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the SARS-CoV-2 infection ranges from asymptomatic to critical forms and several prognostic factors have been described. Atrial fibrillation (AF) is common in acute situations where it is linked with more complications and mortality. We aimed to evaluate the prognostic information of AF in this population.retrospective analysis of a cohort of 517 patients consecutively admitted in a tertiary hospital due to SARS-CoV-2 infection. We divided the patients in two groups according the development of AF and compared the main features of both groups. An univariable and multivariable analysis of mortality were also performed.among 517 patients with SARS-CoV-2 infection admitted in a tertiary center, 54 (10.4%) developed AF. These patients are older (81.6 vs 66.5 years old,Atrial fibrillation appears in 10% of hospitalized patients with SARS-CoV-2 infection. These patients present more comorbidities and two-fold increase in hospital mortality. Atrial fibrillation is not an independent prognostic factor.La infección por SARS-CoV-2 presenta un amplio espectro clínico, y varios factores pronósticos han sido descritos. La fibrilación auricular (FA) es frecuente en situaciones agudas, donde se ha relacionado con aumento de complicaciones y mortalidad. Nuestro objetivo ha sido evaluar el impacto pronóstico de la FA en esta población.Análisis retrospectivo de una cohorte de 517 pacientes con infección SARS-CoV-2 consecutivamente ingresados en un hospital terciario. Dividimos a los pacientes en dos grupos de acuerdo al desarrollo de FA durante el ingreso y comparamos las características de los grupos. Realizamos análisis univariado y multivariado de mortalidad.De los 517 pacientes, 54 (10,4%) desarrollaron FA. Estos pacientes son mayores (81,6 vs. 66,5 años, p 0,001) y presentan más hipertensión (74% vs. 47%, p 0,001), miocardiopatía (9% vs. 1%, p = 0,002), ingreso previo por insuficiencia cardiaca (9% vs. 0,4%, p 0,001), historia de FA (83% vs. 1%, p 0,001) y mayor aurícula izquierda (47,8 vs. 39,9 mm, p 0,001). Los pacientes con FA presentan más fallo respiratorio agudo (72% vs. 40%, p 0,001) y mayor mortalidad hospitalaria (50% vs. 22%, p 0,001). Los predictores de FA son la edad y la historia de FA previa. La FA no es un predictor independiente de mortalidad hospitalaria. Los predictores son: edad, creatinina 1,5 mg/dL al ingreso, LDH 250 U/L al ingreso y el fallo respiratorio agudo.La FA aparece en el 10% de los pacientes hospitalizados por SARS-CoV-2. Estos presentan mayor comorbilidad y el doble de mortalidad hospitalaria, pero la FA no es un factor pronóstico independiente.

Resumen Introduccion y objetivos La endocarditis infecciosa (EI) es una enfermedad compleja con elevada mortalidad. La evaluacion pronostica es esencial en el tratamiento de la enfermedad; sin embargo, las guias internacionales no aportan una evaluacion objetiva del riesgo individual. Se desarrollo un modelo predictivo de mortalidad hospitalaria en EI izquierda combinando las variables pronosticas propuestas por la guia europea. Metodos Se utilizaron 2 cohortes prospectivas de pacientes con EI izquierda. La cohorte 1 (n = 1.002) se aleatorizo 2:1 para obtener 2 muestras: muestra de derivacion (n = 688) y muestra de validacion interna (n = 314). La cohorte 2 (n = 133) se utilizo para la validacion externa. Resultados El modelo incluyo edad, endocarditis protesica, comorbilidades, insuficiencia cardiaca, insuficiencia renal, shock septico, Estafilococo aureus, hongos, complicaciones perianulares, disfuncion ventricular y vegetaciones como predictores independientes de mortalidad hospitalaria. El modelo mostro buena capacidad discriminativa (area bajo la curva ROC = 0,855; IC95%, 0,825-0,885) y calibracion (p valor test Hosmer-Lemeshow = 0,409) que se ratificaron en la validacion interna (area bajo curva ROC = 0,823; IC95%, 0,774-0,873) y externa (area bajo curva ROC = 0,753; IC95%, 0,659-0,847). Para la muestra de validacion interna (mortalidad 29,9%) el modelo predijo una mortalidad de 30,7% (IC95%, 27,7-33,7) y para la muestra de validacion externa (mortalidad 27,1%) 26,4% (IC95%, 22,2-30,5). Conclusiones Se presenta un modelo predictivo de mortalidad hospitalaria en EII basado en las variables pronosticas propuestas por la guia europea de EI y con alta capacidad discriminativa.

Laparoscopic sleeve gastrectomies (LSGs) can experience weight-loss failure and conversion to another bariatric procedure. An analysis of the bariatric literature concerning the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) as revisional surgery after LSG in terms of safety and efficacy identified 607 studies. Fifty-nine studies were analyzed for full content review and 9 primary studies (398 patients) were included. Revisional single anastomosis duodeno-ileal bypass (SADI) was performed in 294 patients at a mean interval of 37.7 months (range 11-179). Total weight loss (%) varies from 20.5% to 46.2%. Early complications after surgery occurred in 4.1% surgeries including leak (7 cases -1.9%). Mortality was nil. SADI after LSG, after failed sleeve gastrectomy or as a sequential procedure, offers a satisfactory weight loss result. Both early and late term complications are acceptable.

