Implementing an outpatient surgical management in moderated-high risk patients with groin hernia repair.

PURPOSE: There is a growing trend to expand Ambulatory Surgery (AS) criteria in abdominal wall surgery. No Admission (NOADS) circuit. The present study aimed to assess the impact of classification criteria on postoperative results and hospital stays in a NOADS versus a conventional admission circuit to throw some light on surgical circuit inclusion. METHODS: A retrospective analysis of a prospective;y maintained database was performed comparing groin hernia's interventions in a NOADS vs Admission circuit in our center in 2018-2021. A multiple regression predictive model followed by a retrospective retest were dessigned to assess the impact of each criterion on hospital stay. In total, 743 patients were included, 399 in the Admission circuit (ADC) and 344 in NOADS circuit (NOADS). RESULTS: There were no statistical differences in complication or readmission rates (p = 0.343 and p = 0.563), nevertheless, a shorter hospital stay was observed in NOADS (p = 0.000). A hierarchical multiple regression predictive model proposed two opposite scenarios. The best scenario, not likely to need admission, was a female patient operated via the laparoscopic approach of a unilateral primary hernia (Estimated Postoperative Stay: 0.049 days). The worst scenario, likely to need admission, was a male patient operated via the open approach of a bilateral and recurrent hernia (Estimated Postoperative Stay: 1.505 Days). CONCLUSION: Groin hernia patients could safely benefit from a No Admission (NOADS) circuit. Our model could be useful for surgical circuit decision-making, especially for best/worst scenarios.

Endoscopic retromuscular technique (eTEP) vs conventional laparoscopic ventral or incisional hernia repair with defect closure (IPOM +) for midline hernias. A case-control study.

PURPOSE: This study aimed at clinical results in terms of postoperative pain and functional recovery of new technique (eTEP) compared to IPOM + for ventral/incisional midline hernias. Recurrence rate, intra/postoperative complications and aesthetic results are secondary aims. METHODS: Data from consecutive patients requiring minimally invasive hernia repair were collected. From January 2015 to September 2018, patients with midline ventral/incisional hernias underwent IPOM + were compared to patients underwent eTEP procedure from October 2018 to December 2019 in a case/control study. RESULTS: Thirty-nine patients in IPOM + group and 40 in eTEP group were included. No significant differences were identified when hernias types, mean defect area, mean mesh area and intraoperative/postoperative complications (except seroma rate in favor of eTEP group) were compared. Operative time and hospital stay were significantly higher in eTEP group and IPOM + group, respectively. eTEP group showed significantly less pain on 1st, 7th and 30th postoperative days than IPOM + group. Restriction of activities was significantly decreased in eTEP group on the 30th and 180th day after surgery. Significant differences were observed in terms of cosmetic results 30th and 180th days after surgery in favor of eTEP group. Average follow-up was 15 months in eTEP group and 28 months in IPOM + group. No recurrences were identified in eTEP group and one recurrence in IPOM + group with no significant differences. CONCLUSION: Endoscopic retromuscular technique shows significant lower postoperative pain, better functional recovery and cosmesis than IPOM + without differences in intra/postoperative complications (except seroma rate) or recurrences during the follow-up. eTEP requires longer operative time.

Could we reduce adhesions to the intra-abdominal mesh in the first week? Experimental study with different methods of fixation.

BACKGROUND: Adhesion formation is a major problem when a mesh is exposed to intraabodminal viscera, with potential severe complications (bowel occlusion, fistulas or abscesses). New methods for preventing adhesions from a polypropylene mesh placed intra-abdominally or to solve difficult situations, such as when the peritoneum cannot be closed during a TAPP repair for an inguinal hernia, are still being seeked. This study mimics in an animal model a situation that can be found in clinical practice during laparoscopic inguinal hernioplasty. A polypropylene mesh could be exposed to the intra-abdominal cavity even when the peritoneum is closed due to different circumstances, with no options to guarantee the prosthetic material of being exposed to the intrabdominal viscera. Different options have been suggested to solve these situations, being proposed in this study to cover the visceral surface of the mesh with an absorbable sponge containing thrombin, fibrinogen, and clotting factors (Tachosil®, Nycomed, Takeda, Osaka, Japan), to assess its use as a barrier to prevent postoperative adhesion formation. MATERIAL AND METHODS: Thirty Wistar white rats (300-450 mg) were included in this study as experimental animals, being randomized into three groups (A, B, and C). We performed a bilateral prosthetic repair with conventional polypropylene mesh (2 × 2 cm, 82 kD). Prosthesis fixation was performed as follows. Group A: absorbable suture; group B: metal staples; group C: metal tackers. A piece of insulating absorbable sponge (Tachosil® 5 × 5 cm) was placed to cover the visceral surface of mesh placed at the right side of each animal. After 10 days, we performed a gross examination (by laparoscopy and laparotomy), measuring the quantity and the quality of the adhesions. Samples were taken for histopathological analysis. RESULTS: Tachosil®-treated prostheses showed a statistically significant decrease in the quality of the adhesion found (p < 0.05). In addition, a smaller quantity of adhesions was identified in barrier-treated animals, although this lacked statistical significance. The histologic analysis showed no significant differences: more edema with the untreated mesh and increased angiogenesis and a lower degree of necrosis in mesh covered with Tachosil®. CONCLUSIONS: The use of Tachosil® as a barrier material led to the absence of strong adhesions as it prevented direct contact between the mesh and the internal organs, preventing major problems associated with strong adhesions.

