Resultados de la rehabilitación multimodal en la duodenopancreatectomía cefálica / Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy

INTRODUCCIÓN: La rehabilitación multimodal precoz (RMP) ha demostrado en la cirugía colorrectal una reducción de la morbilidad y de la hospitalización sin comprometer la seguridad de los pacientes. La experiencia de la RMP en la duodenopancreatectomía cefálica (DPC) es más limitada. Los objetivos de este estudio fueron analizar la aplicabilidad de un programa RMP en los pacientes intervenidos mediante una DPC en nuestro medio y evaluar los resultados postoperatorios. MÉTODOS: Estudio retrospectivo utilizando una base de datos prospectiva de 41 pacientes a los que se realizó DPC y fueron incluidos en un programa de RMP. Se evaluaron 3 elementos clave: retirada precoz de sondas y drenajes, ingesta oral y movilización precoz. Las variables analizadas fueron la mortalidad, morbilidad, datos perioperatorios, estancia hospitalaria, reintervenciones y reingresos. Este grupo de pacientes fue comparado con un grupo control de 44 pacientes consecutivos, en los que se realizó una DPC con manejo postoperatorio estándar. RESULTADOS: Se estudió a 85 pacientes intervenidos con DPC (41 pacientes en el grupo RMP y 44 pacientes en el grupo control). La mortalidad global fue del 2,4%: 2 pacientes pertenecientes al grupo control. No encontramos diferencias significativas en la mortalidad, ingreso en Reanimación, reintervenciones ni reingresos. El grupo RMP presentó una morbilidad menor que el grupo control (32 vs. 48%; p = 0,072), y una estancia hospitalaria menor (14,2 vs. 18,7 días; p = 0,014). Todos los elementos clave propuestos fueron conseguidos. CONCLUSIONES: La RMP en la DPC puede implantarse con seguridad en nuestro medio. Permite unificar los cuidados perioperatorios, disminuir la variabilidad clínica y la estancia media y como consecuencia, el coste hospitalario

BACKGROUND: Enhanced recovery after surgery (ERAS) has demonstrated in colorectal surgery a reduction in morbidity and length of stay without compromising security. Experience with ERAS programs in pancreatoduodenectomy (PD) is still limited. The aims of this study were first to evaluate the applicability of an ERAS program for PD patients in our hospital, and second to analyze the postoperative results. METHODS: A retrospective study using a prospectively maintained database identified 41 consecutive PD included in an ERAS program. Key elements studied were early removal of tubes and drainages, early oral feeding and early mobilization. Variables studied were mortality, morbidity, perioperative data, length of stay, re-interventions and inpatient readmission. This group of patients was compared with an historic control group of 44 PD patients with a standard postoperative management. RESULTS: A total of 85 pancreatoduodenectomies were analyzed (41 patients in the ERAS group, and 44 patients in the control group. General mortality was 2.4% (2 patients) belonging to the control group. There were no statistical differences in mortality, length of stay in intensive care, reoperationss, and readmissions. ERAS group had a lower morbidity rate than the control group (32 vs. 48%; P=.072), as well as a lower length of stay (14.2 vs. 18.7 days). All the key ERAS proposed elements were achieved. CONCLUSIONS: ERAS programs may be implemented safely in pancreaticoduodenectomy. They may reduce the length of stay, unifying perioperative care and diminishing clinical variability and hospital costs

Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) has demonstrated in colorectal surgery a reduction in morbidity and length of stay without compromising security. Experience with ERAS programs in pancreatoduodenectomy (PD) is still limited. The aims of this study were first to evaluate the applicability of an ERAS program for PD patients in our hospital, and second to analyze the postoperative results. METHODS: A retrospective study using a prospectively maintained database identified 41 consecutive PD included in an ERAS program. Key elements studied were early removal of tubes and drainages, early oral feeding and early mobilization. Variables studied were mortality, morbidity, perioperative data, length of stay, re-interventions and inpatient readmission. This group of patients was compared with an historic control group of 44 PD patients with a standard postoperative management. RESULTS: A total of 85 pancreatoduodenectomies were analyzed (41 patients in the ERAS group, and 44 patients in the control group. General mortality was 2.4% (2 patients) belonging to the control group. There were no statistical differences in mortality, length of stay in intensive care, reoperationss, and readmissions. ERAS group had a lower morbidity rate than the control group (32 vs. 48%; P=.072), as well as a lower length of stay (14.2 vs. 18.7 days). All the key ERAS proposed elements were achieved. CONCLUSIONS: ERAS programs may be implemented safely in pancreaticoduodenectomy. They may reduce the length of stay, unifying perioperative care and diminishing clinical variability and hospital costs.

Duodenopancreatectomía en ancianos. Evaluación de resultados / Duodenopancreatectomy in the elderly. Evaluation of results

Introducción Con el aumento de la esperanza de vida, cada vez se diagnostican más tumores periampulares resecables en la población geriátrica. A pesar de la disminución de la mortalidad postoperatoria, el debate sobre la relación riesgo-beneficio de la duodenopancreatectomía cefálica (DPC) en ancianos sigue vigente.Objetivo Analizar la morbimortalidad de la DPC en los pacientes mayores de 70 años. Diseño Estudio prospectivo observacional. Pacientes Entre enero de 2005 y diciembre 2010, se realizaron 54 duodenopancreatectomías. Se compararon 2 grupos de pacientes: grupo 1 (pacientes>70 años, n: 24), y grupo 2 (pacientes<70 años, n: 30). Se analizó la morbimortalidad, transfusión, reintervenciones, estancia media y supervivencia. Resultados El grupo>70 años incluyó más pacientes ASA 2 y 3 (p=0,010), y presentaron mayor número de antecedentes personales por paciente (p=0,037). La mortalidad postoperatoria fue superior en el grupo de más edad, aunque sin diferencias significativas (8,3 vs. 3,3%). La morbilidad postoperatoria (45,8 vs. 46,6%), la tasa de reintervenciones (16,6 vs. 13,3%), la estancia hospitalaria (18 vs. 13 días), y la supervivencia a 6 y 12 meses, tampoco presentaron diferencias significativas (84 y 72% vs. 90 y 86%).Conclusiones La edad no parece ser una contraindicación por sí misma para la DPC, si bien los ancianos presentan mayor riesgo de complicaciones debido a los cambios fisiológicos relacionados con el envejecimiento. La disparidad de resultados evidencia la necesidad de disponer de estudios poblacionales de ámbito nacional que aporten una visión global de la morbimortalidad en la DPC (AU)

Introduction With the increase in life expectancy, more and more resectable periampullary tumours are being diagnosed in the geriatric population. Despite the decrease in post-operative mortality, there continues to be a debate on the risk-benefit of cephalic duodenopancreatectomy (CPD) in the elderly. Objective To analyse the morbidity and mortality of CPD in patients over 70 years-old. Design Prospective observational study. Patients A total of 54 duodenopancreatectomies were performed between January 2005 and December 2010. Two groups of patients were compared: Group 1 (patients>70 years-old, n: 24), and Group 2 (patients<70 years-old, n: 30). The morbidity and mortality, transfusion, reinterventions, mean hospital stay, and survival were analysed. Results The>70 years group included more ASA 2 and 3 patients (P=.010), and had a higher number of previous medical problems per patient (P=.037). The post-operative mortality was higher in the older age group, although the difference was not significant (8.3 vs 3.3%). There were also no significant differences in post-operative morbidity (45.8 v. 46.6%), reintervention rate (16.6 vs 13.3%), length of hospital stay (18 vs 13%), and survival at 6 and 12 months (84 and 72% vs 90 and 86%).Conclusions Age, in itself, does not seem to be a contraindication for CPD, but the elderly do have a higher risk of complications due to the physiological changes associated with ageing. The disparity of results demonstrates the need for more population studies at national level that may give an overall view of morbidity and mortality in CPD (AU)

[Duodenopancreatectomy in the elderly. Evaluation of results]. / Duodenopancreatectomía en ancianos. Evaluación de resultados.