Background: Surgical site infections (SSIs) remains a concern for surgeons because of the negative impact on outcomes and health care costs. Our purpose was to assess whether topical antibiotics before primary incision closure reduced the rate of SSIs. Methods: Systematic review of MEDLINE/PubMed, Scopus, CINAHL, and Web of Science databases from inception to January 2017. Only randomized controlled trials (RCTs) were retrieved. The primary outcome was the SSI rate. Meta-analysis was complemented with trial sequential analysis (TSA). Results: Thirty-five RCTs (10,870 patients) were included. Only β-lactams and aminoglycosides were used. A substantial reduction of the incidence of SSIs with the application of antibiotic agents before incision closure (risk ratio [RR] 0.49, 95% confidence interval [CI] 0.37-0.64) was found, which remained in the analysis of 12 RCTs after removal of studies of uncertain quality. The use of β-lactams was effective to reduce SSI in elective surgery only (RR 0.33, 95% CI 0.13-0.85). In clean-contaminated fields and as an irrigation solution, β-lactams did not reduce the risk of SSI. Aminoglycosides were not effective (RR 0.74, 95% CI 0.49-1.10). After TSA, the evidence accumulated was far below the optimal information size. The heterogeneity of studies was high and methodological quality of most RCTs included in the meta-analysis was uncertain. Conclusions: Results of this meta-analysis show the data present in the literature are not sufficiently robust and, therefore, the use of topical β-lactams or aminoglycosides before incision closure to reduce SSI cannot be recommended or excluded.

The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has been introduced in the past few years for the treatment of morbid obesity. SADI-S has shown good results in terms of long-term results and short-term complications. However, the management of patients undergoing SADI-S and suffering from a leak is a great challenge for surgeons. We present an extensive review of the currently available literature on the management of leak after SADI in morbid obese (MO) patients. We aim at providing objective information regarding the optimal management, including diagnosis, technical options for the different strategies that have been proposed, to facilitate the selection of the best individual approach for each MO patient.

The management of morbidly obese patients with a concomitant ventral hernia (VH) is a great challenge for surgeons. There is controversy over the optimal strategy to tackle both health problems, requiring an individualized approach. Obese patients have a higher recurrence rate after hernia repair, and bariatric surgery in the presence of a VH can be difficult. As morbid obesity is related with severe comorbidities, including increased cardiovascular and anesthetic risks, some advocate for a single-stage strategy. A primary hernia repair carried out during the bariatric surgery, however, may increase morbidity without definitively solving the problem. Biological meshes are expensive and also have a high recurrence rate. The laparoscopic placement of a synthetic mesh offers good results, but it is worrisome because bariatric surgery is a clean-contaminated procedure. Moreover, there is a great chance that a plastic surgery would be necessary after completing the weight-loss process, and the abdominal wall surgery could be performed at that point. There are many arguments, but the evidence is weak. We present an extensive review of the currently available literature on the management of VH in morbidly obese patients. We aim to provide objective information regarding the pros and cons of the different strategies that have been proposed, to facilitate the selection of the best approach to individual morbidly obese patients with abdominal wall hernias precising both of surgical repair.

The aim of this study was to assess the reduction in the incidence of parastomal hernia (PH) after placement of prophylactic synthetic mesh using a modified Sugarbaker technique when a permanent end-colostomy is needed.Prevention of PH formation is crucial given the high prevalence of PH and difficulties in the surgical repair of PH.A randomized, prospective, double-blind, and controlled trial. Rectal cancer patients undergoing laparoscopic abdominoperineal resection with permanent colostomy were randomized (1 : 1) to the mesh and nonmesh arms. In the mesh group, a large-pore lightweight composite mesh was placed in the intraperitoneal/onlay fashion using a modified Sugarbaker technique. PH was detected by computed tomography (CT) after a minimum follow-up of 12 months. Analysis was per-protocol.The mesh group included 24 patients and the control group 28. Preoperative data, surgical time, and postoperative morbidity were similar. The median follow-up was 26 months. After CT examination, 6 of 24 PHs (25%) were observed in the mesh group compared with 18 of 28 (64.3%) in the nonmesh group (odds ratio 0.39, 95% confidence interval 0.18-0.82; P = 0.005). The Kaplan-Meier curves showed significant differences in favor of the mesh group (long-rank = 4.21, P = 0.04). The number needed to treat was 2.5, which confirmed the effectiveness of the intervention.Placement of a prosthetic mesh by the laparoscopic approach following the modified Sugarbaker technique is safe and effective in the prevention of PH, reducing significantly the incidence of PH.

