CONCLUSION: For patients with giant hiatal hernias, it is essential to conduct a preoperative evaluation of the angle of vision and the working area for surgery. When parts of the intrathoracic sac are inaccessible laparoscopically, the thoracoscopic approach should be considered.

A New, Conservative Treatment for Perianal Fistula that May Halve the Need for Surgical Intervention: Case Series.

PURPOSE: In the last two decades, many sphincter preservation techniques have been proposed for the treatment of anal fistula. Since 2011, our surgical team has treated fistulas by sealing them with platelet-rich fibrin (PRF). This is performed actually as an outpatient process, without anaesthesia. METHODS: Patients were treated with PRF sealant, during the period June 2012-March 2017. The fibrin preparation is applied in the fistulous tract, with no need for any type of anaesthesia, and so the patient can go home immediately afterwards, without further observation. RESULTS: After an average follow-up of 26.49 months, the perianal fistula had healed completely in 52.86% of the patients (n = 37), who each received an average of 1.92 sealant operations. In another 10 cases, the sealing was initially successful, but a relapse occurred during the follow-up period. CONCLUSION: The outpatient treatment of perianal fistula with PRF is totally harmless, is very low cost and achieves very acceptable results. In our opinion, therefore, this could be considered an appropriate initial treatment for perianal fistula, with surgical treatment being reserved if this approach is unsuccessful, thereby avoiding many complications and producing significant economic savings for the health system.

Novel suturing technique, based on physical principles, achieves a breaking point double that obtained by conventional techniques.

BACKGROUND: Sutures have been used to repair wounds since ancient times. However, the basic suture technique has not significantly changed. In Phase I of our project, we proposed a "double diabolo" suture design, using a theoretical physical study to show that this suture receives 50% less tension than conventional sutures, and so a correspondingly greater force must be applied to break it. AIM: To determine whether these theoretical levels of resistance were met by the new type of suture. METHODS: An observational study was performed to compare three types of sutures, using a device that exerted force on the suture until the breaking point was reached. The tension produced by this traction was measured. The following variables were considered: Tearing stress on entry/exit points, edge separation stress, and suture break stress. The study sample consisted of 30 sutures with simple interrupted stitches (Group 1), 30 with continuous stitches (Group 2), and 30 with the "double diabolo" design (Group 3). RESULTS: The mean degree of force required to reach the breaking point for each of these variables (tearing, separation, and final breaking) was highest in Group 3 (14.56, 18.28, and 21.39 kg), followed by Group 1 (7.36, 10.38, and 12.81 kg) and Group 2 (5.77, 7.7, and 8.71 kg). These differences were statistically significant (P < 0.001) in all cases. CONCLUSION: The experimental results show that with the "double diabolo" suture, compared with conventional sutures, greater force must be applied to reach the breaking point (almost twice as much as in the simple interrupted suture and more than double that required for the continuous suture). If these results are confirmed in Phase III (the clinical phase) of our study, we believe the double diabolo technique should be adopted as the standard approach, especially when the suture must withstand significant tension (e.g., laparotomy closure, thoracotomy closure, diaphragm suture, or hernial orifice closure).

Review of incomplete macroscopic resections (R2) in rectal cancer: Treatment, prognosis and future perspectives.

Colorectal cancer is one of the most prevalent tumours, but with improved treatment and early detection, its prognosis has greatly improved in recent years. However, when the tumour is locally advanced at diagnosis or if there is local recurrence, it is more difficult to perform a complete tumour resection, and there may be a residual macroscopic tumour. In this paper, we review the literature on residual macroscopic tumour resections, concerning both locally advanced primary tumours and recurrences, evaluating the main problems encountered, the treatments applied, the prognosis and future perspectives in this field.

Preoperative calculation of angles of vision and working area in laparoscopic surgery to treat a giant hiatal hernia.

