RESUMEN
BACKGROUND: Mechanic sutures represent an enormous benefit for digestive surgery in decreasing postoperative complications. Currently, the advantages of motorized stapler are under evaluation. AIMS: To compare the efficacy of mechanic versus motorized stapler in gastric surgery, analyzing rate of leaks, bleeding, time of stapling, and postoperative complications. METHODS: Ninety-eight patients were submitted to gastric surgery, divided into three groups: laparoscopic sleeve gastrectomy (LSG) (n=47), Roux-en-Y gastric bypass (LRYGB) (n=30), and laparoscopic distal gastrectomy (LDG) (n=21). Motorized staplers were employed in 61 patients. The number of firings, number of clips, time of total firings, total time to complete the surgery, and postoperative outcome were recorded in a specific protocol. RESULTS: Patients submitted to LSG, LRYGB, and LDG recorded a shorter time to complete the procedure and a smaller number of firings were observed using motorized stapler (p<0.0001). No differences were identified regarding the number of clips used in patients submitted to LSG. In the group that used mechanic stapler to complete gastrojejunostomy, jejuno-jejuno-anastomosis, and jejunal transection, it was observed more prolonged time of firing and total time for finishing the procedure (p=0.0001). No intraoperative complications were found comparing the two devices used. Very similar findings were noted in the group of patients undergoing LDG. CONCLUSIONS: The motorized stapler offers safety and efficacy as demonstrated in prior reports and is relevant since less total time of surgical procedure without intraoperative or postoperative complications were confirmed.
Asunto(s)
Gastrectomía , Engrapadoras Quirúrgicas , Humanos , Estudios Prospectivos , Masculino , Femenino , Gastrectomía/métodos , Gastrectomía/instrumentación , Persona de Mediana Edad , Adulto , Complicaciones Posoperatorias/prevención & control , Diseño de Equipo , Grapado Quirúrgico/instrumentación , Grapado Quirúrgico/métodos , Laparoscopía/métodos , Laparoscopía/instrumentación , Resultado del TratamientoRESUMEN
BACKGROUND: Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques. OBJECTIVE: To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy. DATA SOURCE: Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. STUDY SELECTION: Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis. INTERVENTION: IPAA technique. MAIN OUTCOME MEASURES: Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function). RESULTS: Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques. LIMITATIONS: A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy. CONCLUSIONS: Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.
Asunto(s)
Anastomosis Quirúrgica , Colitis Ulcerosa , Proctocolectomía Restauradora , Humanos , Colitis Ulcerosa/cirugía , Proctocolectomía Restauradora/métodos , Proctocolectomía Restauradora/efectos adversos , Anastomosis Quirúrgica/métodos , Anastomosis Quirúrgica/efectos adversos , Grapado Quirúrgico/métodos , Fuga Anastomótica/etiología , Fuga Anastomótica/epidemiología , Reservorios Cólicos/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: Insufficient research exists on the stapling technique in and duration of laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: This study aimed to assess the clinical outcomes using a 30-second precompression and post-firing waiting time without extra support for the stapling line. DESIGN AND SETTINGS: Randomized controlled prospective study at a university hospital. METHODS: This study included 120 patients treated between January 2022 and February 2023. The patients were divided into the non-waiting group (T0) and waiting group (T1), each with 60 patients. Perioperative complications were analyzed using statistical tests. RESULTS: The waiting group (T1) showed a significant reduction in the number of intraoperative bleeding points requiring intervention compared with the non-waiting group (T0) (81 versus 134, P < 0.05). In T0, postoperative C-reactive protein (CRP) levels increased (P < 0.05) and hemoglobin levels decreased significantly (P <0.05). The study recorded 22 postoperative complications, accounting for 18.3% of all cases during the 30-day postoperative period. CONCLUSIONS: The study concluded that the 30 sec + 30 sec stapling technique reduces perioperative bleeding, length of stay, and serious complication rates and is practical and effective for LSG. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov with registration code NCT05703035; link: https://clinicaltrials.gov/ct2/show/NCT05703035.
