Bariatric Surgery Waiting Lists in Spain.

Bariatric surgery is one of the most common general surgery procedures in countries that, like Spain, have public healthcare systems, but is also one of the procedures for which patients have to wait the longest. The Spanish Society of Obesity Surgery (SECO) conducted a survey to estimate the situation of bariatric surgery waiting lists in Spain's public hospitals and to gather information on a number of related aspects. METHODS: An online survey was sent to the members of the SECO. The survey received 137 visits, all via the click-through link provided, from 52 health centers (47 public and 5 private). The data collected were included in a database and later analyzed using the SPSS18.0 statistical software package. RESULTS: A total of 4724 patients were on bariatric surgery waiting lists (BWLs), at an average of 100 per public hospital. Sixty-eight percent had been waiting for more than 6 months. The mean delay per patient was 397 days, and the longest wait was 1661 days. A further 46.2% of respondents were able to recall cases of patients who in the past 5 years had suffered cardiovascular events with sequelae while awaiting surgery, and 21.2% recalled at least one fatal cardiovascular event in that time. CONCLUSION: Our data revealed an unacceptably long wait for obesity surgery. Notwithstanding the limitations and potential biases of our research, the long wait for surgery in our context inevitably has serious consequences for a potentially significant number of patients.

Laparoscopic repair of incarcerated low spigelian hernia with transperitoneal PTFE DualMesh.

There are different types of hernias that can develop at certain sites in the abdominal wall. Spigelian hernia (SH) is a protrusion of abdominal contents through a defect in the spigelian aponeurosis, in proximity to the external margin of the rectus muscle. Usually, abdominal wall hernia sac contains the omentum but may also contain small intestine that might become trapped in the hernia. When ischemia of herniated contents is suspected, urgent surgical treatment is advocated. Elective laparoscopic repair of SH is still under discussion. However, a recent randomized study comparing open and laparoscopic repair as elective treatment suggested that extraperitoneal laparoscopic repair is the technique that offers best results for the patients. Recent development of new biologic materials and technologies in laparoscopy has led to improved results. We report the successful repair of incarcerated low SH that was successfully managed by urgent laparoscopic intraperitoneal onlay polytetrafluoroethylene mesh hernioplasty.

Restorative proctocolectomy with an ileoanal pouch: the role of laparoscopy.

OBJECTIVES: The Aim of this retrospective study was to evaluate early experience with laparoscopic restorative proctocolectomy by analyzing the perioperative results of surgical treatment. PATIENTS AND METHODS: Seven major surgeries were performed in six patients with familial adenomatous polyposis and ulcerative colitis. All procedures were performed under laparoscopy at our third-level hospital from June 2003 to October 2004. RESULTS: Mean surgical time was 287.5 +/- 80.7 min, and median blood loss was 300 +/- 249.0 cc. There were no conversions; return of peristalsis began at 32 +/- 12.4 h; average time to first oral intake was 64.0 +/- 32.8 h, and mean duration of hospital stay was 9.3 +/- 1.2 days. There was one case of perineal sepsis due to ileal pouch-anal anastomotic leakage, which was successfully treated with oral intake restriction, parenteral nutrition, and intra-rectal drainage. The most common postoperative complication was postoperative ileus. CONCLUSIONS: We believe that the laparoscopic approach to restorative proctocolectomy may be considerably improved in our center. Particular aspects for improvement include efforts to achieve lower operating and hospitalization times to equate our results with those reported by multicenter studies for laparoscopic colon cancer surgery. In our opinion, learning and further training opportunities should be encouraged to improve surgeon experience in the field of laparoscopy, preferably at centers specializing in restorative proctocolectomy.

Usefulness of Clinical Signs and Diagnostic Tests for Suspected Leaks in Bariatric Surgery.