Background: Robotic bariatric surgery (RBS) has increased in recent years. Many doubts continue to exist regarding its utility in terms of postoperative complications, costs and technical aspects. RBS has increased its number and shows a more technical challenge associated with more post-operative complications compared to primary bariatric surgery. We herein present a single institution experience and review to describe its utility in revisional surgery. Methods: A retrospective review of our experience and a review of the literature has been conducted to evaluate the impact of robotic revisional surgery in the bariatric field. Results: A total of 17 patients (5 female and 12 male) were operated on. Most frequent surgery was conversion of sleeve gastrectomy to gastric bypass (n=9). No leaks were found nor severe complications. A systematic review showed similar results including a decreased number for complications when performing robotic revisional surgery. Conclusions: Revisional robotic surgery shows better results compared to standard laparoscopic revisional bariatric surgery in terms of efficacy, safety and hospital stay. No differences were seen in rates of mortality, morbidity and reintervention between both approaches. We encourage surgeons to learn to perform the robotic technique as part of the process of democratization and standardization of bariatric surgery.

Povidone iodine (PVI) is a widely used antiseptic solution among surgeons. A meta-analysis based on randomized controlled trials (RCTs) was conducted to establish whether application of PVI before wound closure could reduce surgical site infection (SSI) rates. Systematic review of MEDLINE/PubMed, Scopus, CINAHL, and Web of Science databases from inception to September 2017, with no language restrictions. Only RCTs were retrieved. The primary outcome was the SSI rate. Meta-analysis was complemented with trial sequential analysis (TSA). A total of 7601 patients collected from 16 RCTs were analyzed. A reduction in overall SSI rate was found (RR 0.64, 95% CI 0.48–0.85, P = 0.002, I2 = 65%), which was attributed to patients undergoing elective operations (n = 2358) and mixed elective/urgent operations (n = 2019). When RCTs of uncertain quality (n = 9) were excluded, the use of PVI before wound closure (n = 4322 patients) was not associated with a significant reduction of SSI (RR 0.81, 95% CI 0.55–1.20, P = 0.29, I2 = 51%) and was only significant in clean wounds (RR 0.25, 95% CI 0.09–0.70, P = 0.008, I2 = 0%). For the primary outcome, the TSA calculation using a relative risk reduction of 19% and an 11% proportion of control event rate (CER) with 51% of I2, the accrued information size (n = 4322) was 32.8% of the estimated optimal information size (n = 13,148). There is no conclusive evidence for a strong recommendation of topical PVI before wound closure to prevent SSI.

Low anterior resection syndrome (LARS) is frequent following sphincter-sparing procedures for rectal cancer. This study aims to assess surgeons’ awareness of LARS. This was a survey study. Members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP). Three hundred thirty-four surgeons from the ASCRS and 150 from the Spanish Societies completed a 23-item electronic questionnaire. Surgeons’ opinions regarding different aspects of LARS. The proportion of rectal cancer patients undergoing sphincter-sparing operations ranged between 71 and 90 %. Low anterior resection with end-to-end anastomosis was the most frequently cited procedure after mesorectal excision. More than 80 % of participants were recognized to be moderately or extremely aware of the condition, but regarding the method used to assess LARS, the majority relied on clinical manifestations. Around 35 % of surgeons considered that severe LARS developed in less than 40 % of patients. The most important factor related to defecatory function impairment in the surgeons’ opinion was the distance from the anal margin to anastomosis. Other factors thought to be involved were anastomotic leakage, preoperative radiation therapy, age, and postoperative radiotherapy, with similar percentages in the two groups of surgeons. Lifestyle changes and dietary measures associated with or without drug treatment was the modality of choice. The experience with transanal irrigation or sacral nerve stimulation was limited. It was considered that

Aim: To assess the outcome (postoperative morbidity and mortality and/or development of incisional hernia) of patients with burst abdomen (BA) of midline laparotomy without intestinal fistula comparing early closure of the abdominal wall with a running suture alone vs. running suture plus reinforcement with a non-absorbable synthetic mesh. Methods: Retrospective analysis of the medical records of all patients undergoing surgical repair of a BA in three hospitals between 2006 and 2011. Risk factors, postoperative complications and the incidence of incisional hernia (IH) after a minimum of 12-month follow-up period were compared between groups. Results: A total of 109 patients were treated for BA, 18 patients treated by non-standard procedures were excluded from analysis. Of the remaining 91 patients, 56 belong to the mesh group and 35 to the suture group. The overall rate of postoperative complications was high in both groups (79.1%). Mortality rate was higher in the suture group than in the mesh group (31.4% vs. 14.3%; P = 0.06). IH was also more frequent in the suture group (36.4% vs. 17.6%; P = 0.057). Conclusions: Patients with BA and without intestinal fistula could be candidates for surgical repair using a running suture and a non-absorbable polypropylene mesh in the “onlay” position.

Aim To assess factors independently associated with low anterior resection syndrome (LARS) following resection or rectal cancer. Method Cross-sectional study carried out in two acute-care teaching hospitals in Barcelona, Spain. Patients who had undergone sphincter preserving low anterior resection with curative intent, with total or partial mesorectal excision (with and without protective ileostomy) between January 2001 and December 2009 completed a self-administered questionnaire to assess bowel dysfunction after rectal cancer surgery. Predictors of LARS were assessed by univariate and multivariate analyses. Results The questionnaire was sent to 329 patients (response rate 57.7%). Six cases of incomplete questionnaires were excluded. The study population included 184 patients (66.8% men) with a mean age of 63 years. There were 44 (23.9%) patients with no LARS, 36 (19.6%) with minor LARS and 104 (56.2%) with major LARS. In the univariate analysis, total mesorectal excision (P = 0.0008), protective ileostomy (P = 0.002), preoperative and postoperative radiotherapy (P = 0.0000), postoperative chemotherapy (P = 0.0046) and age (P = 0.035) were significantly associated with major LARS, whereas in the multivariate analysis, total mesorectal excision (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.02-4.65), preoperative radiotherapy (OR 4.33, 95% CI 2.03-9.27) and postoperative radiotherapy (OR 9.52, 95% CI 1.74-52.24) were independent risk factors for major LARS. Conclusions In this study, the risk of having major LARS increases with total mesorectal excision and both neoadjuvant and adjuvant radiotherapy. This article is protected by copyright. All rights reserved.