INTRODUCTION: With the increase in life expectancy, more and more resectable periampullary tumours are being diagnosed in the geriatric population. Despite the decrease in post-operative mortality, there continues to be a debate on the risk-benefit of cephalic duodenopancreatectomy (CPD) in the elderly. OBJECTIVE: To analyse the morbidity and mortality of CPD in patients over 70 years-old. DESIGN: Prospective observational study. PATIENTS: A total of 54 duodenopancreatectomies were performed between January 2005 and December 2010. Two groups of patients were compared: Group 1 (patients>70 years-old, n: 24), and Group 2 (patients<70 years-old, n: 30). The morbidity and mortality, transfusion, reinterventions, mean hospital stay, and survival were analysed. RESULTS: The>70 years group included more ASA 2 and 3 patients (P=.010), and had a higher number of previous medical problems per patient (P=.037). The post-operative mortality was higher in the older age group, although the difference was not significant (8.3 vs 3.3%). There were also no significant differences in post-operative morbidity (45.8 v. 46.6%), reintervention rate (16.6 vs 13.3%), length of hospital stay (18 vs 13%), and survival at 6 and 12 months (84 and 72% vs 90 and 86%). CONCLUSIONS: Age, in itself, does not seem to be a contraindication for CPD, but the elderly do have a higher risk of complications due to the physiological changes associated with ageing. The disparity of results demonstrates the need for more population studies at national level that may give an overall view of morbidity and mortality in CPD.

Hybrid natural orifice transluminal endoscopic cholecystectomy: prospective human series.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) makes it possible to perform intraperitoneal surgical procedures with a minimal number of access points in the abdominal wall. Currently, it is not possible to perform these interventions without the help of abdominal wall entryways, so these procedures are hybrids fusing minilaparoscopy and transluminal endoscopic surgery. This report presents a prospective clinical series of 25 patients who underwent transvaginal hybrid cholecystectomy for cholelithiasis. METHODS: The study comprised a clinical series of 25 consecutive nonrandomized women who underwent a fusion transvaginal NOTES and minilaparoscopy procedure with two trocars for cholelithiasis: one 5-mm umbilical trocar and one 3-mm trocar in the upper left quadrant. The study had no control group. RESULTS: The scheduled surgical intervention was performed for all 25 women. No intraoperative complications occurred. One patient had mild hematuria that resolved in less than 12 h, but no other complications occurred during an average follow-up period of 140 days. Of the 25 women, 20 were discharged in 24 h, and 5 were discharged less than 12 h after the procedure. CONCLUSION: Hybrid transvaginal cholecystectomy, combining NOTES and minilaparoscopy, is a good surgical model for minimally invasive surgery. It can be performed in surgical settings where laparoscopy is practiced regularly using the instruments normally used for endoscopy and laparoscopic surgery. Due to the reproducibility of the intervention and the ease of vaginal closure, hybrid transvaginal cholecystectomy will permit further development of NOTES in the future.

NOTES. Historia y situación actual de la cirugía endoscópica por orificios naturales en nuestro país / NOTES. History and current situation of natural orifice transluminal endoscopic surgery in Spain

La cirugía endoscópica transluminal a través de orificios naturales (NOTES, del inglés Natural Orifice Translumenal Endoscopic Surgery), engloba un conjunto de nuevas vías de abordaje endoscópico de la cavidad abdominal, con ventajas potenciales sobre la cirugía laparoscópica convencional. Se fundamenta en la posibilidad de realizar técnicas quirúrgicas intraperitoneales mediante la entrada en la cavidad peritoneal a través de los orificios naturales perforando el órgano que permite la entrada directa a dicha cavidad (estómago, vagina, recto, vejiga). Posteriormente se ha postulado la posibilidad de este mismo acceso para acceder al retroperitoneo y al mediastino. A continuación se comenta como se ha desarrollado la técnica y cómo ha sido la aplicación en nuestro país, intentado dar una visión general sobre los riesgos y beneficios de la NOTES y las necesidades básicas para poder iniciarse en esta nueva cirugía (AU)