Totally endoscopic surgery on diastasis recti associated with midline hernias. The advantages of a minimally invasive approach. Prospective cohort study.

PURPOSE: To evaluate prospectively the feasibility and the duration of the plication of both aponeurosis through a totally endoscopic approach to the diastasis recti associated with midline hernias, correcting both pathologies simultaneously and objectively looking at their advantages and complications. METHODS: The prospective cohort study included patients suffering from midline hernias equal to or bigger than 2 cm size and associated diastasis recti, from April 2011 to October 2012. Full endoscopic subcutaneous approach is used to perform the surgery. An ultrasound scan was carried out to identify inter-rectus distances and recurrences in xiphoid, 3 cm supraumbilical and 2 cm subumbilical locations. RESULTS: A total of 21 patients were included in the study, with a mean follow-up of 20 months. The main complication was seroma. A significant reduction in the average distance between the rectus muscles was shown before surgery and at 1 month postoperative measures in all three locations (p < 0.001). No significant differences between the measured distances to the first and second year. A significant improvement at first postoperative year in cosmetic outcome compared with preoperative cosmetic condition (p < 0.001) was confirmed. Back pain improves significantly when diastasis recti is surgically corrected. CONCLUSIONS: Totally endoscopic approach to diastasis recti associated with midline hernias is a feasible and reproducible method. It brings considerable esthetic advantages. Diastasis or hernia recurrences in medium term follow-up have not been observed. Diastasis greater than 6-7 cm or associated with severe musculoaponeurotic laxity of the abdominal wall could benefit from the use of reinforced prosthesis.

Antibiotic embedded absorbable prosthesis for prevention of surgical mesh infection: experimental study in rats.

INTRODUCTION: Ventral hernias are a common problem in a general surgery and hernioplasty is an integral part of a general surgeon's practice. The use of prosthetic material has drastically reduced the risk of recurrence, but has introduced additional potential complications such as surgical wound infections, adhesion formation, graft rejection, etc. The development of a wound infection in a hernia that is repaired with a prosthetic material is a grave complication, often requiring removal of the prosthesis. This experimental study examined efficacy of completely absorbable, hydrophilic, PGA-TMC (polyglycolic acid-trimethylene carbonate) prosthesis impregnated with antibiotic for reduction of infectious complications. METHODS: Antibiotic-impregnated PGA-TMC prostheses were placed intraperitoneally in 90 Wistar white rats that were randomized and distributed into four groups. Group 0 (23 rats): there were placed PGA-TMC prosthesis without antibiotic impregnation (control group). Group 1 (25 rats): meshes were placed and infected later with 1 × 10(8) UFC of S. aureus/1 ml/2 cm(2) (Staphylococcus aureus ATCC 6538 American Type Culture Collection, Rockville, MD). Group 2 (21 rats): cefazolin-impregnated prostheses were placed (1 g × 100 ml, at the rate of 1 ml/cm(2) of prosthesis) and were subsequently infected with the same bacterial inoculate. Group 3 (21 rats): cefazolin-impregnated prostheses with double quantity of cefazolin and infected. A week later these animals were killed and specimens were extracted for bacterial quantification and histological studies. RESULTS: Evident decrease of bacterial colonization was observed in series 2 and 3 [the ones impregnated with cefazolin, in comparison with the group 1 (infected without previous antibiotic impregnation)] with statistically significant results (p < 0.00). Results were really positive when the antibiotic solution had been applied to the mesh. There have been formed adherences to the prosthesis when placing it in contact with intraabdominal viscera. However, cefazolin impregnation of the mesh has reduced an adhesion formation, mostly when the infection reached a minimum, inhibiting the inflammatory answer to the infection in a prosthetic material. CONCLUSION: Impregnation of the absorbable hydrophilic prosthesis PGA-TMC with cefazolin prevents the infection of the prosthesis placed in infected localization. Therefore, we think this option should be considered as a new and useful alternative in case of contaminated and dirty surgical fields or when a replacement of the prosthesis is required.

