A prospective bicenter study investigating the diagnostic value of procalcitonin in patients with acute appendicitis.

BACKGROUND: Procalcitonin (PCT) is an established laboratory marker for disease severity in patients with infection and sepsis. In addition, PCT has been shown to be an effective marker for a limited number of localized infections. However, whether or not PCT has any diagnostic value for acute appendicitis, still remains unclear. The purpose of this prospective bicenter study was, therefore, to determine whether or not the PCT levels in the serum of patients with acute appendicitis have any diagnostic value. METHODS: This prospective study included 103 patients who received an appendectomy, based on the clinical diagnosis of acute appendicitis, in a surgical department of an academic teaching hospital in Germany or in a county hospital in Spain. White blood cell count (WBC), C-reactive protein (CRP) and procalcitonin (PCT) values were determined preoperatively. All appendectomy specimens were sent for routine histopathological evaluation. Based on this information, the patients were assigned to 1 of 5 groups that reflected the severity of the appendicitis. RESULTS: Of the 103 patients who were included in the study, 98 had appendicitis. Fourteen (14.3%) showed an increase in PCT values. Of those 14, 4 had a serum PCT >0.5 ng/ml, 9 had a PCT value >2-10 ng/ml and 1 had a PCT value >10 ng/ml. The sensitivity of PCT was calculated to be 0.14. The mean WBC value was 13.0/nl (+/- 5.2, 3.4-31), and for CRP it was 8.8 mg/dl (+/- 13, 0-60.2). The values of CRP, WBC and PCT increased with the severity of the appendicitis. CONCLUSIONS: PCT is potentially increased in rare cases of severe inflammation and, in particular, after appendiceal perforation or gangrenous appendicitis. However, its remarkably low sensitivity prohibits its routine use for the diagnosis of appendicitis.

Unusual upper gastrointestinal diseases associated with achalasia: laparoscopic approach.

BACKGROUND: As a result of the high success rate associated with the laparoscopic approach for achalasia, surgery for the disease has become the treatment of choice in recent years. With the greater number of patients undergoing surgery, surgeons may encounter other upper gastroesophageal illnesses associated with achalasia, and these may require evaluation for simultaneous surgical treatment. This study aimed to evaluate the incidence of gastroesophageal diseases associated with achalasia, and to determine the possibility for simultaneous management using the laparoscopic approach. METHODS: From January 1999 to May 2006, 81 patients were referred from the Service of Gastroenterology to the Service of General and Digestive Surgery as candidates for the surgical management of achalasia. Data for this group were recorded prospectively in laparoscopic surgery databases at the Hospital Sant Pau and the Hospital de Igualada. A total of 78 patients underwent laparoscopic Heller myotomy with gastric fundoplication. RESULTS: In 8 of 81 patients, nine additional gastroesophageal diseases (11.1%) were found: three cases of pseudoachalasia (3.7%), three cases of paraesophageal hiatal hernia (3.7%), two cases of esophageal diverticulum (2.5%), and one case of gastric volvulus (1.2%). Pseudoachalasia was diagnosed for three patients. The diagnosis was made preoperatively for one of these patients. For the other two patients, an adenocarcinoma arising from the gastroesophageal junction was diagnosed during the laparoscopy. In three cases, a paraesophageal hiatal hernia was found and treated by laparoscopic Heller myotomy, sac excision, hiatal closure, and posterior fundoplication. Esophageal diverticulectomy was performed for one patient. Another patient presented with an organoaxial gastric volvulus associated with achalasia, for which laparoscopic Heller myotomy, posterior fundoplication, and anterior gastropexy were performed. The median follow-up period was 39 months, with no recurrence. CONCLUSIONS: Despite their infrequency, several gastroesophageal diseases may be found in association with achalasia. Laparoscopic surgery may be useful for the diagnosis and/or treatment of both diseases.

[Expert opinion on the basic surgical technique for laparoscopic ventral hernia repair]. / Técnica quirúrgica básica consensuada para el tratamiento por vía laparoscópica de las hernias ventrales.

Laparoscopic ventral hernia repair is currently the subject of intense debate, even though it provides a series of advantages over open surgery and is feasible and safe. Various studies have shown this technique to be as effective as open repair with a lower recurrence rate. Despite the excellent results of laparoscopic repair of ventral hernias, there are numerous controversies associated with this procedure. These controversies concern the indications and contraindications of the procedure, and technical aspects such as how to create the pneumoperitoneum, perform adhesiolysis, manage the hernia sac, and insert and fix the mesh to the anterior abdominal wall. Also controversial are outcome, complications related to postoperative seroma, and which type and size of mesh should be used. The present article aims primarily to address many of these issues, based on the experience of distinct surgeons with expertise in this approach, in order to provide data to establish a consensus on how laparoscopic ventral hernia repair should be performed.

The impact of the surgeon's experience on the results of laparoscopic hernia repair.

BACKGROUND: The aim of this study was to evaluate our experience with the totally extraperitoneal (TEP) laparoscopic approach to hernia repair. METHODS: We performed a prospective study of 1227 hernia repairs using the TEP technique over a 7-year period. The main outcome measurements were postoperative complications, conversion rate, learning curve effect, surgery time, hospital stay, return to work, and recurrence rate. RESULTS: The mean operating time was > 60 min during the first 50 cases, but it fall to 32 min for the last 200 cases (p < 0.05). The conversion rate was 5.7% (56 patients); declining from 17% in the first 100 cases to 2.2% for the final 500 cases (p < 0.01). There were 79 complications (6.4%) and 23 recurrences (2.3%); 42% of the complications and 61% of the recurrences appeared in the first 100 cases (p < 0.05). CONCLUSION: This study shows that postoperative complications, conversion rate, operating time, and recurrences are all substantially reduced as the surgeon's experience increases. Thus, once the learning curve is surpassed, TEP repair represents a good alternative to open techniques.