Advanced age is a risk factor of major abdominal surgery due to diminished functional reserve and increased comorbidity. Laparoscopy-assisted colectomy is a well-established procedure in colon cancer surgery. The aim of this study was to compare early outcome of elective laparoscopy surgery and open colectomy in colon cancer patients according to age.A total of 545 patients with colonic adenocarcinoma underwent elective surgery between 2005 and 2009. There were 277 patients in the laparoscopic group and 268 in the open. Patient characteristics in both groups were homogeneous and further stratified into three subgroups by age:75, between 75-84, and ≥ 85 years. Main outcome measures were early morbidity, mortality, and hospital stay.Open surgery group showed a higher overall morbidity rate (37.3 vs. 21.6%, P = 0.001), medical complications (16.4 vs. 10.5%, P = 0.033), surgical complications (23.5 vs. 15.5%, P = 0.034), and mortality (6.7 vs. 3.2%, P = 0.034). The overall morbidity rate difference between open and laparoscopy approach disappeared in the oldest group (≥ 85 years old). Surgical site infections rate was inferior for patients75 years old in laparoscopy group compared with open. Mortality was also significantly inferior in laparoscopy group in younger patients (75 years, 0 vs. 3%, P = 0.038). Mean hospital stay was shorter for patients in75 and 75-84 groups with laparoscopic approach (7.8 vs. 11.4 days and 10 vs. 14.3, respectively, P = 0.001) as compared with those who underwent open surgery, but these differences disappeared in patients aged ≥ 85 years.Laparoscopy-assisted colectomy in patients underwent elective surgical resections for colon cancer showed advantages in rate of early complications in patients younger than 85 years of age and was found to be as safe and well tolerated as open surgery in patients over 85 years of age.

Resumen Revertir un estoma temporal implica 2 procedimientos quirurgicos diferentes: la reconstruccion del transito intestinal y el cierre de la pared abdominal en el sitio del estoma. Este ultimo presenta diferentes aspectos que deben ser analizados: a) la infeccion del sitio quirurgico (ISQ), b) el manejo de una hernia coincidente en el sitio del estoma en el momento de su cierre, c) la prevencion del desarrollo de una hernia incisional posterior, d) el cierre del estoma en el caso de que se realice la reconstruccion del transito por via laparoscopica, o e) el cierre de la piel del sitio del estoma. El objetivo de este trabajo es analizar estos aspectos en relacion con la reconstruccion de la pared abdominal por la que emerge un estoma temporal cuando se procede al cierre de este.

Resumen Introduccion El objetivo de este trabajo es valorar si los resultados del cierre de ileostomia en asa en terminos de morbimortalidad y estancia hospitalaria se ven influidos por el tipo de anastomosis y de sutura empleada. Metodo Se ha revisado el grupo de pacientes intervenidos por cierre de ileostomia en asa, y se ha realizado un analisis retrospectivo de cohortes comparando la morbimortalidad y estancia hospitalaria en funcion del tipo de anastomosis (TT o LL) y del tipo de sutura (manual/mecanica). Resultados Desde enero del 2003 a noviembre del 2011 se han analizado 167 procedimientos de reconstruccion del transito en ileostomia en asa. La distribucion por grupos fue: tipo de anastomosis (TT 95; LL 72) y tipo de sutura (manual 105; mecanica 62). En el 76% de la poblacion observada la enfermedad de base fue de origen oncologico. La mortalidad ha sido de un caso. El analisis de morbilidad estratificado por tipo de complicaciones no mostro diferencias significativas entre los grupos en cuanto a complicaciones locales (TT 7,4%; LL 8,3%; manual 6,7%; mecanica 9,7%), generales (TT 9,5%; LL 16,7%; manual 6,7%; mecanica 6,5%) y quirurgicas (TT 15,8%; LL 19,4%; manual 17,1%; mecanica 17,7%), ni en el indice de reintervencion (TT 6,3%; LL 6,9%; manual 6,7%; mecanica 6,5%) ni estancia hospitalaria expresada en dias (TT 7,8; LL 8; manual 8,6; mecanica 6,7). Conclusiones La reconstruccion del transito intestinal en las ileostomias en asa puede realizarse independientemente del tipo de anastomosis y de sutura empleadas, con la misma tasa de morbimortalidad y estancia hospitalaria.