Asunto(s)
Gastrectomía , Obesidad Mórbida , Grapado Quirúrgico , Humanos , Gastrectomía/métodos , Laparoscopía , Obesidad Mórbida/cirugía , Estudios Prospectivos , Grapado Quirúrgico/métodos , Resultado del TratamientoRESUMEN
Introduction: Staple line oversewing (SLO) is a prophylactic alternative due to its low cost and its effect of decreasing the incidence and severity of bleeding complications in sleeve gastrectomy (SG). However, this approach significantly increases the surgical time and may be associated with stenosis. The study aims to identify whether its usage was sufficient to optimize the surgical time in patients whose screening for the risk of occult bleeding was negative. Materials and Methods: The study enrolled 103 patients. Having the systolic blood pressure goal of 140 mmHg, the staple line is checked for bleeding points, counting as follows: >5 bleeding points proceed to SLO, <5 bleeding points are managed using clips, and if no bleeding points are found, the procedure can be completed. Results: The bleeding test was positive in 79.6% of the cases and oversewing was necessary for 44.7% of the total. The bleeding test result was significant for the increased surgical time. The mean surgical time in SLO was 16.4% higher than in clipping. There was a significant difference in surgical time between SLO and clipping; however, no significant difference was identified between clipping and continuing the procedure without further measures. No postoperative complication related to staple line bleeding was identified. Discussion: In a scenario with limitations for the use of high-cost homeostatic agents, the stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time without significant added risks. Conclusion: A stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time.
Asunto(s)
Laparoscopía , Obesidad Mórbida , Humanos , Tempo Operativo , Grapado Quirúrgico/métodos , Laparoscopía/métodos , Gastrectomía/efectos adversos , Gastrectomía/métodos , Hemorragia/cirugía , Obesidad Mórbida/cirugíaRESUMEN
CONTEXTO: La obesidad se ha convertido en uno de los principales problemas de salud pública en el mundo, afectando a la mayoría de la población adulta, siendo una causa importante de discapacidad, muerte prematura y comorbilidades asociadas. La cirugía bariátrica es una opción terapéutica importante para el tratamiento de este padecimiento en pacientes con obesidad mórbida. Dos de las técnicas quirúrgicas más comunes son el bypass gástrico en Y de Roux (BGYR) y la manga gástrica (MG), aunque existe debate sobre cuál es la más efectiva en términos de pérdida de peso y complicaciones a largo plazo. Esta evaluación busca responder a la pregunta sobre la eficacia, seguridad y costoefectividad de la cirugía bariátrica en el tratamiento de la obesidad mórbida, específicamente la comparación entre las técnicas quirúrgicas previamente mencionadas. MÉTODOS: Se realizó una revisión sistemática de la literatura, donde se eligieron ensayos clínicos, revisiones sistemáticas con metanálisis, evaluaciones económicas y evaluaciones de tecnologías, publicados de 2018 a 2023 y que respondieron a la pregunta PICO establecida. La búsqueda se realizó en 9 bases de datos. El análisis se llevó a cabo utilizando herramientas de lectura crítica como PRISMA, GRADEpro y CHEERS. RESULTADOS: Se identificaron un total de 1979 documentos en la búsqueda clínica, de los cuales, 4 fueron seleccionados (una revisión sistemática con metanálisis y 3 ensayos clínicos aleatorizados). Con respecto a la evidencia económica, se identificaron 1230 documentos; entre ellos, 4 fueron seleccionados (tres evaluaciones económicas completas y 1 reporte de evaluación de tecnologías sanitarias). Los resultados de la evidencia clínica indican una tendencia que favorece a BGYR sobre MG, relacionada a la pérdida de peso. En la revisión sistemática analizada los resultados a 1, 3 y 5 años indican que BGYR logró una mayor reducción del IMC en comparación con MG, con una diferencia de 1.25 kg/m² (p = .001) en el primer año; de 1.71 kg/m² (p < .001) en el tercer año y de 1.46 kg/m² (p = .09) en el quinto año. Un ensayo clínico de seguimiento de 1 a 5 años, mostró que la comparación entre BGYR y MG expresada como la diferencia de medias absolutas favorecía a la BGYR en todos los años, sin embargo, esta