Efficacy, tolerance, and safety of mammalian target of rapamycin inhibitors as rescue immunosuppressants in liver transplantation.

BACKGROUND: Mammalian target of rapamycin (mTOR) inhibitors behave as potent immunosuppressants which have the advantages, with respect to calcineurin inhibitors (CNI: cyclosporine or tacrolimus), of no nephrotoxicity and inhibition of cell proliferation. They are particularly suitable for patients with renal insufficiency or neoplasias. MATERIALS AND METHODS: Twenty-two liver transplant patients were immunosuppressed with everolimus or sirolimus as rescue therapy after CNI treatment: 7 hepatocellular carcinomas; 5 de novo malignancies; 4 renal insufficiencies; 4 chronic rejections; and 2 acute rejection episodes. RESULTS: There were 16.7% tumor recurrences, and 25% improvements in renal function, 75% in chronic rejection, and 50% in acute rejection. There was no incidence of rejection, kidney failure, gastrointestinal intolerance, hydrocarbon intolerance, hypertension, or arterial or venous thrombosis. We observed incidences of 50% for hypercholesterolemia, 31.8% for hypertriglyceridemia, 22.7% for thrombocytopenia, 18.2% for leukopenia, and 9.1% for anemia. The intercurrent infection rate was 13.6%, including oral thrush in 13.6%. Lower limb edema occurred in 13.6%, with 1 case of facial edema and 1 of alopecia. CONCLUSIONS: mTOR inhibitors were safe immunosuppressive drugs whose side effects were controlled and easily managed. They have advantages with respect to CNI due to their slight effects on kidney function and lack of promotion of diabetes mellitus. Although their long-term effectiveness for control of neoplastic diseases is yet to be seen, they can be used safely in these patients with no incidence of rejection. Their effectiveness to control chronic rejection seems significant, but it is doubtful for steroid-resistant acute rejection episodes.

Presentación atípica de tuberculosis peritoneal. Caso clínico diagnosticado por laparoscopia / No disponible

La sospecha clínica de tuberculosis peritoneal debe estar presenteen todo paciente con dolor abdominal de etiología desconocida;sobre todo si se acompaña de fiebre, ascitis y distensión abdominal.El acceso por vía laparoscópica a la cavidad abdominalde forma reglada contribuye de manera primordial al diagnósticotanto por la imagen macroscópica como para la toma de biopsia,que dará posteriormente la confirmación anatomopatológica ymicrobiológica. Ayudando a discriminar entre los posibles diagnósticosdiferenciales que acontecen con clínica similar. Otraspruebas diagnósticas analíticas deben ser tenidas en cuenta paraayudar tanto a la indicación de laparoscopia como de cara al diagnóstico,son tales como la ADA, gammagrafía con Galio-67 y Ca-125

The presence of peritoneal tuberculosis has to be clinically suspectedin all patients with abdominal pain of unknown etiology,particularly when it is accompanied by fever, ascites, and abdominaldistension. Access to the abdominal cavity using routine laparoscopyprovides essential information on the diagnosis, fromboth macroscopic images and biopsy sampling, which will laterprovide a pathological and microbiological confirmation. Thishelps discriminate between potential differential diagnoses thatmay include similar symptoms. Other laboratory tests have to beconsidered as diagnostic aids, as well as for the indication of laparoscopy,including ADA, and Gallium-67 or Ca-125 scans (AU)

Fístula gastrocutánea resuelta mediante inyección endoscópica de cola biológica / Closure of gastrocutaneous fistula using endoscopic biological glue injection

No disponible

Íleon perforado y fistulizado a piel contenido en gran hernia umbilical incarcerada / Perforated, fistulized-to-skin ileum within a large incarcerated umbilical hernia

No disponible

[Role of malnutrition in intestinal anastomosis collagenization: an analysis of procollagen (PINP) and carboxyterminal telopeptide (ICTP) by radioimmunoassay]. / Efectos de la desnutrición sobre la colagenización de anastomosisintestinales: análisis de procolágeno y telopéptido carboxiterminalmediante radioinmunoanálisis.