Resumen Los materiales sinteticos permanentes son de eleccion en la actualidad para la reparacion de las hernias de la pared abdominal. Sin embargo, no son ideales y se describen complicaciones relacionadas con ellos a corto y largo plazo. Fruto de la investigacion y desarrollo de nuevos materiales han surgido los implantes biologicos derivados de la matriz extracelular (IBMEC). En los ultimos anos han aparecido varios tipos de IBMEC, cada uno con caracteristicas propias de manufacturacion y diferentes a los demas. En este trabajo se analiza el panorama actual de los IBMEC xenogenicos disponibles en nuestro medio, el laberinto que suponen, las incognitas que plantean a largo plazo y la experiencia clinica disponible en las hernias incisionales e inguinales.

ResumenObjetivoEvaluamos la utilidad de un cuestionario postal en el seguimiento de la cirugía de la eventración.Pacientes y métodoSe analiza prospectivamente una cohorte de 285 pacientes intervenidos por una eventración entre 1998 y 2003 mediante una técnica con malla prefascial y que recibieron un cuestionario de 6 preguntas e ideogramas, con estrategia de reenvíos y llamada telefónica para aumentar la respuesta. Se citaron a examen clínico a los pacientes sin inconveniente a ser visitados. Se revisaron todas las hojas operatorias. Se estudia la respuesta al cuestionario y hallazgos de la visita (test exacto de Fisher y Chi cuadrado), la concordancia con los datos operatorios (índices Kappa de Cohen y de Fleiss) y el valor predictivo del cuestionario.ResultadosUn total de 215 pacientes devolvieron el cuestionario después de tres envíos, con lo que se recogió información de un 75.4% de la cohorte, que aumentó al 94% después de la llamada telefónica. Un total de 168 pacientes (el 78.2%) aceptaron ser visitados, aunque finalmente solo acudieron 62 (el 36.9%). La concordancia entre las respuestas al cuestionario e ideogramas y los datos de las hojas operatorias fue baja (índice Kappa de Cohen de 0.065 e índice Kappa de Fleiss de 0.170).ConclusionesUn cuestionario postal con medidas para aumentar la respuesta puede ser efectivo para recoger información básica sobre la cirugía de la hernia incisional. La utilidad de dicha información resulta cuestionable por falta de cumplimiento de los pacientes en los controles y por dificultades en la comprensión del cuestionario, aunque este sea corto y/o en forma de ideograma.AbstractAimTo assess the usefulness of a short postal questionnaire as a method of follow-up in incisional hernia repair.Patients and methodAll consecutive patients (n=285) undergoing open mesh repair of incisional hernia using an onlay technique between 1998 and 2003 received a six-item self-administered questionnaire complemented with ideograms. Non-responders received two successive new questionnaires and a telephone call. All patients’ operation forms were reviewed. Patients with no objections to physical examination were contacted by phone for an appointment. The Fisher's exact test or the chi-square (χ2) tests were used to compare categorical variables between clinical visits and response to questionnaire. Agreement between response to the questionnaire and data on the operation forms was measured with the Cohen's kappa index and the Fleiss kappa index. The predictive values of the questionnaire were calculated.Results215 patients returned questionnaires after three reminders, allowing us to reach 75.4% of the study cohort, which in turn increased to 94% after the telephone call. A total of 168 (78.2%) patients were willing to come for a physical examination. Finally 62 (36.9%) patients were examined. The overall agreement between response to the questionnaire and data on the operation forms was poor (Cohen's kappa coefficient = 0.065 and Fleiss kappa coefficient = 0.170).ConclusionsA postal questionnaire can be effective to gather information. However, the usefulness of this information in the follow-up was low due to the small percentage of patients examined and difficulties in comprehension despite making the questionnaire short and illustrated by ideograms.

Permanent synthetic materials are currently of choice for abdominal wall hernia repair. However, they are not ideal as short- and long-term complications with these have been reported. Extracellular matrix-derived biological implants (EMDBI) have emerged as a result of research and development into new materials. Several types of EMDBI have appeared in the last few years, each with its own manufacture characteristics and different from the rest. The current panorama of the xenogeneic EMDBI available in Spain is analysed, their complications, the unknown factors arising in the long-term, and the clinical experience available on incisional and inguinal hernias.

Prevention of parastomal hernia represents an important aim when a permanent stoma is necessary. The objective of this work is to assess whether implantation of a prophylactic prosthetic mesh during laparoscopic abdominoperineal resection contributed to reduce the incidence of parastomal hernia. Rectal cancer patients undergoing elective laparoscopic abdominoperineal resection with permanent colostomy were randomized to placement of a large-pore lightweight mesh in the intraperitoneal/onlay position by the laparoscopic approach (study group) or to the control group (no mesh). Parastomal hernia was defined radiologically by a CT scan performed after 12 months of surgery. The usefulness of subcutaneous fat thickness measured by CT to discriminate patients at risk of parastomal hernia was assessed by ROC curve analysis. Thirty-six patients were randomized, 19 to the mesh group and 17 to the control group. Parastomal hernia was detected in 50 % of patients in the mesh group and in 93.8 % of patients in the control group (P = 0.008). The AUC for thickness of the subcutaneous abdominal was 0.819 (P = 0.004) and the optimal threshold 23 mm. Subcutaneous fat thickness ≥23 mm was a significant predictor of parastomal hernia (odds ratio 15.7, P = 0.010), whereas insertion of a mesh was a protective factor (odds ratio 0.06, P = 0.031). Use of prophylactic large-pore lightweight mesh in the intraperitoneal/onlay position by a purely laparoscopic approach reduced the incidence of parastomal hernia formation. Subcutaneous fat thickness ≥23 mm measured by CT was an independent predictor of parastomal hernia.

