Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain / Resultados de una encuesta sobre el soporte nutricional perioperatorio en la cirugía pancreática y biliar en España

INTRODUCTION: a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten years later we sent a questionnaire to check the current situation. METHODS: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. RESULTS: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95% CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95% CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95% CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2% of the sites used nutritional support (< 50% used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4% tried to use early oral feeding, but 88.2% of the surveyed teams used some nutritional support; 26.5% of respondents used TPN in 100% of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6% used TPN always, and EN in 19.3% of cases. CONCLUSIONS: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4% of the units used early oral feeding, and 32.3% used EN; 22.6% used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country

INTRODUCCIÓN: realizamos una encuesta sobre soporte nutricional perioperatorio en cirugía pancreática y biliar en hospitales españoles en 2007, que mostró que pocos grupos quirúrgicos seguían las guías de ESPEN 2006. Diez años después enviamos un cuestionario para comprobar la situación actual. MÉTODOS: treinta y ocho centros recibieron un cuestionario con 21 preguntas sobre tiempo de ayunas antes y después de la cirugía, cribado nutricional, duración y tipo de soporte nutricional perioperatorio, y número de procedimientos. RESULTADOS: respondieron 34 grupos. La mediana de pancreatectomías (cabeza/total) fue de 29,5 (IC 95 %: 23,0-35; rango, 5-68) (total, 1002), la de cirugías biliares malignas de 9,8 (IC 95 %: 7,3-12,4; rango, 2-30) y la de resecciones biliares por patología benigna de 10,4 (IC 95 %: 7,6-13,3; rango, 2-33). Solo el 41,2 % de los grupos utilizaban soporte nutricional antes de la cirugía (< 50 % habian efectuado un cribado nutricional). El tiempo medio de ayuno preoperatorio para sólidos fue de 9,3 h (rango, 6-24 h), y de 6,6 h para líquidos (rango, 2-12). Tras la pancreatectomía, el 29,4 % habían intentado administrar una dieta oral precoz, pero el 88,2 % de los grupos usaron algún tipo de soporte nutricional y el 26,5 % usaron NP en el 100 % de los casos. Los demás grupos usaron diferentes porcentajes de NP y NE en sus casos. En la cirugía biliar maligna, el 22,6 % utilizaron NP siempre y NE en el 19,3 % de los casos. CONCLUSIONES: la NP es el soporte nutricional más utilizado tras la cirugía de cabeza pancreática. Solo el 29,4 % de las unidades usan nutrición oral precoz y el 32,3 % emplean la NE tras este tipo de cirugía. El 22,6 % de las instituciones usan NP habitualmente tras la cirugía de tumores biliares malignos. Las guías ESPEN 2006 no se siguen de forma habitual en nuestro país tras más de 10 años desde su publicación

Biliobronchial fistula after liver surgery for giant hydatid cyst.

Background. Biliobronchial fistula (BBF) is a rare complication in the natural history of liver hydatid disease by Echinococcus granulosus. We present a case of BBF after resection of a giant liver hydatid cyst in a 72-year-old woman. Case Report. A total cystpericystectomy was done, leaving the left lateral section of the liver that was fixed to the diaphragm. Postoperatively, the patient developed obstructive jaundice. An ERCP showed an obstruction at the junction of the left biliary duct and the main biliary duct and contrast leak. At reoperation, the main duct was ischemic, likely due to torsion along its longitudinal axis. A hepatotomy was done at the hilar plate, and the biliary duct was dissected and anastomosed to a Roux-en-Y jejunal loop. She was discharged without complications. Five months later, the patient developed cholangitis and was successfully treated with antibiotics. However, she suffered repeated respiratory infections, and four months later she was admitted to the hospital with fever, cough, bilioptysis, and right lower lobe pneumonia. The diagnosis of BBF was confirmed with (99m)Tc Mebrofenin scintigraphy. At transhepatic cholangiography, bile duct dilation was seen, with a biliothoracic leak. She underwent dilatation of cholangiojejunostomy stricture with placement of an external-internal catheter. The catheter was removed 3.5 months later, and two years later the patient remains in very good condition. Conclusion. An indirect treatment of the BBF by percutaneous transhepatic dilation of the biliary stenosis avoided a more invasive treatment, with satisfactory outcome.

Initial surgical experience in laparoscopic total mesorectal excision for middle and lower third rectal cancer: short-term results.