diferencia no era estadísticamente significativa; en el análisis sin ajuste variando solo el IMC, se observa que a mayor valor inicial la diferencia absoluta de medias fue significativa a favor de BGYR (-1.44 kg/m² (p < .001). Dos de los estudios de seguimiento del ensayo "SLEEVEPASS" a los 7 y 10 años, indicaron que BGYR tuvo una media mayor del porcentaje de pérdida del exceso de peso en comparación con la MG en ambos años, sin embargo, aunque esta diferencia fue estadísticamente significativa, no resulto ser clínicamente relevante. En dos evaluaciones económicas realizadas en Estados Unidos, los resultados muestran que BGYR fue una estrategia dominante y costo efectiva sobre MG. Uno de los estudios, indica que en el grupo de pacientes con obesidad grado II (IMC 35-39.9 kg/m2 ) la MG fue una opción costo-efectiva y BGYR fue la estrategia más costo-efectiva para mujeres y pacientes adultos jóvenes con un IMC inicial más alto. En el segundo estudio que analiza pacientes con obesidad y diabetes mellitus, los resultados de costoefectividad son similares y se mantienen en horizontes temporales más largos. En un estudio realizado en Australia BGYR resultó ser una opción costo-efectiva, manteniendo la tendencia en periodos de análisis más largos. CONCLUSIONES: La evidencia recopilada para el análisis fue limitada, dado que existen pocos estudios que hagan la comparación directa entre ambas técnicas El bajo nivel de evidencia y las limitaciones encontradas deben ser consideradas en la interpretación de los resultados, debido a que no pueden generalizarse.
Asunto(s)
Humanos , Derivación Gástrica/tendencias , Grapado Quirúrgico/métodos , Cirugía Bariátrica/métodos , Obesidad/cirugía , Evaluación en Salud/economía , Eficacia , Análisis Costo-Beneficio/economíaRESUMEN
INTRODUCCIÓN: El cáncer colorrectal es el tercer tipo de cáncer más frecuentemente diagnosticado en varones, y la segunda en mujeres a nivel mundial. En el Perú, el cáncer de recto es el décimo noveno cáncer de mayor incidencia, registrando 864 nuevos casos y una mortalidad de 403 casos anualmente. Los tumores se clasifican de acuerdo a la distancia del tumor con el margen anal, estos pueden ser: tumores de recto inferior localizados a menos de 5 cm del margen anal, tumores del recto medio localizados entre 5.1 cm-10cm y tumores del recto superior que se encuentran localizados entre 10.1-15 cm. TECNOLOGÍA: Dispositivo médico estéril de uso manual, que coloca de 02 a 03 hileras concéntricas paralelas y alternas de grapas de titanio. Está compuesta de partes metálicas (yunque) y partes no metálicas (elementos de manejo y control de la grapadora). Tiene aplicación en cirugía del tracto digestivo abdominal, para la creación y disminución de la tensión en anastomosis extremo a extremo y extremo a lado. Es de un solo uso (descartable) y no recargable. Se comercializa con grapas precargadas. MÉTODOS: La perspectiva adoptada fue la del financiador, que en este caso es el Sistema Integrado de Salud (S.I.S); por ello los costos directos están seleccionados en función de los costos que el S.I.S debe asumir. No se consideró una tasa de descuento, ya que los flujos financieros se comparan a lo largo del tiempo, además, desde la perspectiva de los costos diferenciales, al no comparar entre dos intervenciones sino solo el impacto bajo un comparador, la utilización del descuento como reflejo de oportunidades perdidas de inversión deja de tener valor. El horizonte temporal que se está considerando para el Análisis de Impacto Presupuestario es de 5 años después del año base 2021. Para la población se estimaron los pacientes con cáncer de recto inferior de tipo histológico adenocarcinoma estadio I, II y III con tumores ubicados a más de 1 cm del anillo ano rectal. La población con las características mencionadas anteriormente en el INEN es de 16 pacientes en el año 2021, de los cuales 4 corresponden a estadio II, 2 al estadio IIa, 3 al estadio III, 5 al estadio IIIb y 2 al estadio IIIc. La población base para realizar el AIP es de 16 pacientes, este número aumenta cada año en 1.2% utilizando la tasa de crecimiento poblacional en Perú del año 2021. RESULTADOS: El Escenario de Referencia presenta resultados cuando se realiza el procedimiento resección abdominoperineal, y el nuevo Escenario presenta resultados cuando la