BACKGROUND: Giant hiatal hernias still pose a major challenge to digestive surgeons, and their repair is sometimes a highly complex task. This is usually performed by laparoscopy, while the role of the thoracoscopic approach has yet to be clearly defined. AIM: To preoperatively detect patients with a giant hiatal hernia in whom it would not be safe to perform laparoscopic surgery and who, therefore, would be candidates for a thoracoscopic approach. METHODS: In the present study, using imaging test we preoperatively simulate the field of vision of the camera and the working area (instrumental access) that can be obtained in each patient when the laparoscopic approach is used. RESULTS: From data obtained, we can calculate the access angles that will be obtained in a preoperative computerised axial tomography coronal section, according to the location of the trocar. We also provide the formula for performing the angle calculations If the trocars are placed in loss common situations, thus enabling us to determine the visibility and manoeuvrability for any position of the trocars. CONCLUSION: The working area determines the cases in which we can operate safely and those in which certain areas of the hernia cannot be accessed, which is when the thoracoscopic approach would be safer.

3D-Printed Surgical Steel Curettes for the Treatment of Perianal Fistula.

Need. The diversity of approaches proposed for the treatment of complex perianal fistulas reflects the fact that no method has yet been shown to be fully satisfactory. We believe the successful treatment of this condition is directly proportional to the amount of fibrous tissue that can be removed. Technical solution. We use a kit of small curettes, of different thicknesses and sizes, incorporating spicules that enable the physician to remove fibrous tissue from the fistula tract. The small size and varying thicknesses of the curettes enable them to mould to the curves of the fistula tract and to remove tissue by deroofing from the shallowest to the deepest layers, thus excising the entire fibrous tract. Our hospital has recently incorporated into clinical practice a new model of 3D-printed surgical steel curette, flanked by 2 lateral rings through which the suture is threaded. The central part of the curette contains radially graduated discs, the tips of which perform the debriding action, removing the fibrous tissue from the tract. Proof of concept. By using these curettes in conjunction with our standard technique (plugging the tract with platelet-rich fibrin), we have improved the success rate from 67% to 88%. Next steps. We have contacted several companies with a view to marketing this product. Conclusion. The results obtained are significantly better than those offered by the techniques in current use for the treatment of complex fistulas, without prejudice to outcomes such as anal continence and morbidity and mortality.

Rotura espontánea de hepatocarcinoma ¿está indicado el trasplante hepático? / Spontaneous rupture of a hepatocellular carcinoma: is a liver transplant indicated?

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Uso endoscópico de electrocauterio en el tratamiento de estenosis anastomótica ileorrectal / Endoscopic treatment with diathermy of ileorectal anastomotic stricture

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Signo de Mercedes Benz / Mercedes-Benz sign

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Hepatectomía por metástasis de leiomiosarcoma de vena safena / Hepatectomy due to a saphenous vein leiomyosarcoma metastasis

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Infección de sitio quirúrgico tras apendicectomía urgente: tasa global y tipo según la vía de abordaje (abierta/laparoscópica) / Postappendectomy surgical site infection: Overall rate and type according to open/laparoscopic approach

OBJETIVO: Evaluar la incidencia y el perfil de la infección de sitio quirúrgico (ISQ) postapendicectomía en relación con la vía de abordaje (abierta [AA] vs laparoscópica [AL]).Material y método Estudio observacional analítico de cohortes, con pacientes > 14 años intervenidos por sospecha de apendicitis aguda a lo largo de 4 años (2007-2010) en un hospital de tercer nivel (n = 868), divididos en 2 grupos según la vía de abordaje para la apendicectomía (AL, grupo de estudio, 135; AA, grupo control, 733). Variable resultado: ISQ, global y por tipos. Estratificación del riesgo infeccioso mediante: a) índice NNIS (bajo riesgo: NNIS 0E, 0 y 1; alto riesgo: NNIS 2 y 3); b) estadio evolutivo apendicular (bajo riesgo: normal o flemonoso; alto riesgo: gangrenoso o perforado). Análisis estadístico: software SPSS. Resultado principal y análisis estratificado con el test de χ2. Parámetros de riesgo: OR cruda y de Mantel-Haenszel respectivamente, con su IC 95% y aceptando significación estadística con p < 0,05.ResultadosAmbos grupos fueron homogéneos en cuanto a edad, género, ASA y formas evolucionadas. ISQ global: 13,4% (más de la mitad detectadas en el seguimiento tras el alta). Distribución: AA, 13% (superficial 9%, profunda 2%, órgano-espacio 2%); AL, 14% (superficial 5%, profunda 1%, órgano-espacio 8%) (global: n.s.; distribución: p < 0,000). El análisis estratificado mostró asociación entre ISQ parietal/acceso abierto e ISQ órgano-espacio/abordaje laparoscópico y que resulta especialmente evidente en pacientes de alto riesgo de ISQ postoperatoria (NNIS alto o presentación evolucionada).Conclusión La AA conlleva un mayor riesgo de ISQ parietal y la AL de órgano-espacio. Esta asociación es especialmente evidente en pacientes con especial riesgo de ISQ