INTRODUCTION: Total mesorectal excision (TME) of the rectum has been advocated as the gold standard surgical treatment of middle and lower third rectal cancer. Laparoscopy has gained acceptance among surgeons in the treatment of colon malignancies, while scepticism exists about laparoscopic TME in terms of safety and its oncological adequacy. OBJECTIVE: To evaluate the impact of laparoscopic TME on surgical and oncological outcome in a group of consecutive unselected patients. METHODS: One hundred and thirty-two patients with middle or inferior rectal cancer were admitted to our unit and underwent TME from December 1998 to February 2008. Eighty-nine patients were approached with laparoscopy. Patients staged cT3/4 cTxN+ or uTxN+ were submitted to neoadjuvant treatment. Postoperative complications and oncological outcomes were registered. RESULTS: In the laparoscopic group 80 anterior resections (including 4 intersphincteric resections and manual colo- anal anastomosis) and 9 abdominal-perineal resections were performed. 33.3% of patients were enrolled in "long-course" neoadjuvant chemo-radiotherapy (partial and complete response rates 88.2% and 11.8%, respectively). Protective lateral ileostomy was performed in 72% of patients. Mean operative time was 254.3+/-38.3 min and mean blood loss was 215+/-180 ml. Conversion rate was 12.7%. Morbidity rate was 39.3% without mortality. The rate of anastomotic leaks was 13.48%, reoperation rate 13.48%, recovery rate 3.1+/-1.4 days and hospital stay 10.4+/-4.6 days. Concerning adequacy of oncologic resection, mean distance of the tumour from the anal verge was 4.3+/-2.2 cm. Nodal sampling of 12.4+/-4.8 were obtained. Six patients (6/89, 6.74%) had a R1 margin: 3 distal and 3 circumferential. Median follow-up was 29 months and local recurrence rate was 5.79%. Four-year cumulative overall survival was 78% and disease-free survival was 63% (Kaplan-Meier method). CONCLUSIONS: Laparoscopic approach for rectal tumour is a technically demanding procedure, but it is oncologically safe.

[Tailgut cysts]. / Hamartomas quísticos retrorrectales.

Retrorectal cystic hamartomas (tailgut cysts) are rare congenital lesions thought to arise from remnants of the embryonic postanal gut. They predominantly occur as asymptomatic retrorectal multicystic masses in women. The treatment of choice is by complete surgical excision. The most important complications of these cysts are infection with a secondary fistula and malignant degeneration. The differential diagnosis includes a wide variety of conditions that occur in the retrorectal space. In this article, 3 cases showing different surgical technical aspects of treatment are presented. In addition, the aetiopathogenic features and histopathological appearance, clinical presentation and complications, imaging features and differential diagnosis of tailgut cysts are described.

Hamartomas quísticos retrorrectales / Tailgut cysts

Los hamartomas quísticos retrorrectales (tailgut cysts) son tumores congénitos poco frecuentes derivados de remanentes embrionarios postanales del intestino. La mayoría de los hamartomas quísticos son multiquísticos y aparecen como masas asintomáticas en mujeres de mediana edad. El tratamiento de elección es la extirpación completa. Las complicaciones más frecuentes son la infección y el desarrollo de fístulas cutáneas y la degeneración maligna. El diagnóstico diferencial incluye una extensa variedad de patologías que pueden existir en el espacio retrorrectal. En este artículo presentamos 3 pacientes con hamartomas quísticos y realizamos una revisión de su etiopatogenia, las manifestaciones clínicas, las técnicas de diagnóstico, sus complicaciones y los diagnósticos diferenciales. Asimismo, se discuten las diferentes técnicas quirúrgicas posibles para su abordaje quirúrgico (AU)

Retrorectal cystic hamartomas (tailgut cysts) are rare congenital lesions thought to arise from remnants of the embryonic postanal gut. They predominantly occur as asymptomatic retrorectal multicystic masses in women. The treatment of choice is by complete surgical excision. The most important complications of these cysts are infection with a secondary fistula and malignant degeneration. The differential diagnosis includes a wide variety of conditions that occur in the retrorectal space. In this article, 3 cases showing different surgical technical aspects of treatment are presented. In addition, the aetiopathogenic features and histopathological appearance, clinical presentation and complications, imaging features and differential diagnosis of tailgut cysts are described (AU)

Hernioplastias preperitoneales en M. Técnica y resultados en una serie de 280 casos / M-shaped preperitoneal hernioplasties. Technique and results in a series of 280 cases

Introducción. La efectividad del tratamiento de las hernias inguinocrurales por vía preperitoneal sigue siendo objeto de discusión. El desarrollo de la hernioplastia videoasistida totalmente extraperitoneal (TEP) ha reavivado el interés por los resultados a largo plazo de las técnicas preperitoneales abiertas. La técnica descrita en este trabajo combina algunas de las principales ventajas de los dos procedimientos preperitoneales abiertos más extendidos (Nyhus y Stoppa). Métodos. Entre marzo de 1995 y enero de 2002, 256 pacientes consecutivos, con un total de 280 hernias inguinocrurales, han sido tratados mediante una técnica preperitoneal abierta modificada, con una prótesis de polipropileno de 12 × 10 cm, sin suturas. Se analizan las características de la serie, los datos más relevantes de la técnica, la morbimortalidad y el seguimiento a medio plazo. Resultados. La edad media de los pacientes fue de 57 años (rango 15-88). La duración media de la intervención fue de 38 min, con una tasa de complicaciones postoperatorias del 7,3 por ciento. La estancia hospitalaria global media fue de 1,98 días. Con un seguimiento medio de 5,5 años, la tasa de recidiva ha sido del 0,87 por ciento. Conclusiones. La hernioplastia preperitoneal en M (HPM) es una técnica segura y relativamente sencilla para el tratamiento de las hernias inguinocrurales, independientemente del tipo de hernia o de las condiciones clinicopatológicas del paciente (AU)