BACKGROUND: The early diagnosis of leakage poses a challenge to bariatric surgeons, who need to suspect and treat it promptly. The aim of this study is to determine the value of clinical signs and complementary tests in its detection. METHODS: Between January 2007 and 2012, 200 patients underwent surgery for pathological obesity. Perioperative variables were collected prospectively, and univariate and multivariate analyses were conducted to study the factors related to leak occurrence and the predictive value of the tests performed. RESULTS: The study includes 172 proximal gastric bypasses and 28 sleeve gastrectomies. Nine patients (4.5 %) had leaks in the immediate postoperative period. Multivariate analyses found that age over 48 years and preoperative BMI > 48 kg/m(2) were the patient-related variables associated with a higher risk of leakage. The clinical variables significantly related to postoperative leaks were heart rate over 100 bpm, leukocytes over 15,000/mm(3) and systolic arterial pressure below 100 mmHg. In patients with a clinical suspicion of leakage (n = 19), 7.7 % of abdominal CT scans returned false negatives, versus 28.6 % for oral methylene blue and 22.2 % for upper gastrointestinal (UGI) Gastrografin swallow [Corrected]. CONCLUSIONS: Bariatric surgery proved to be a safe technique at our medical centre. Patient-related variables associated with a higher risk of leakage were age and BMI. Early clinical signs of leakage were tachycardia, leukocytosis and hypotension. The most reliable diagnostic test was the abdominal CT scan.

Effectiveness of colorectal laparoscopic surgery on patients at high anesthetic risk: an intervention cohort study.

AIMS: The aim of the study was to assess the effectiveness of laparoscopic colorectal surgery in patients at high preoperative anesthetic risk because of associated pathologies. MATERIALS AND METHODS: From January 2003 until January 2005, 116 patients were systematically assigned at a ratio of 1:1 to one of two groups: laparoscopy surgery (n=59, of which 31 were American Society of Anesthesiologists score [ASA] I-II [L1] and 28 ASA III-IV [L2]) or open surgery (n=57, of which 30 were ASA I-II [O1] and 27 ASA III-IV [O2]). Data on patient demographics and clinical and anesthetic variables were collected prospectively. Informed consent was obtained from the patients, and approval was obtained from the designated review board of the institution involved. RESULTS: The number of minor anesthetic complications during surgery was higher in L2 patients. No differences were observed in blood gas parameters studied during surgery (pCO(2), pH, and pO(2)/FiO(2)). Transfusion rates in the laparoscopy group at greater anesthetic risk (L2) were lower than those of the high-risk conventional surgery group (O2; 21.4 vs 63%, P<0.02). Duration of stay in the surgical recovery room and the inpatient ward were also shorter in the L2 group than in the O2 group (8.7+/-4.5 vs 12.2+/-6 days, P=0.02). There was no difference in perioperative clinical variables between laparoscopy groups (L1, L2). CONCLUSION: Postoperative recovery of ASA III-IV patients is better after laparoscopic surgery for colorectal cancer, at the expense of a higher rate of minor anesthetic occurrences during surgery.

An unusual case of hemoperitoneum owing to acute splenic torsion in a child with immunoglobulin deficiency.

Wandering spleen is an uncommon clinical entity, which rarely affects children and adolescents. It is usually described in adults, being most common in the multiparous women of childbearing age. A case of a 14-year-old girl with a past history of splenomegaly and immunoglobulin A (IgA) deficiency, who presented with a sudden onset of abdominal pain, is presented. Diagnosis of hemoperitoneum secondary to torsion of a wandering spleen was made by computed tomography scan and Doppler ultrasound. Laparoscopy revealed hemoperitoneum owing to a ruptured and infarcted spleen. Laparotomy was undertaken and open splenectomy was successfully performed. The patient was discharged after an uneventful postoperative course that was not punctuated by any major complication. Management of this rare surgical emergency is discussed. Based on the details of this case, the authors hypothesize that IgA deficiency causes splenomegaly, which in turn predisposes to ligamentous laxity and splenic torsion.

Primary cutaneous mucormycosis: a diagnosis to consider.

Primary cutaneous mucormycosis is a deep fungal infection, mainly seen in diabetics and immunocompromised subjects. Rapid diagnosis and therapy are necessary to avoid fatal outcome. We describe the complete histopathological and microbiological studies of primary cutaneous mucormycosis in a 74-year-old man with several risk factors, such as chronic obstructive pulmonary disease, respiratory acidosis, hemolytic anemia, myelodysplastic syndrome and iatrogenic diabetes, due to corticosteroid therapy. He developed two cutaneous necrotic scars on his left leg. Mucormycosis was suspected and specimens from surgical débridement were histopathologically and microbiologically studied confirming the clinical diagnosis. Amphotericin B was given topically and intravenously resulting in complete healing of the ulcer. Risk factors and microbiological studies are compared with those in the current literature. It is necessary in certain cases to suspect mucormycosis infections in diabetics, immunocompromised subjects and even in healthy individuals. Rapid diagnosis and treatment are important, but they should be based on complete histopathological and microbiological studies, to establish the genus of the causal agent.