OBJECTIVE: To compare the incidence and profile of surgical site infection (SSI) after laparoscopic (LA) oropen (OA) appendicectomy. MATERIAL AND METHOD: Observational and analytical study was conducted on patients older than 14 years old with suspected acute appendicitis operated on within a 4-year period (2007-2010) at a third levelhospital (n = 868). They were divided in two groups according to the type of appendicectomy (LA, study group, 135; OA, control group, 733). The primary endpoint was a surgical site infection (SSI), and to determine the overall rate and types (incisional/organ-space). The risk of SSI was stratified by: i) National Nosocomial Infection Surveillance (NNIS) index (low risk: 0E, 0 and 1; high risk: 2 and 3); ii) status on presentation (low risk: normal or phlegmonous; high risk: gangrenous or perforated). The statisticalanalysis was performed using the software SPSS. The main result and stratified analysis was determined with 2, and the risk parameters using OR and Mantel-Haenszel OR with 95%CI, accepting statistical significance with P < .05. RESULTS: Age, gender, ASAindex and incidence of advanced cases were similar in both groups. The overall lSSI rate was 13.4% (more than a half of them detected during follow-up after discharge). Type of SSI: OA,13% (superficial 9%, deep 2%, organ-space 2%); AL, 14% (superficial 5%, deep 1%, organ-space 8%) (overall:not significant; distribution: P < .000). Stratified analysis showed that there is an association between incisional SSI/OA and organ-space SSI/LA, and is particularly stronger in those patients with high risk of postoperative SSI (high risk NNIS or gangrenous-perforated presentation).CONCLUSION: OA and LA are associated with a higher rate of incisional and organ-space SSI respectively. This is particularly evident in patients with high risk of SSI

[Post-appendectomy surgical site infection: overall rate and type according to open/laparoscopic approach]. / Infección de sitio quirúrgico tras apendicectomía urgente: tasa global y tipo según la vía de abordaje (abierta/laparoscópica).

OBJECTIVE: To compare the incidence and profile of surgical site infection (SSI) after laparoscopic (LA) or open (OA) appendicectomy. MATERIAL AND METHOD: Observational and analytical study was conducted on patients older than 14years-old with suspected acute appendicitis operated on within a 4-year period (2007-2010) at a third level hospital (n=868). They were divided in two groups according to the type of appendicectomy (LA, study group, 135; OA, control group, 733). The primary endpoint was a surgical site infection (SSI), and to determine the overall rate and types (incisional/organ-space). The risk of SSI was stratified by: i)National Nosocomial Infection Surveillance (NNIS) index (low risk: 0E, 0 and 1; high risk: 2 and 3); ii)status on presentation (low risk: normal or phlegmonous; high risk: gangrenous or perforated). The statistical analysis was performed using the software SPSS. The main result and stratified analysis was determined with χ(2), and the risk parameters using OR and Mantel-Haenszel OR with 95%CI, accepting statistical significance with P<.05. RESULTS: Age, gender, ASA index and incidence of advanced cases were similar in both groups. The overall SSI rate was 13.4% (more than a half of them detected during follow-up after discharge). Type of SSI: OA, 13% (superficial 9%, deep 2%, organ-space 2%); AL, 14% (superficial 5%, deep 1%, organ-space 8%) (overall: not significant; distribution: P<.000). Stratified analysis showed that there is an association between incisional SSI/OA and organ-space SSI/LA, and is particularly stronger in those patients with high risk of postoperative SSI (high risk NNIS or gangrenous-perforated presentation). CONCLUSION: OA and LA are associated with a higher rate of incisional and organ-space SSI respectively. This is particularly evident in patients with high risk of SSI.