Determining the need for a thoracoscopic approach to treat a giant hiatal hernia when abdominal access is poor.

BACKGROUND: Giant hernias present a significant challenge for digestive surgeons. The approach taken (laparoscopic vs thoracoscopic) depends largely on the preferences and skills of each surgeon, although in most cases today the laparoscopic approach is preferred. AIM: To determine whether patients presenting inadequate laparoscopic access to the intrathoracic hernial sac obtain poorer postoperative results than those with no such problem, in order to assess the need for a thoracoscopic approach. METHODS: For the retrospective series of patients treated in our hospital for hiatal hernia (n = 112), we calculated the laparoscopic field of view and the working area accessible to surgical instruments, by means of preoperative imaging tests, to assess the likely outcome for cases inaccessible to laparoscopy. RESULTS: Patients with giant hiatal hernias for whom a preoperative calculation suggested that the laparoscopic route would not access all areas of the intrathoracic sac presented higher rates of perioperative complications and recurrence during follow-up than those for whom laparoscopy was unimpeded. The difference was statistically significant. Moreover, the insertion of mesh did not improve results for the non-accessible group. CONCLUSION: For patients with giant hiatal hernias, it is essential to conduct a preoperative evaluation of the angle of vision and the working area for surgery. When parts of the intrathoracic sac are inaccessible laparoscopically, the thoracoscopic approach should be considered.

A New, Conservative Treatment for Perianal Fistula that May Halve the Need for Surgical Intervention: Case Series.

PURPOSE: In the last two decades, many sphincter preservation techniques have been proposed for the treatment of anal fistula. Since 2011, our surgical team has treated fistulas by sealing them with platelet-rich fibrin (PRF). This is performed actually as an outpatient process, without anaesthesia. METHODS: Patients were treated with PRF sealant, during the period June 2012-March 2017. The fibrin preparation is applied in the fistulous tract, with no need for any type of anaesthesia, and so the patient can go home immediately afterwards, without further observation. RESULTS: After an average follow-up of 26.49 months, the perianal fistula had healed completely in 52.86% of the patients (n = 37), who each received an average of 1.92 sealant operations. In another 10 cases, the sealing was initially successful, but a relapse occurred during the follow-up period. CONCLUSION: The outpatient treatment of perianal fistula with PRF is totally harmless, is very low cost and achieves very acceptable results. In our opinion, therefore, this could be considered an appropriate initial treatment for perianal fistula, with surgical treatment being reserved if this approach is unsuccessful, thereby avoiding many complications and producing significant economic savings for the health system.

Novel suturing technique, based on physical principles, achieves a breaking point double that obtained by conventional techniques.

BACKGROUND: Sutures have been used to repair wounds since ancient times. However, the basic suture technique has not significantly changed. In Phase I of our project, we proposed a "double diabolo" suture design, using a theoretical physical study to show that this suture receives 50% less tension than conventional sutures, and so a correspondingly greater force must be applied to break it. AIM: To determine whether these theoretical levels of resistance were met by the new type of suture. METHODS: An observational study was performed to compare three types of sutures, using a device that exerted force on the suture until the breaking point was reached. The tension produced by this traction was measured. The following variables were considered: Tearing stress on entry/exit points, edge separation stress, and suture break stress. The study sample consisted of 30 sutures with simple interrupted stitches (Group 1), 30 with continuous stitches (Group 2), and 30 with the "double diabolo" design (Group 3). RESULTS: The mean degree of force required to reach the breaking point for each of these variables (tearing, separation, and final breaking) was highest in Group 3 (14.56, 18.28, and 21.39 kg), followed by Group 1 (7.36, 10.38, and 12.81 kg) and Group 2 (5.77, 7.7, and 8.71 kg). These differences were statistically significant (P < 0.001) in all cases. CONCLUSION: The experimental results show that with the "double diabolo" suture, compared with conventional sutures, greater force must be applied to reach the breaking point (almost twice as much as in the simple interrupted suture and more than double that required for the continuous suture). If these results are confirmed in Phase III (the clinical phase) of our study, we believe the double diabolo technique should be adopted as the standard approach, especially when the suture must withstand significant tension (e.g., laparotomy closure, thoracotomy closure, diaphragm suture, or hernial orifice closure).

Review of incomplete macroscopic resections (R2) in rectal cancer: Treatment, prognosis and future perspectives.

Colorectal cancer is one of the most prevalent tumours, but with improved treatment and early detection, its prognosis has greatly improved in recent years. However, when the tumour is locally advanced at diagnosis or if there is local recurrence, it is more difficult to perform a complete tumour resection, and there may be a residual macroscopic tumour. In this paper, we review the literature on residual macroscopic tumour resections, concerning both locally advanced primary tumours and recurrences, evaluating the main problems encountered, the treatments applied, the prognosis and future perspectives in this field.

COVID-19 pandemic, as experienced in the surgical service of a district hospital in Spain.