Proctocolectomía restauradora con reservorio ileoanal: el papel de la laparoscopia / Restorative proctocolectomy with an ileoanal pouch: the role of laparoscopy

Objetivos: el objetivo de este estudio restrospectivo es evaluarla experiencia inicial en la proctocolectomía restauradora laparoscópica,analizando los resultados perioperatorios obtenidos durantela fase de introducción de la técnica.Pacientes y métodos: entre junio de 2003 y octubre 2004,realizamos siete intervenciones mayores en seis pacientes afectosde poliposis colónica familiar y colitis ulcerosa mediante abordajelaparoscópico.Resultados: el tiempo medio quirúrgico fue: 287,5 ± 80,7min y las pérdidas hemáticas: 300 ± 249,0 cc. No hubo conversiones;el inicio del peristaltismo fue: 32 ± 12,4 h; el tiempo mediode reintroducción de la alimentación: 64,0 ± 32,8 h; el tiempomedio de estancia hospitalaria: 9,3 ± 1,2 días. Hubo un casode dehiscencia del reservorio ileoanal con sepsis perineal tratadasatisfactoriamente con dieta absoluta, nutrición parenteral y drenajedel mismo mediante punción intrarrectal. La complicaciónpostoperatoria más frecuente fue la presencia de íleo postoperatorio.Conclusiones: creemos que la proctocolectomía restauradoralaparoscópica aún debe mejorar. Estas mejoras deberían reducirlos tiempos operatorios y la estancia hospitalaria para que la laparoscopiaen este campo iguale los resultados tan favorables obte-nidos en estudios multicéntricos en la cirugía oncológica del colon.En nuestra opinión, estos cambios deberían producirse con elaprendizaje y formación de los cirujanos en laparoscopia colorrectaly siempre en centros dedicados especialmente a este tipo de cirugía

Objectives: the aim of this retrospective study was to evaluateearly experience with laparoscopic restorative proctocolectomy byanalyzing the perioperative results of surgical treatment.Patients and methods: seven major surgeries were performedin six patients with familial adenomatous polyposis and ulcerativecolitis. All procedures were performed under laparoscopyat our third-level hospital from June 2003 to October 2004.Results: mean surgical time was 287.5 ± 80.7 min, and medianblood loss was 300 ± 249.0 cc. There were no conversions;return of peristalsis began at 32 ± 12.4 h; average time to firstoral intake was 64.0 ± 32.8 h, and mean duration of hospital staywas 9.3 ± 1.2 days. There was one case of perineal sepsis due toileal pouch-anal anastomotic leakage, which was successfullytreated with oral intake restriction, parenteral nutrition, and intrarectaldrainage. The most common postoperative complicationwas postoperative ileus.Conclusions: we believe that the laparoscopic approach torestorative proctocolectomy may be considerably improved in ourcenter. Particular aspects for improvement include efforts toachieve lower operating and hospitalization times to equate ourresults with those reported by multicenter studies for laparoscopiccolon cancer surgery. In our opinion, learning and further trainingopportunities should be encouraged to improve surgeon experiencein the field of laparoscopy, preferably at centers specializingin restorative proctocolectomy

Linfangiectasias vulvares / Vulvar lymphangiectases

Las linfangiectasias cutáneas se han descrito clásicamente como una rara complicación tras mastectomía radical o tratamiento radioterápico o quirúrgico de carcinomas de cervix con o sin linfadenectomía. El principal factor desencadenante que se ha barajado es la obstrucción linfática profunda. Con posterioridad han aparecido en la literatura algunos casos cuyos antecedentes parecen tener más relación con factores locales en la matriz intercelular dérmica, que con daño profundo del sistema linfático.Describimos el caso de un linfangioma adquirido localizado en vulva tras una histerectomía radical con radioterapia posterior debido a un carcinoma de cervix y discutiremos la etiopatogenia de esta entidad (AU)

Queratosis seborreicas irritadas simétricas en paciente con trasplante renal / Simetric irritated seborrhoeic keratoses in a renal transplant recipient

La queratosis seborreica es uno de los tumores epidérmicos benignos más frecuentes encontrados en la práctica clínica. Su transformación maligna es excepcional. Presentamos el caso de la aparición inusual de dos queratosis seborreicas irritadas simétricas en los brazos de un trasplantado renal (AU)