INTRODUCTION: some clinical, anatomo-pathological, and technical factors influence the correct healing of intestinal suture following an intestinal resection. One of the most influential factors is patient nutritional status. OBJECTIVES: to evaluate the influence of malnutrition on the viability of primary intestinal anastomosis by the analysis of collagen I deposition. METHODS: 40 Wistar rats, radioimmunoassay material. We used 2 groups of rats, 20 animals in each group: a control group (A) and a "malnutrition" group (B). RESULTS: there was a decrease in PINP (procollagen) deposition in the colon of group B rats as compared to the colon of group A (0.3620 and 0.4340 mg/g respectively) (p = 0.032). There is an increase in ICTP (carboxyterminal telopeptide) in the colon of group B (0.9545 as against 0.8460 mg/g in group A) (p = 0.875). In anastomoses of group B there was a decrease in PINP synthesis as compared to group A (0.376 and 0.468 mg/g respectively, p = 0.002). As regards ICTP, there was an increase in group B (p = 0.330). In relation to the control group no differences were observed in ICTP increases in group B (p = 1). CONCLUSIONS: colonic anastomosis increases the levels of PINP and ICTP in healed tissue (p = 0.000); malnutrition reduces collagenization in anastomoses (p = 0.000).

Efectos de la desnutrición sobre la colagenización de anastomosis intestinales: análisis de procolágeno y telopéptido carboxiterminal mediante radioinmunoanálisis / Role of malnutrition in intestinal anastomosis collagenization: an analysis of procollagen (PINP) andcarboxyterminal telopeptide (ICTP) by radioimmunoassay

Introducción: diversos factores influyen en la cicatrización correcta de las suturas intestinales tras la práctica de una resección intestinal. Uno de los factores más implicados es el estado nutricional del paciente. Objetivos: evaluar la influencia de la desnutrición inducida sobre la viabilidad de una anastomosis intestinal primaria mediante el análisis del procolágeno (PINP) como marcador de la síntesis de colágeno I, y del telopéptido carboxiterminal del colágeno I (ICTP) como marcador de la destrucción del mismo. Métodos: 40 ratas Wistar y material de radioinmunoensayo. Métodos: diseñamos 2 grupos de ratas, 20 animales por cada grupo: grupo control (A) y grupo “desnutrición” (B). Se analiza PINP e ICTP mediante RIA sobre tejido colónico homogeneizado, preanastomótico y anastomótico. Resultados: existen unos niveles menores de PINP en el colon de las ratas del grupo B comparado con el colon del grupo A (0,3620 y 0,4340 μg/g respectivamente) (p = 0,032). Hay un mayor nivel de ICTP analizado en el colon del grupo B (0,9545 en contraposición a 0,8460 μg/g en el grupo A) (p = 0,875). En las anastomosis del grupo B existe una menor síntesis de PINP en comparación con el grupo A (0,376 y 0,468 μg/g respectivamente, p = 0,002). Conclusiones: la anastomosis colónica incrementa los niveles de PINP e ICTP en el tejido cicatricial (p = 0,000); la malnutrición reduce la colagenización de las anastomosis (p = 0,000)

Introduction: some clinical, anatomo-pathological, and technical factors influence the correct healing of intestinal suture following an intestinal resection. One of the most influential factors is patient nutritional status. Objectives: to evaluate the influence of malnutrition on the viability of primary intestinal anastomosis by the analysis of collagen I deposition. Methods: 40 Wistar rats, radioimmunoassay material. We used 2 groups of rats, 20 animals in each group: a control group (A) and a “malnutrition” group (B). Results: there was a decrease in PINP (procollagen) deposition in the colon of group B rats as compared to the colon of group A (0.3620 and 0.4340 μg/g respectively) (p = 0.032). There is an increase in ICTP (carboxyterminal telopeptide) in the colon of group B (0.9545 as against 0.8460 μg/g in group A) (p = 0.875). In anastomoses of group B there was a decrease in PINP synthesis as compared to group A (0.376 and 0.468 mg/g respectively, p = 0.002). As regards ICTP, there was an increase in group B (p = 0.330). In relation to the control group no differences were observed in ICTP increases in group B (p = 1). Conclusions: colonic anastomosis increases the levels of PINP and ICTP in healed tissue (p = 0.000); malnutrition reduces collagenization in anastomoses (p = 0.000)

Angiomatosis mesentérica masiva y hemorragia digestiva baja en paciente con síndrome de Klippel-Trenaunay-Weber / Massive mesenteric angiomatosis and low digestive hemorrhage in a patient with Klippel-Trenaunay-Weber syndrome

No disponible