Development and Implementation of an Enhanced Recovery Protocol for Bariatric Patients in a Third World Environment.

Introduction: An applicable and reproducible enhanced recovery protocol was developed and implemented to improve our outcomes in a third-world environment. Methods: We compared the results obtained prospectively. The group treated before the application of the enhanced recovery protocol was called usual care (UC) and included all bariatric surgeries operated on between 2014 and 2017. The new protocol was applied between 2017 and 2019 including all operated patients, and this group was called Fast Track (FT). The variables analyzed were the length of stay, readmissions, and complications recorded during the first 30 days. We also analyzed the milligrams of morphine used by each patient, and a cost analysis was performed. Results: During the study period, 816 patients were studied. Of these, 385 (47.2%) belonged to the UC group and 431 (52.8%) to the FT group. The mean hospital stay was 58.5 hours (UC) versus 40.3 hours (FT) (P = .0001). When comparing the global morbidity of both groups, we did not find significant differences (P = .47). There was also no statistically significant difference when comparing major complications (P = .79). No mortality was recorded. Morphine indication reported a statistically significant difference that favored FT. Costs were significantly higher in UC than in FT (P < .0001). Conclusions: We believe that the implementation of an enhanced recovery protocol in bariatric surgery is a reliable measure and can be implemented even in an underdevelopment environment enlarging the benefit for patients.

[Accelerated recovery in elective laparoscopic colorectal surgery: two years of experience. ] / Recuperación acelerada en cirugía colorrectal laparoscópica electiva: dos años de experiencia.

Background: Accelerated recovery protocols in colorectal surgery have enhanced the perioperative cares optimizing recovery in this group of patients. A reduction in surgical stress and therefore early hospital discharge and lower morbidity is pursued, however, the literature offers few outcomes regarding its application in developing countries. Objective: to analyze short- and medium-term outcomes of the application of an accelerated recovery protocol in a terciary care hospital in Argentina. Methods: In the period between January 2015 and March 2017 patients were included prospectively and consecutively with indication of elective laparoscopic colorectal surgery and under strict follow-up according to the protocol created by the institution. Patients older than 80 years, ASA IV, emergency surgeries and conventional approach were excluded. We analyzed demographic data, diagnosis of surgery, type of intervention, hospital stay, complications, readmissions and reinterventions at 30 postoperative days. Results: Sixty-four patients with a mean age of 62 years were included. The mean hospitalization was 4.9 days, with 10.9% readmissions and 4.7% of reinterventions. We recorded 69% of the patients whit not complications at all and 5 major complications (8%) . Conclusion: Based on the adaptation of the international guidelines to our health reality, it is feasible to create an accelerated recovery protocol applicable in our country, with a low complication rate and early discharge.

Introducción: El desarrollo de los protocolos de recuperación acelerada en cirugía colorrectal ha revalorizado los cuidados que conforman la recuperación perioperatoria de los pacientes sometidos a cirugía. Se persigue una reducción del stress quirúrgico y por tanto alta precoz y menor morbilidad, sin embargo, la literatura aporta pocos resultados respecto a su aplicación en países en desarrollo. Objetivo: analizar los resultados a corto y mediano plazo de un protocolo de recuperación acelerada en un hospital de alta complejidad de nuestro medio. En el periodo comprendido entre enero 2015 y marzo 2017 se incluyeron pacientes de manera prospectiva y consecutiva con indicación deAñadir colaborador/a cirugía colorrectal laparocopica electiva y bajo estricto seguimiento según protocolo creado por la institución. Fueron excluidos pacientes mayores de 80 años, ASA IV, cirugías de urgencia y abordaje convencional. Se analizaron datos demográficos indicación de cirugía, tipo de intervención, estadía hospitalaria en días, complicaciones, readmisiones y reintervenciones a los 30 días de postoperatorio. Resultados: Fueron incluidos 64 pacientes con una edad media de 62 años. El promedio de internación en días fue de 4,9, con 10,9% de reinternaciones y 4,7% de reintervenciones. El 69% de los pacientes no presento complicaciones, registrándose 5 complicaciones mayores (8%). Conclusión: A partir de la adecuación de los lineamientos internacionales a nuestra realidad sanitaria, es factible la creación de un protocolo de recuperación acelerada aplicable en nuestro medio, con baja tasa de complicaciones y alta precoz.

ALPPS torniquete complicado con giro de la vena suprahepática izquierda. Nuevas complicaciones en nuevas hepatectomías / ALPPS tourniquet complicated with twisting of the left hepatic vein. New complications in new hepatectomies

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Sleeve Gastrectomy after Renal Transplantation.

BACKGROUND: Obesity induces or accelerates diabetes (DBT), hypertension (HT), and dyslipidemia (DSL), which are the main causes of renal failure. Obesity exacerbates in patients after renal transplantation (RT), and it has been associated with increased mortality rate, postoperative complications, and graft loss. We hypothesize that bariatric surgery might have a positive effect on obese patients with history of previous RT. METHODS: This was a retrospective review from prospectively collected data. Patients with sleeve gastrectomy (SG) with history of RT were studied. Demographics, anthropometric data, effect on comorbidities, postoperative course, immunosuppressive treatment, reason for transplantation, kidney function, graft survival, and quality of life associated with SG in obese patients with previous RT were assessed using a survey. RESULTS: From January 1, 2012 to January 1, 2016, five kidney transplant patients were operated on; 80% were female, with an average preoperative BMI of 42.18 ± 8.5 kg/m2 (range 37-54). Related comorbidities: 100% of the patients had HT and DSL, whereas 40% had DBT and gout. The average time gap between RT and SG was 15 ± 8.4 years (range 3-22). Average operative time was 65 ± 12 min (range 60-85), and there were neither complications nor mortality. At 16.8 ± 14.5 months (range 5-46) of follow-up, BMI was 29.8 ± 7.3 kg/m2 (range 26-44). All patients with HT and DSL were able to decrease their medication, showing improvement in blood pressure levels and laboratory test values. Regarding DBT, insulin was discontinued in one case, limiting the treatment to the use of oral hypoglycemic agents only. In another case, insulin dosage was significantly reduced. Graft function and proteinuria level improved in 80% of patients. All patients experienced a significant improvement in their quality of life. CONCLUSION: In this specific group of high-risk patients, SG showed encouraging results in terms of weight loss and resolution/improvement of comorbidities, renal function, and quality of life.

