Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial.

BACKGROUND: Previous observational studies have demonstrated the safety of discharging patients after laparoscopic appendectomy within the same day without hospitalization. The application of Enhanced Recovery After Surgery (ERAS) guidelines has resulted in shorter length of stay, fewer complications, and reduction in medical costs. The aim of this study was to investigate if ERAS protocol implementation in patients with acute uncomplicated appendicitis decreases the length of stay enough to allow for ambulatory laparoscopic appendectomy. METHODS: In this prospective, randomized controlled clinical trial, 108 patients were randomized into two groups: laparoscopic appendectomy with ERAS (LA-E) or laparoscopic appendectomy with conventional care (LA-C). The primary endpoint was postoperative length of stay. The secondary end points were time to resume diet, postoperative pain, postoperative complications, re-admission rate, and reoperation rate. RESULTS: From January 2016 through May 2017, 50 patients in the LA-E group and 58 in the LA-C were analyzed. There were no significant differences in preoperative data. Regarding the primary end point of the study, the ERAS protocol significantly reduced the postoperative length of stay with a mean of 9.7 h (SD: 3.1) versus 23.2 h (SD: 6.8) in the conventional group (p < 0.001). The ERAS protocol allowed ambulatory management in 90% of the patients included in this group. There was a significant reduction in time to resume diet (110 vs. 360 min, p < 0.001) and less moderate-severe postoperative pain (28 vs. 62.1%, p < 0.001) in the LA-E versus LA-C group. The rate of complications, readmissions, and reoperations were comparable in both groups (p = 0.772). CONCLUSIONS: ERAS implementation was associated with a significantly shorter length of stay, allowing for the ambulatory management of this group of patients. Ambulatory laparoscopic appendectomy is safe and feasible with similar rates of morbidity and readmissions compared with conventional care.

[Laparoscopic drainage of liver abscess. Initial experience]. / Drenaje laparoscópico de absceso hepático. Experiencia inicial.

BACKGROUND: Radiologically guided percutaneous drainage has proven to be simple and effective and currently is considered the gold standard of care with success rates between 80 and 87%. However, not all abscesses are amenable to or will resolve with percutaneous drainage. The purpose of this study is to report our 1-year initial experience with laparoscopic drainage of liver abscesses. METHODS: Patients with diagnosis of liver abscess and who had a surgical indication and were submitted to laparoscopic drainage were studied prospectively from January to December of 2004. RESULTS: Six patients underwent laparoscopic drainage. There were three men and three women with a mean age of 50.8 years. Four patients had single lesions and two had multiple lesions. Mean size of the abscesses was 10.9 x 7.7 cm, segments primarily affected were 5 and 8. Two patients had amebic and four pyogenic abscesses. Mean operative time was 142 min. All patients were eating by the day following surgery and were ambulating between 24 and 72 h postoperatively. All patients reported to be asymptomatic at the time of their last visit. There was one recurrence that resolved with a second procedure. CONCLUSIONS: Success rate with the laparoscopic drainage of liver abscesses (83.3%) makes this procedure an effective and viable surgical alternative as a primary approach in selected patients or after a failed percutaneous drainage.

[Sigmoid diverticulitis in adolescent. Case report]. / Diverticulitis de sigmoides en adolescente. Reporte de caso.

BACKGROUND: Few cases have been reported in children and adolescents of sigmoid diverticulitis. Most of the case reports in medical literature are associated with true congenital diverticula and genetic diseases of collagen synthesis. CLINICAL CASE: 13 year-old female who was admitted to General and Endoscopic Surgery service with diagnosis of complicated appendicitis. Laparotomy was performed finding complicated sigmoid diverticular disease. Lavage, sigmoidectomy and primary anastomosis were performed. The histopathological findings reported a perforated pseudo-diverticulum of the sigmoid colon with peritonitis. The patient was discharged 72 hours after surgery and no complications were reported. CONCLUSION: There are only case reports about colonic diverticulitis in children and adolescents, and its etiology has not yet been well established. This patient had sigmoid pseudo-diverticula and did not present genetic concomitant disease. This case is an exception to data reported on literature about diverticular disease in this population.

Antecedentes: la enfermedad diverticular colónica en niños y adolescentes es poco frecuente y sólo existen reportes de casos aislados en la bibliografía. La mayoría de los casos reportados se asocian con divertículos verdaderos congénitos y enfermedades genéticas de producción de la colágena. Caso clínico: paciente femenina de 13 años de edad, que ingresó a la División de Cirugía General y Endoscópica con diagnóstico de apendicitis aguda complicada. En la laparotomía se encontró enfermedad diverticular complicada de colon sigmoides. Se le practicó sigmoidectomía y colorrecto-anastomosis. El reporte histopatológico evidenció perforación de pseudodivertículo de colon sigmoides y peritonitis. La paciente fue dada de alta del hospital 72 horas posteriores a la cirugía, sin complicaciones. Conclusión: existen sólo reportes de casos aislados de niños y adolescentes con diverticulitis colónica, y su etiología no ha sido aún debidamente establecida. Esta paciente tuvo diverticulitis de sigmoides, similar a la enfermedad en adultos, sin padecimientos genéticos concomitantes. El caso es una excepción a lo reportado en la bibliografía de las diverticulitis en niños y adolescentes.