The coronavirus disease 2019, which is caused by severe acute respiratory syndrome coronavirus 2, was first identified in December 2019 in Wuhan, China, and has since spread rapidly, evolving into a full-blown pandemic. We would like to report our experience after 1 year of this pandemic in the surgical service of a district hospital in Spain. There have been many changes (including new protocols) that our service and the hospital have undergone, to adapt to the new situation. We believe that this experience can be useful for other professionals who have lived and are living a similar situation.

3D-Printed Surgical Steel Curettes for the Treatment of Perianal Fistula.

Need. The diversity of approaches proposed for the treatment of complex perianal fistulas reflects the fact that no method has yet been shown to be fully satisfactory. We believe the successful treatment of this condition is directly proportional to the amount of fibrous tissue that can be removed. Technical solution. We use a kit of small curettes, of different thicknesses and sizes, incorporating spicules that enable the physician to remove fibrous tissue from the fistula tract. The small size and varying thicknesses of the curettes enable them to mould to the curves of the fistula tract and to remove tissue by deroofing from the shallowest to the deepest layers, thus excising the entire fibrous tract. Our hospital has recently incorporated into clinical practice a new model of 3D-printed surgical steel curette, flanked by 2 lateral rings through which the suture is threaded. The central part of the curette contains radially graduated discs, the tips of which perform the debriding action, removing the fibrous tissue from the tract. Proof of concept. By using these curettes in conjunction with our standard technique (plugging the tract with platelet-rich fibrin), we have improved the success rate from 67% to 88%. Next steps. We have contacted several companies with a view to marketing this product. Conclusion. The results obtained are significantly better than those offered by the techniques in current use for the treatment of complex fistulas, without prejudice to outcomes such as anal continence and morbidity and mortality.

Prospective Study of Lactose Intolerance as a Potential Cause of Gas Bloat Syndrome in Patients Treated Surgically for Gastroesophageal Reflux.

Introduction. The high incidence of lactose intolerance leads us to consider that many of our patients could suffer from this alteration. Therefore, as its main sign (even when asymptomatic) is increased intestinal gas, patients recovering from a Nissen fundoplication have a significant probability of suffering from gas bloat syndrome. Materials and Methods. This prospective study was conducted from November 2012 to January 2017, we included all the patients who had been treated by the Nissen technique for gastroesophageal reflux disease with gas bloat syndrome detected during follow-up and tested positive for lactose intolerance. The study participants were then prescribed a lactose-poor diet to be followed for 3 months. The patients were asked to complete quality of life and symptomatology questionnaires before and after diet. The pre- and post-diet results were then compared. Results. The pre- and post-diet results showed statistically significant improvements in both questionnaires. Conclusion. Lactose intolerance may account for the symptoms presented by a significant number of patients with gas bloat syndrome following antireflux surgery; these patients could benefit from consuming a lactose-free diet, which we expect to alleviate or, in some cases, eliminate the above symptoms.

Can Perianal Fistula Be Treated Non-surgically with Platelet-Rich Fibrin Sealant?

INTRODUCTION: In the last 20 years, various procedures have been suggested for the treatment of anal fistula whilst minimising anal sphincter injury and preserving optimal function. Since 2011, patients at our hospital have been treated for anal fistula by means of platelet-rich fibrin plugs. To do so, three different application techniques have been used, the most recent of which is a non-surgical approach. In this paper, we compare and contrast the results obtained by each of these three techniques. MATERIAL AND METHOD: This study compares three procedures in which the anal fistula was sealed using platelet-rich fibrin: for the patients in group A, the plug was surgically inserted, under anaesthesia, and traditional methods were used to curette the fistula tract and close the internal orifice; for those in group B, the plug was surgically inserted, under anaesthesia, after curettage of the fistula tract using a graduated set of cylindrical curettes, and the internal orifice was closed as before; and for those in group C, the plug was inserted during outpatient consultation, without anaesthesia, without curettage and without closure of the internal orifice. RESULTS: The patients in the three groups were homogeneous in terms of sex, age, ASA classification, location of the fistula and previous insertion of the seton. There were no significant differences in morbidity or postoperative continence. However, there was a statistically significant difference in the outcomes achieved, in favour of group B, while groups A and C obtained similar results. CONCLUSIONS: Outpatient treatment of perianal fistula is totally innocuous. It is a very low cost procedure and the results obtained are highly acceptable (similar to those of the surgical insertion of a plug, with traditional curettage). Therefore, we believe this approach should be considered a valid initial treatment for perianal fistula, reserving surgical treatment (curettage and sealing using a cylindrical-curette kit) for cases in which this initial method is unsuccessful. This would avoid many complications and achieve considerable financial savings for the health system.

Using FloSeal® to control digestive bleeding in the distal large bowel.

We present an alternative treatment to resolve lower gastrointestinal bleeding by the application of FloSeal, a haemostatic matrix. Fundamentally, the treatment consists of inserting the tube containing the Sengstaken-Blakemore probe impregnated with FloSeal into the rectum-sigma. This procedure is simple, easy to reproduce and can be very useful to control bleeding in the last section of the gastrointestinal tract.

Migración de aguja de Kirschner al parénquima pulmonar / Migration of a Kirschner wire to the pulmonary parenchyma

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