Initial experience with intraoperative testing and repair of colorectal anastomosis using a TAMIS approach after a positive leak test.

Anastomotic leak is one of the most feared complications of colorectal anastomosis. Different techniques have been described for intraoperative testing of anastomotic integrity. These include air insufflation, methylene blue and endoscopic visualisation. If an anastomotic leak is identified intraoperatively, there are various management options. Redo anastomosis is a possibility, but may be difficult in some cases. Defunctioning is another option, but there is an associated morbidity and signficant detrimental effect on quality of life. Direct transanal repair is only possible when a low anastomosis has been performed. When the anastomotic leak occurs high in the rectum or a partial mesorectal excision is performed a transanal approach is technically very challenging. We present our experience with transanal minimally invasive surgery (TAMIS) approach for anastomotic assessment and repair in four patients. In all cases, a colorectal anastomosis was performed and the air insufflation test was positive. We assessed the anastomosis with TAMIS. In three cases, a defect was found and subsequently sutured. In one case, a scar in the rectal mucosa was found and reinforced with a suture. A protective ileostomy was performed in two cases, while in the other two cases, no stoma was added. All four patients were discharged with no further complications. Both protective ileostomies were taken down after radiological and endoscopic confirmation of anastomotic integrity and all 4 anastomoses remain intact after follow-up. TAMIS intraoperative assessment and repair of anastomotic leak is a safe and feasible technique whcih may avoid the need for a defunctioning stoma.

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.

Formación de un residente de cirugía general en la unidad de cirugía mayor ambulatoria de un hospital de tercer nivel / General surgery trainee education in the ambulatory surgery setting of a tertiary hospital

Objetivos: la cirugía mayor ambulatoria ha adquirido entidad propia dentro de las unidades asistenciales, con un importante papel en la formación del residente. El objetivo de este estudio es valorar la formación actual de un residente de cirugía general en la unidad de cirugía ambulatoria de un hospital de tercer nivel. Materiales y método: se trata de un estudio retrospectivo, observacional y descriptivo. Las variables estudiadas han sido meses de rotación, intervenciones realizadas como cirujano principal, primer o segundo ayudante, sesiones de la unidad y tiempo de consulta. Resultados: en nuestro hospital dedicamos 6 meses de la residencia a la unidad de cirugía ambulatoria (2 en el primer año, 4 en el tercero), abarcando patologías de la pared abdominal, proctología básica, colelitiasis, patología benigna de la mama y patología de piel y partes blandas. El primer año se intervienen una media de 125 pacientes (36,16% como cirujano principal, 56% como primer ayudante y 7,84% como segundo). Durante el tercer año se realiza patología más compleja, llevándose a cabo una media de 206 intervenciones (68,40% como cirujano, 30,90% como primer ayudante y el 0,70% como segundo ayudante). Durante estos meses se realiza además actividad asistencial en consultas externas, sesiones clínicas relacionadas con patología de la unidad y sesión conjunta semanal sobre la evolución de los pacientes de pared compleja. Conclusión: dicha rotación realizada por un residente de cirugía general es imprescindible ya que en ella adquiere los cimientos para futuras intervenciones más complejas (AU)

Objectives: Ambulatory surgery has become entity within the health care units, with an important role in the learning of residents. The aim of this study is to assess the current training of general surgery residents in a ambulatory surgery unit of a tertiary hospital. Materials and methods: We show a retrospective, observational and descriptive study. The variables studied have been months of rotation, as chief surgeon interventions, first or second assistant, unit meetings and consultation time. Results: In our hospital, we dedicated 6 months of our residence period in the ambulatory surgery unit (two in the first year, four in the third), including diseases of the abdominal wall, basic proctology, cholelithiasis, benign breast disease and pathology of skin and soft tissue. The first year we operate an average of 125 procedures (36.16% as surgeon, 56% as first assistant and 7.84% as second). During the third year, there is a more complex pathology index, with an average of 206 interventions (68.40% as surgeon, 30.90% as first assistant and 0.70 as second). During these months we also participate in outpatient care activities, clinical sessions and a weekly staff session. Conclusions: This period is essential in a general surgery resident learning because it stablish the basis for their future more complex technics (AU)

Sutureless colic anastomoses with cyanoacrylates

BACKGROUND AND AIMS. The present research project has been made mainly with the idea of comparing the tensile strength values and histological answers of three types of colon anatomises: sutured with silk and sutureless anastomoses with 2-octylcyanocrylate and N-butyl-2-cyanoacrylate. METHODS. 112 Wistar rats distributed into three groups of 35 animals and a last control group of 7 have been used for this. Group 1: silk, group 2: 2-octyl-cyanocrylate, group 3: N-butyl-2-cyanoacrylate, group 4: Control group. The following surgical interventions were practiced on them: A cross section of the colon, followed by: group 1: an end-to-end discontinuoussuture anastomoses with Silk; group 2: sutureless anastomoses with 2-octyl-cyanocrylate; group 3: sutureless anastomoses with N-butyl-2-cyanoacrylate. On the 10th, 20th, 30th, 40th and 50th days we proceeded to measure the anastomoses' tensile strength value for each series. In the same period of time we carried out the following anatomic-pathological determinations: a) sharp inflammation; b) oedema; c) non-specific chronic inflammatory infiltrate; d) granulomatous inflammatory infiltrate to foreign bodies; e) fibrosis. RESULTS. The results obtained indicate a greater anastomoses' tensile strength for group 2 and 3. The anatomic-pathological values show a better response to anastomoses with adhesives than with conventional sutures. CONCLUSIONS. All these experimental results lead us to conclude that the cyanocrilates used to carry out sutureless anastomoses may be an alternative to the handmade conventional anastomoses. Moreover they are easy to be implemented (AU)

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Expresión de p53 en 63 carcinomas gástricos consecutivos / p53 expresssion in 63 consecutive gastric carcinomas

Planteamiento: La p53 es una proteína implicada de manera importante en el desarrollo de muchas neoplasias, interviniendo en el crecimiento celular, aunque su verdadera función aún tiene que ser más investigada. La idea de este estudio fue valorar la expresión de p53 como marcador de progresión tumoral y factor pronóstico en el carcinoma gástrico. Materiales y métodos: Hemos determinado la expresión inmunohistoquímica de p53 (clon D07) en 63 carcinomas gástricos consecutivos (62 biopsias endoscópicas y 37 especímenes de resección), relacionándolo con los parámetros histológicos y la evolución. Resultados: El 70 por ciento de las piezas quirúrgicas (26/37) y el 64 por ciento de las biopsias endoscópicas (40/62) muestran manifiesta o intensa expresión de p53, sin relación claramente significativa con el tipo histológico o el grado de diferenciación. Conclusiones: Los carcinomas gástricos frecuentemente expresan p53, siendo independiente de otros parámetros (tipo histológico, infiltración, grado de diferenciación), y no constituyen una variable pronóstica independiente. Existe una buena correlación entre la expresión de p53 en las biopsias endoscópicas y las piezas quirúrgicas. (AU)