resección baja de recto se realiza con sutura mecánica utilizando la grapadora circular. La Tabla 14 y la Tabla 15 ilustran el número de pacientes en cada régimen dentro de la población de pacientes objetivo bajo el escenario de referencia (suponiendo que se realice resección abdominoperineal) y el nuevo escenario (asumiendo que se realice resección baja de recto con sutura mecánica utilizando grapadoras circulares) respectivamente. CONCLUSIONES: La introducción de las engrapadoras quirúrgicas para realizar anastomosis rectales y anales ha tenido un impacto positivo en el tratamiento de cáncer de recto, permitiendo reducir la necesidad de ablación del esfíncter. El Metanálisis del resultado oncológico después de la resección abdominoperineal (APR) o la resección anterior baja (LAR) para el cáncer de recto inferior, mostró que el grupo LAR estuvo altamente correlacionado con la supervivencia a 5 años (OR agrupado = 1,73, IC del 95%: 1,30-2,29, P = 0,0002 efecto aleatorio). Además, los incidentes de complicaciones generales del grupo APR fueron mayores en comparación con el grupo LAR (OR agrupado = 0,52, IC 95%: 0,29-0,92, P = 0,03 efecto aleatorio). Los pacientes tratados con APR tienen una mayor tasa de compromiso del margen de resección circunferencial (CRM), una mayor recurrencia local y un peor pronóstico que la LAR. Y hay evidencia de que, en pacientes seleccionados con cáncer de recto bajo, LAR se puede usar de manera segura con un mejor resultado oncológico que la APR. El estudio de Nasvall (19) mostro que la calidad de vida relacionada con la salud global de los pacientes operados de cáncer de recto con estoma permanente fue inferior a la de los pacientes sin estoma. Los resultados en salud no se incluyeron debido a que los análisis de impacto presupuestario AIP solo comparan costos. La adopción de la grapadora circular en el procedimiento de resección baja de recto con anastomosis como parte del tratamiento de cáncer de recto, resulta en una disminución del gasto. Es decir, el costo total es menor en el escenario donde se encuentra disponible la grapadora circular con un monto de S/. 488,906.67 ya que no genera un monto adicional por el uso de bolsa de ostomía. En comparación, con el escenario donde no se encuentra disponible la grapadora circular con un monto de S/. 572,776.48. El impacto económico de las grapadoras circulares en cáncer de recto inferior en el INEN requiere un mayor esfuerzo presupuestario el primer año, sin embargo, a largo plazo se espera que el gasto presupuestario total disminuya progresivamente.
Asunto(s)
Humanos , Neoplasias del Recto/cirugía , Grapado Quirúrgico/métodos , Eficacia , Análisis Costo-Beneficio/economíaRESUMEN
BACKGROUND: Stapled hemorrhoidopexy has been widely used for the treatment of hemorrhoids, but concerns about complications and recurrences after prolonged follow-up are still under debate. AIMS: The aim of this study was to evaluate the very long-term results of the stapled hemorrhoidopexy technique. METHODS: Stapled hemorrhoidopexy was performed on 155 patients between 2000 and 2003, and the early results have already been published. In this study, we evaluated the same patients after a very long follow-up. Data were collected with regard to late complications, rate and timing of recurrences, and patients' degree of satisfaction. RESULTS: From a total of 155 patients, 98 patients were evaluated: 59 (60.2%) were interviewed by telephone and 39 (39.8%) were evaluated by outpatient consultation. The mean follow-up was 193 months (range: 184-231), 52 were female, 52 were grade III hemorrhoids, and 46 were grade IV. Recurrence was higher in grade IV (26.1%) than in grade III (7.7%) (p=0.014). Recurrence after prolonged follow-up was seen in 16 patients (16.3%) and 11 (11.2%) required reoperations. The complications were skin tags (3.1%), anal sub-stenosis (2.1%), and fecal incontinence (2.1%). After a prolonged follow-up, 82.5% of patients were either very satisfied or satisfied with the surgery. CONCLUSIONS: Stapled hemorrhoidopexy is a safe and effective treatment for hemorrhoidal disease grades III and IV. Recurrence is higher for grade IV hemorrhoids and may occur up to 9 years of follow-up. Reoperations were infrequent and there is a high patient's degree of satisfaction associated with this technique.