Natural orifice transluminal endoscopic surgery (NOTES), involves a group of new endoscopic approaches to the abdominal cavity, with potential advantages over conventional laparoscopic surgery. It is based on the possibility of performing intra-peritoneal surgical techniques through natural orifices by entering the peritoneal cavity through natural orifices perforating the organ that allows direct access to that cavity (stomach, vagina, rectum, bladder). The possibility of using this same route to access the retroperitoneum and mediastinum has subsequently been postulated. Comments are made on how the technique has been developed, as well as how it has been applied in our country, attempting to give a general view on the risks and benefits of NOTES and the basic requirements to be able to start in this new surgery (AU)

[NOTES. History and current situation of natural orifice transluminal endoscopic surgery in Spain]. / NOTES. Historia y situación actual de la cirugía endoscópica por orificios naturales en nuestro país.

Natural orifice transluminal endoscopic surgery (NOTES), involves a group of new endoscopic approaches to the abdominal cavity, with potential advantages over conventional laparoscopic surgery. It is based on the possibility of performing intra-peritoneal surgical techniques through natural orifices by entering the peritoneal cavity through natural orifices perforating the organ that allows direct access to that cavity (stomach, vagina, rectum, bladder). The possibility of using this same route to access the retroperitoneum and mediastinum has subsequently been postulated. Comments are made on how the technique has been developed, as well as how it has been applied in our country, attempting to give a general view on the risks and benefits of NOTES and the basic requirements to be able to start in this new surgery.

Cirugía laparoscópica a través de incisión única / Single incision laparoscopic surgery

Uno de los objetivos de las nuevas tecnologías y técnicas en cirugía mínimamente invasiva es lograr una cirugía sin o con mínimas cicatrices visibles. La cirugía a través de orificios naturales podría considerarse como un paradigma de este desarrollo pero todavía no ha sido posible su completa implantación. Sin embargo, la innovación resultante de la investigación en cirugía a través de orificios naturales ha permitido introducir una serie de «tecnologías puente» que permiten desarrollar la cirugía mínimamente invasiva con los estándares de eficacia y seguridad exigibles, siendo la cirugía laparoscópica a través de incisión única el concepto más atractivo en este momento. El objetivo de este trabajo es revisar el concepto de cirugía laparoscópica a través de incisión única y clasificar las herramientas disponibles para su implantación y desarrollo (AU)

One of the aims of the new technologies and techniques in minimally invasive surgery (MIS) is to achieve a surgery without or with minimal visible scars. Natural orifice transluminal endoscopic surgery (NOTES) might be considered to be a paradigm of this development but it has not yet been possible to implement this universally. Nevertheless, the resultant innovation of research into NOTES has enabled “bridge technologies" to be introduced that allow MIS to be developed with the required standards of efficiency and safety. The aim of this paper is to review the concept of single incision surgery and to classify the available tools for its development and implementation (AU)

[Single incision laparoscopic surgery]. / Cirugía laparoscópica a través de incisión única.

One of the aims of the new technologies and techniques in minimally invasive surgery (MIS) is to achieve a surgery without or with minimal visible scars. Natural orifice transluminal endoscopic surgery (NOTES) might be considered to be a paradigm of this development but it has not yet been possible to implement this universally. Nevertheless, the resultant innovation of research into NOTES has enabled "bridge technologies" to be introduced that allow MIS to be developed with the required standards of efficiency and safety. The aim of this paper is to review the concept of single incision surgery and to classify the available tools for its development and implementation.