Resumen Introduccion La obesidad es uno de los factores implicados en la genesis del cancer colorrectal (CCR); sin embargo, no esta claro cual es el impacto que puede tener en las caracteristicas anatomopatologicas de estos tumores una vez que se han desarrollado. El objetivo de este estudio es determinar en nuestros pacientes como influye el indice de masa corporal (IMC) en las caracteristicas histologicas de estos tumores. Material y metodos Estudio retrospectivo observacional. Se incluyo en el estudio a los pacientes intervenidos electivamente por CCR con intencion curativa en el Hospital Universitario de Girona, Espana, durante los anos 1990 a 2001. Se ha realizado un analisis descriptivo y bivariable para evaluar posibles diferencias en funcion del IMC por lo que respecta a los datos tumorales. Resultados Se incluyo en el estudio a 369 pacientes con CCR: 213 pacientes (57,7%) con cancer de colon y 156 pacientes (42,3%) con cancer de recto. En el caso de los tumores de colon, los pacientes con IMC mayor de 25 kg/m2 tuvieron tumores peor diferenciados (p=0,011), y los de IMC de mas de 30 kg/m2 tuvieron mayor afectacion ganglionar que el resto. Para los tumores de recto, cuanto mayor fue el IMC mayor la afectacion ganglionar (p=0,041) y el estadio tumoral TNM (p=0,023). Conclusiones Los pacientes con mayor IMC tienen mayor afectacion ganglionar. En el caso del cancer de colon son, ademas, tumores mas indiferenciados, y en el caso del cancer de recto son tumores en estadios mas avanzados.

Resumen En la actualidad el desarrollo de la informatica permite el acceso a algunos modelos tridimensionales (3D) de situaciones humanas fisiologicas o patologicas obtenidas de datos de pacientes con diferentes circunstancias medicas o quirurgicas. Estos modelos tienen una variacion amplia en aplicaciones: el conocimiento de mecanismos patogenicos, la ayuda en el diagnostico, la planificacion de estrategias quirurgicas, el entrenamiento de medicos en formacion, la ensenanza de la medicina y la cirugia, el diseno de instrumentos o materiales para su uso en la practica medica o quirurgica o incluso las intervenciones a distancia. Nuestro objetivo es disenar un modelo 3D de la region inguinal humana con el fin de mejorar en el conocimiento de la patogenia de las hernias inguinales, la ensenanza de su anatomia y la cirugia, la planificacion de sus estrategias quirurgicas y el comportamiento mecanico de los biomateriales en la pared abdominal.

“Chemical Component Separation” is a novel concept that involves the application botulinum neurotoxin A (BoNT-A), a potent muscle-paralyzing agent, to achieve muscle relaxation of the abdominal wall muscles as an aid in the surgical repair of complex ventral and incisional hernias and for facilitating closure of midline abdominal wall defects. However, the number of clinical studies is limited and the experience with the application of BoNT-A in the field abdominal wall surgery is still preliminary. Achievement of tension- and retraction-free conditions in complex abdominal wall reconstruction is the main objective taking advantage of BoNT-A-related paralysis of abdominal wall muscles following injections in selected points on both sides of the abdomen. Better postoperative pain control and reduction of opioid analgesia are related to the antinociceptive effects of BoNT-A. Recommended techniques to guide botulinum toxin injection include electromyography, electric nerve stimulation, ultrasound, and anatomical localization. Formulations are not interchangeable. Potential applications of BoNT-A in adult patients may include complex and non-complex midline incisional hernias with loss of domain, open abdomen, or reconstructions when the abdominal wall is intact, with or without preoperative progressive pneumoperitoneum. Further studies, preferably randomized-controlled designs are necessary to clarify a number of relevant clinical questions, including patient’s eligibility, dosing of the different botulinum A formulations, optimal administration technique, or benefits of potential association with other procedures. The evidence available at the present time is still weak and a clear role of BoNT-A in abdominal wall surgery remains to be defined.

The use of prophylactic antibiotics in addition to mechanical cleansing is the current standard of care prior to colonic surgery. The question of whether the antibiotics should be administered intravenously or orally, or by both routes, remains controversial. Our aim was to compare three methods of prophylactic antibiotic administration in elective colorectal surgery. Three hundred consecutive elective colorectal resections were studied. All patients had preoperative mechanical colon cleansing with oral sodium phosphate and intravenous antibiotic prophylaxis with cefoxitin (one dose before skin incision and two postoperative doses). Patients were randomised to one of the following three groups: group A: three doses of oral antibiotic (neomycin and metronidazole) at the time of mechanical colon cleansing; group B: one dose of oral antibiotic; group C: no oral antibiotics. All patients were followed during their hospital stay and at 7, 14 and 30 days post-surgery. Vomiting occurred in 31%, 11% and 9% of the studied patients (groups A, B and C, respectively) (p