Asunto(s)
Hemorroides , Femenino , Estudios de Seguimiento , Hemorroides/cirugía , Humanos , Masculino , Satisfacción Personal , Recurrencia , Grapado Quirúrgico/métodos , Resultado del TratamientoRESUMEN
OBJECTIVE: Staple line bleeding control (SLBC) after laparoscopic sleeve gastrectomy (LSG) is a serious problem. Cauterization alone is generally not preferred because of concerns about weakening the staple line. The aim of this study was to compare the suturing and monopolar cauterization methods for SLBC in LSG. METHODS: 212 patients were divided into two groups as cautery and suture groups. Demographic characteristics, intraoperative, and post-operative results were analyzed. RESULTS: Post-operative complications were seen in seven patients, four of them staple line bleeding (three patients were in the cautery group and one patient was in the suture group), and three of them leakage (all patients were in the suture group) from the staple line. There was no significant difference between the groups in terms of staple line bleeding (p = 0.35), staple line leakage (p = 0.09), blood loss (p = 0.12), intraoperative complications (p = 0.16), post-operative hemoglobin decrease (p = 0.63), and length of hospital stay (p = 0.35), but the operation time was longer in the suture group. CONCLUSION: This is the first study in literature comparing monopolar cauterization with another technique. Monopolar cauterization can be used for SLBC in LSG. It is a safe and efficient method as well as inexpensive.
OBJETIVO: El control del sangrado de la línea de grapas (SLBC) después de la gastrectomía en manga laparoscópica(LSG) es un problema grave. Generalmente, no se prefiere la cauterización sola debido a preocupaciones sobre el debilitamiento de la línea de grapas. El objetivo de este estudio fue comparar los métodos de sutura y cauterización monopolar para SLBC en LSG. MÉTODOS: 212 pacientes fueron divididos en 2 grupos de cauterización y sutura. Se analizaron las características demográficas, los resultados intraoperatorios y posoperatorios. RESULTADOS: Se observaron complicaciones posoperatorias en siete pacientes, cuatro de ellos sangrado en la línea de grapas (tres pacientes estaban en el grupo de cauterización, un paciente en el grupo de sutura) y tres de ellos fuga (todos los pacientes estaban en el grupo de sutura) del línea de grapas. No hubo diferencia significativa entre los grupos en términos de sangrado de la línea de grapas (p = 0.35), fuga dela línea de grapas (p = 0.09), pérdida de sangre (p = 0.12), complicaciones intraoperatorias (p = 0.16), disminución de hemoglobina postoperatoria (p = 0.63), duración dela estancia hospitalaria (p = 0.35), pero el tiempo de operación fue mayor en el grupo de sutura. CONCLUSIÓN: Este es el primer estudio que compara la cauterización monopolar con otra técnica. La cauterización monopolar se puede utilizar para SLBC en LSG. Es un método seguro, eficaz y económico.
Asunto(s)
Laparoscopía , Obesidad Mórbida , Cauterización , Gastrectomía/efectos adversos , Gastrectomía/métodos , Hemorragia/etiología , Humanos , Laparoscopía/métodos , Obesidad Mórbida/cirugía , Grapado Quirúrgico/métodos , Suturas/efectos adversos , Resultado del TratamientoRESUMEN
OBJECTIVE: Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service. METHODS: We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention. RESULTS: A total of 151 patients (median age, 78 years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2 days (range, 0-18 days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16 months; P < .001). During further follow-up (median, 52 months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n = 5) or redo transoral stapling (n = 3). CONCLUSIONS: Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.