Tratamiento laparoscópico de la hernia inguinal / Laparoscopic treatment of the inginal hernia

El tratamiento laparoscópico de la hernia inguinal sigue siendo uno de los procedimientos laparoscópicos más cuestionados ya que todavía no se han demostrado claramente las ventajas de este método sobre el tratamiento clásico anterior. Se presenta una breve historia de la cirugía laparoscópica de la hernia, describiéndose la técnica totalmente extraperitoneal utilizada hoy día por los autores, así como los resultados obtenidos en 1.177 hernioplastias laparoscópicas realizadas por ellos en los últimos 6 años, destacando una recidiva del 2,1 por ciento y la progresiva mejora de resultados al aumentar la experiencia. Se revisan los estudios publicados por grupos especializados en hernioplastia laparoscópica y aquellos que la comparan con la cirugía abierta en cuanto a análisis del coste económico, resultados, curva de aprendizaje, indicación y diferencias entre los tipos de hernioplastia laparoscópica. Los resultados actuales obtenidos por grupos con experiencia son equiparables o superiores a las técnicas abiertas, si bien aspectos como el coste económico deben mejorarse. En espera de estudios prospectivos a largo plazo que definan el papel real de la hernioplastia laparoscópica en la cirugía de la hernia, creemos que la técnica totalmente extraperitoneal constituye la mejor alternativa en el tratamiento de la hernia recidivada y bilateral. En la hernia primaria unilateral debería reservarse para pacientes laboralmente activos en los que la disminución de la baja laboral pueda compensar el mayor coste hospitalario. (AU)

Evolution of laparoscopic cholecystectomy in the regional hospitals of Catalonia.

OBJECTIVE: to assess the safety and effectiveness of laparoscopic cholecystectomy in the hands of surgeons with different amounts of experience in laparoscopic surgery at 15 regional hospitals, and to analyze the evolution of the current performance in comparison with results published in 1993. METHODS: prospective study of 1168 laparoscopic cholecystectomies done in 1996 in 15 regional hospitals in Catalonia. RESULTS: in 887 cases (76%) the indication was uncomplicated cholelithiasis. Preoperative cholangiography was done selectively in 12 of the 15 hospitals. Preoperative endoscopic retrograde cholangiopancreatography was positive in only 50 cases (57.4%), with 9 complications (10.3%). In 87 patients (7.4%) conversions to open surgery occurred. Postoperative complications (6. 3%), bile duct injury (0.4%), reintervention (0.4%) and postoperative stay (2.8 days) decreased in comparison with the year 1993. CONCLUSIONS: the current results suggest an overall improvement in comparison with the 1993 findings, since the rate of complications and length of stay decreased. However, the increasing number of conversions was notable; this may be due to the increasing complexity of the indications and the rise in the number of surgeons still on the learning curve. Laparoscopic cholecystectomy is, in our setting and for many surgeons, a safe and effective procedure that yields results similar to those in other multicenter studies.

Evolución de la colecistectomía laparoscópica en los hospitales comarcales de Cataluña* / General and Digestive Surgery Department. Igualada General Hospital. Barcelona, Spain

OBJETIVO: valorar la seguridad y eficacia de la colecistectomía laparoscópica en hospitales de ámbito comarcal con un grupo amplio de cirujanos de experiencia variable en cirugía laparoscópica. Analizar la evolución de los resultados actuales comparándolos con los obtenidos y publicados por el mismo grupo en 1993. MÉTODOS: estudio prospectivo sobre 1.168 colecistectomías laparoscópicas practicadas durante 1996 en 15 hospitales comarcales de Catalunya. RESULTADOS: en 887 casos (76 por ciento) la indicación fue una colelitiasis no complicada. La colangiografía peroperatoria se realiza de forma selectiva en 12 de los 15 hospitales. La colangiopancreatografía retrógrada endoscópica preoperatoria fue positiva sólo en 50 casos (57,4 por ciento), refiriéndose nueve complicaciones (10,3 por ciento). Se han producido 87 (7 4 por ciento) conversiones a cirugía abierta. Las complicaciones postoperatorias (6,3 por ciento), lesión biliar (0,4 por ciento), reintervenciones (0,4 por ciento) y estancia postoperatoria (2,8 días) han disminuido respecto a 1993. CONCLUSIONES: los resultados actuales sugieren una mejoría global respecto a los obtenidos en 1993, ya que han disminuido las complicaciones y la estancia hospitalaria. Sin embargo, destaca el aumento de conversiones que podría atribuirse a la mayor complejidad de las indicaciones y la progresiva incorporación de cirujanos en plena curva de aprendizaje. La colecistectomía laparoscópica es, en nuestro medio y para un amplio número de cirujanos, un procedimiento seguro y eficaz, con unos resultados equiparables a los publicados por otros grupos multicéntricos similares (AU)

[Topical nitroglycerin: an alternative in the conservative treatment of biliary fistula]. / Nitroglicerina tópica: una alternativa en el tratamiento conservador de la fístula biliar.

A patient with post-laparoscopic cholecystectomy cystic duct leak successfully treated with conservative treatment is presented. The cystic duct leak was diagnosed through a CPRE where a Oddy sphyncter spasm was noted. The use of a topic Nytroglicerine resulted in a sphincter release and resolution of the fistula. A literature review of the importance of CPRE in the diagnosis and treatment of biliary injuries was carried out. In patients with nondilated bile ducts where the sphincterotomy or endoprothesis undergo with high morbidity, the use of topic nitroglycerine could be an effective alternative procedure.