Risk factors for surgical site infection in colon surgery in our population.

BACKGROUND: Surgical site infection (SSI) is the most common nosocomial infection in surgical patients with an incidence that varies between 5-30%. OBJECTIVE: Identify the risk factors for SSI in colonic surgery in our population. The secondary aims are to determine the incidence and type of SSI, as well as the incidence of an anastomotic leakage (AL). METHODS: Case-control study of patients undergoing colectomy between 2010-2014 at the Hospital Privado Univeristario de Córdoba and Hospital Raúl Ferreyra. Conventional and laparoscopic interventions, with a 30-day postoperative follow up, between 20-85 years and an ASA I-III were included. Patients undergoing emergency surgery and recto-anal resections were excluded. SSI was defined as an infection that occurred within 30 days after surgery. RESULTS: We included 238 patients. SSI was diagnosed in 27.7% (n=66) of the patients of which 12.2% were superficial, 4.6% deep incisional and 10.9% organ/space. Multivariate analysis showed that SSI was independently associated with male sex (odds ratio [OR] 3.15; IC95%:1.43-6.92; p=0.004), having undergone previous chemotherapy (OR 6.72; IC95%:1.48-30.93; p=0.01), need for conversion (OR 3.32; IC95%:1.13-9.77; p=0.02), reintervention within the 30 postoperative days (OR 12.34; IC95%:2.65-57.37, p=0.001) and AL (OR 12.83; IC95%:2.97- 55.5; p=0.001). AL had an incidence of 9.6%, of which 91% presented SSI and all were organ/space. CONCLUSION: We found that male sex, having undergone previous chemotherapy, conversion, reintervention within 30 postoperative days and AL are risk factors for SSI in our population. These results should be considered in implementing preventive measures for SSI.

Laparoscopic Repair of Giant Bochdalek Hernia in Adults.

INTRODUCTION: Bochdalek hernia is a congenital diaphragmatic defect that results from improper fusion of the septum transversum and the pleuroperitoneal folds. It rarely persists asymptomatic until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases open or through laparoscopy/thoracoscopy. CASE REPORT: We present 2 cases of fully laparoscopic repair of giant Bochdalek hernia in adults. In both cases we used a GORE® DUALMESH® and we had neither complications nor recurrence. It is worthy of mention that hernia sac was not found in any of the cases. This has been described as a distinct characteristic that confirms diagnosis. CONCLUSION: Bochdalek hernia in the adult is a rare entity that requires surgical treatment to avoid complications. CT scan of the abdomen and chest with oral and IV contrast is the gold standard for diagnosis.

Esophageal metalic stent migration. Case report of a dislodged stent retrieval.

BACKGROUND: Metallic stent placing is the first choice in the treatment of malign or benign strictures of the esophagus. Stent migration is a well-known complication of this procedure. We report a case of stent migration in which surgical laparoscopic intervention was used to retrieve it. METHODS: An 85 years old man with unsuccessfully endoscopic retrieval of a migrated stent underwent laparoscopic gastrotomy for solution. The patient recovered without incident. CONCLUSION: This case illustrates that laparoscopic technique can be an optional way to retrieve migrated stents in selected patients.

Tumores retroperitoneales primarios / Primary retroperineal tumors

Introducción: Los tumores retroperitoneales primarios (TRP) se originan en estructuras no parenquimatosas del espacio retroperitoneal. El objetivo del presente trabajo fue analizar nuestra experiencia en el manejo quirúrgico de los TRP;determinar su incidencia, sobrevida y recurrencia. Luego, comparar nuestros resultados con la bibliografía. Material yMétodo: Se describe una serie de casos, donde, en forma retrospectiva, se recogieron los datos de las historias clínicas de los pacientes con TRP sometidos a resección quirúrgica desde enero de 1991 a diciembre de 2005. Resultados: Se incluyeron 12 pacientes con TRP. El 83,3 porciento eran mujeres. La edad promedio fue de 53,9 (17) años. El 58 porciento (Ic95 porciento 27,6 - 84,8) requirióresección de órganos vecinos siendo colon, intestino delgado y riñón los más frecuentes. Los tumores resecados con mayor incidencia fueron liposarcoma 50 porciento (Ic95 porciento 21,09 - 78,9) y leimiosarcoma (16,6 porciento). La recurrencia de la enfermedad fue enel 63,6 porciento de los pacientes, a los 31,3 (18,4) meses. El número de reoperaciones fue de 2 a 5. La mortalidad fue del 25 porciento (Ic95 porciento 5,5 - 57,2), con un promedio de seguimiento de 42,9 (22,5) meses. Conclusiones: Al igual que la literatura la mayoría de los TRP son malignos, siendo el más frecuente el liposarcoma. Un alto porcentaje de pacientes requiere múltiples reoperaciones. Observamos una sobrevida global de 75 porciento a pesar de su alto índice de recurrencia en un seguimiento promedio a 42 meses.