Fundamento y objetivo La miastenia grave (MG) y el timoma varian en terminos de comportamientoclinico y de supervivencia global cuando se consideran de forma individual. Existen pocosestudios que evaluen los posibles factores predictivos independientes que puedan influiren la supervivencia de los pacientes con MG y timoma asociados. En el presente trabajo se hanbuscado factores predictivos independientes que puedan influir en la supervivencia de estospacientes. Pacientes y metodo Entre el 1 de enero de 1967 y el 31 de marzo de 2000 se estudio a 108pacientes con el diagnostico de MG con timoma. Todos los datos fueron analizados medianteregresion de Cox para cuantificar los factores predictivos independientes. Resultados El periodo medio de seguimiento fue de 10 anos. Durante este periodo fallecieron38 pacientes (35,2%), en 14 casos (36,8%) debido a la MG, y en 6 (15,8%) debido al timoma.Mediante un analisis de regresion de Cox solo la edad superior a 55 anos y la practica deuna traqueostomia en el postoperatorio resultaron tener un valor predictivo independiente en lasupervivencia de estos pacientes. Conclusiones La edad mayor de 55 anos y la practica de una traqueostomia en el postoperatoriohan resultado tener un valor predictivo independiente para la supervivencia de los pacientescon MG y timoma.

Background Development of an incisional hernia is one of the most frequent complications of midline laparotomies requiring reoperation. This paper presents the rationale, design, and study protocol for a randomized controlled trial, the aim of which is to evaluate the efficacy and safety of prophylactically placing a bioabsorbable synthetic mesh for reinforcement of a midline fascial closure. Methods The PREBIOUS trial (PREventive midline laparotomy closure with a BIOabsorbable mesh) is a multicenter randomized controlled trial in which adult patients undergoing elective or urgent open abdominal operations through a midline laparotomy incision are assigned to one of two groups based on the laparotomy closure procedure: an intervention group in which a continuous polydioxanone (PDS) suture is reinforced with a commercially available GORE® BIO-A® Tissue Reinforcement prosthesis (W.L. Gore & Associates, Flagstaff, AZ, USA), or a control group with continuous PDS suture only. Both groups are followed over 6 months. Outcomes The primary outcome is the appearance of incisional hernias assessed by physical examination at clinical visits and radiologically (CT scan) performed at the end of follow-up. Secondary outcomes are the rate of complications, mainly infection, hematoma, burst abdomen, pain, and reoperation. The PREBIOUS trial has the potential to demonstrate that suture plus prosthetic mesh insertion for routine midline laparotomy closure is effective in preventing incisional hernias after open abdominal surgery, to avoid the effects on those affected, such as poor cosmesis, social embarrassment, or impaired quality of life, and to save costs potentially associated with incisional hernia surgical repair.

To present a case of resection of a rectal tumour by a transanal robotic approach. A 58-year-old woman with a 3-cm tumour located 6 cm proximal to anal verge (uT1N0). We describe the details of the surgical technique. A complete resection with adequate margins was accomplished. The defect was closed with a running suture. Operation time was 180 min. There were no complications and the patient was discharged 24 h after surgery. A complete resection of a rectal tumour by a robotic approach is feasible and safe. More studies are needed to clearly define the indications where this new approach can show clear advantages over other transanal resection approaches.

Introduction The objective of this study is to assess whether the results of loop ileostomy closure in terms of morbidity and hospital stay are influenced by the type of anastomosis and suture used. Method All patients who underwent loop ileostomy closure were reviewed. A retrospective cohort study comparing morbidity and hospital stay according to the type of anastomosis (TT/LL) and the type of suture (hand sewn/mechanical) was performed. Results From January 2003 to November 2011 a total of 167 loop ileostomy closures were analysed. The groups were: type of anastomosis (TT 95/LL 72) and type of suture (manual 105/stapled 62). In 76% of the observed population the underlying disease was cancer. Mortality occurred in one case. The stratified morbidity analysis by type of complications showed no significant differences between the groups in terms of local (7.4% TT, LL 8.3%, 6.7% hand sewn, stapled 9.7%), general (TT 9.5%, 16.7% LL, hand sewn 6.7%, 6.5% stapled) and surgical (TT 15.8%, 19.4% LL, hand sewn 17.1%, 17.7% stapled) complications, nor in the rate of reoperations (TT 6.3%, 6.9% LL, hand sewn 6.7%, 6.5% stapled) and hospital stay in days (TT 7.8, 8 LL, hand sewn 8.6, stapled 6.7). Conclusions Closure of loop ileostomy can be performed regardless of the type of suture or anastomosis used, with the same rate of morbidity and hospital stay.

Background To asses the influence of body mass index on the tumour characteristics of patients subjected to colorectal cancer surgery. Materials and methods Retrospective observational study. Patients subjected to curative elective colorectal cancer surgery at Hospital Josep Trueta of Girona (Spain), from 1990 to 2001. Univariate and bivariate analyses were performed to evaluate differences in tumour characteristics with regard to body mass index. Results A total of 369 patients with colorectal cancer were included into the study, 213 (57.7%) with colon cancer, and 156 (42.3%) with rectal cancer. For colon cancer patients, when the BMI was higher than 25 kg/m2, the tumour grade was worst (P=.011), and when BMI was above 30 kg/m2 there were more lymph node metastasis. For rectal tumours, the higher the BMI, the more lymph node metastasis (P=.041), and higher tumour stage (P=.023). Conclusions Patients with a higher BMI have more lymph node metastasis when submitted to elective colorectal cancer surgery. In the case of colon cancer they also have worst tumour grades, and in the case of rectal cancer, a more advanced tumour stage.

At the present time the development of computers allows access to some three-dimensional models (3D) of physiological or pathological human situations obtained from patients with different medical or surgical problems. These models have a wide variety of applications: knowledge of the pathogenic mechanisms, help in diagnosis, planning of surgical strategies, training of surgical residents, teaching of medicine and surgery, design of devices and materials for use in medical and surgical practice or even distance interventions. Our objective is to design a 3D model of the inguinal region with the purpose of improving knowledge of the pathogenic mechanisms of inguinal hernia, the planning of surgical strategies and the teaching of the surgery of these hernias. They can also be used study the mechanical response of biomaterials into the abdominal wall.

Simulation of the human muscular system has multiple applications in biomechanics, biomedicine and in the study of motion in general. Mechanical alterations of the normal functioning in the inguinal area (''inguinal shutter'') seems to be involved in the genesis of hernias in adults, but the role of this anatomical mechanisms is poorly understood. A finite element model for the mechanics of the internal oblique muscle allowed creating a dynamic model of the inguinal region applicable to the study of the shutter mechanism as a defence mechanism of contention of the abdominal viscera against development of an inguinal hernia.

Chagas disease is a frequent cause of acquired megacolon in several countries of Latin America. Several procedures have been described to treat this condition. Recently a report of 147 patients treated with an open rectosigmoidectomy with an ileal loop interposition showed a low rate of complications (8.5 percent) and recurrence (3.1 percent).1We present the video of a 42-year-old Latin American man who had a diagnosis of chagasic megacolon and was treated with the technique described by Netinho et al. 1 but with the use of laparoscopy. The patient was placed in a supine modified lithotomy position in Allen stirrups; the monitor was placed near the left leg of the patient, and both the surgeon and the assistant stood at the right side of the patient. Four trocars were used. Exploratory laparoscopy was performed. The proximal third of the rectum, sigmoid, and left colon were fully mobilized. Vascular pedicles were sectioned. The rectum was divided by using a linear laparoscopic cutter. A Pfannensteil incision was made and the colon was proximally divided. An ileal loop was interposed isoperistaltically between the descending colon and the rectum. Both the ileoileal and the ileocolic anastomoses were handsewn, and the distal ileorectal anastomoses were performed with a circular stapler under laparoscopic control. The patient is without symptoms or recurrence one year after the surgery.Laparoscopic approach allows the easy and correct dissection of the lateral attachments and offers the advantages of a more cosmetic and less painful procedure. Laparoscopic rectosigmoidectomy with ileal loop interposition is a technique that can be performed by laparoscopy with good results and should be an option in the treatment of chagasic megacolon.

In 33 inguinal regions, we determined the anthropometric characteristics of the pubic arch and the anatomic structures of the suprainguinal space and assessed whether there is a relationship between anatomic features and function of the defense mechanisms. There was a low position of the pubic arch (pubic tubercle and interspinal line distance >75 mm) in 23 cases. The low-pubic-arch group showed a significantly longer inguinal ligament and a greater angle made by the superior border of the suprainguinal space and the inguinal ligament at its medial insertion. The position of the pubic arch correlated significantly with the diameter of the internal ring, the length of the inguinal ligament, and the angle made by the superior border of the suprainguinal space and the medial insertion of the inguinal ligament. A low pubic arch would represent an unfavorable condition for an adequate function of the anatomic defense mechanism against hernia.

Background Myasthenia gravis is by far the most common paraneoplastic syndrome of thymomas. There is little information regarding the influence of clinical variables and thymoma-associated factors on biologic development of myasthenia gravis. The aim of the study was to determine independent predictors of clinical outcome in thymoma with myasthenia gravis. Methods We studied 108 patients with thymoma-associated myasthenia gravis undergoing removal of the mediastinal mass between 1967 and 2000. Clinical and pathologic variables associated with clinical outcome of myasthenia were assessed by multivariate Cox regression analysis. Results Patients were followed for a mean period of 10 years (9 months to 33 years). A total of 38 patients died (35.2%), in 14 cases (37%) because of myasthenia gravis and in 6 (16%) because of recurrence of thymoma. With respect to clinical outcome of myasthenia gravis, at the end of the follow-up period, the rate of remission was 16% (n = 17). Of the 91 patients in whom remission was not achieved, 55 had no symptoms with immunosuppressive medication and 36 had symptoms with medication. Conclusions In patients with thymoma-associated myasthenia gravis, well-differentiated thymic carcinoma (Muller-Hermelink system), age more than 55 years, and interval from the onset of symptoms to thymectomy of less than 1 year were found to be independent predictors of nonremission of myasthenia gravis after thymectomy.