Asunto(s)
Trastornos de Deglución , Divertículo de Zenker , Anciano , Trastornos de Deglución/etiología , Trastornos de Deglución/cirugía , Esofagoscopía/efectos adversos , Esofagoscopía/métodos , Femenino , Humanos , Masculino , Estudios Retrospectivos , Grapado Quirúrgico/efectos adversos , Grapado Quirúrgico/métodos , Resultado del Tratamiento , Divertículo de Zenker/complicaciones , Divertículo de Zenker/cirugíaRESUMEN
Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world, with 75% of the primary procedures performed in the United States. It is a safe and effective primary bariatric procedure with good weight loss. When comparing with other procedures, LSG is limited to the stomach, avoiding the presence of internal hernias, preserving the pyloric anatomy, with normal gastric emptying, and conveying less severe rebound hypoglycemia. Materials and Methods: We describe the technique, step-by-step, we use to perform a sleeve gastrectomy (SG) and analyze why we think it is a good surgery. Results: The highlights of a safer SG systematization are based on minimum 36F bougie calibration, starting 4-5 cm from the pylorus, keeping â¼1 cm distance from esophagus. We routinely use staple line reinforcement by continuous suture. Comparing with Roux-en-Y gastric bypass, less bowel obstruction, less dumping syndromes, less hypoglycemia, and also less ulcers are described. Conclusion: LSG is a safe and effective primary bariatric procedure with durable weight loss. And when comparing with others with intestinal anastomosis, we found fewer complications such as less internal hernias, access to the bile duct after surgery, and has the great advantage that it can be revised when it fails.
Asunto(s)
Gastrectomía/métodos , Derivación Gástrica/métodos , Laparoscopía/métodos , Obesidad Mórbida/cirugía , Humanos , Estómago/cirugía , Grapado Quirúrgico/métodos , Pérdida de PesoRESUMEN
Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world. LSG is a safe and effective primary bariatric procedure with durable weight loss. We believe LSG should not be called "easy" and should be performed only by surgeons trained in bariatric surgery. Method: We describe the technique, step by step, we use to perform a sleeve gastrectomy (SG). Results: The highlights of a safer SG systematization are based on minimum 36Fr bougie calibration, starting 4-5 cm from the pylorus, keeping â¼1 cm distance from esophagus. We routinely use staple line reinforcement by continuous suture. Conclusions: LSG is a safe and effective primary bariatric procedure with durable weight loss. It should be performed only by surgeons trained in bariatric surgery.
Asunto(s)
Cirugía Bariátrica/métodos , Gastrectomía/métodos , Laparoscopía/métodos , Obesidad Mórbida/cirugía , Humanos , Grapado Quirúrgico/métodosRESUMEN
INTRODUCTION: Postoperative pancreatic fistula (PPF) is still the major source of morbidity in distal pancreatectomy (DP). Despite the many surgical techniques and technology devices developed for the closure of the pancreatic stump, the PPF rate remains high, and there is no consensus with regard to the most appropriate stump closure technique. We herein present, for the first time, an innovative approach for staple-line reinforcement in DP using an autologous peritoneal patch. MATERIALS AND METHODS: The results of 2 consecutive patients who underwent laparoscopic DP due to mucinous cystic neoplasms were included in this report. The pancreas was transected with a reinforced stapler using a peritoneal patch obtained from the anterolateral wall of the abdomen, divided into 2 pieces, and sutured around each stapler jaw. The embedded video (Supplemental Digital Content 1, http://links.lww.com/SLE/A209) reports our standardized technique. RESULTS: Both patients had a favorable recovery without PPF or any complication and were discharged fully recovered 4 and 5 days after surgery without drains. Currently, both patients are alive and free of disease 1 year and 8 months after the procedure. CONCLUSIONS: The use of an autologous parietal peritoneal patch for staple-line reinforcement in DP was feasible and safe in experienced hands. Further studies are needed to confirm our findings and elucidate whether this readily available, inexpensive, rapid, and versatile alternative could reduce the PPF rate.
Asunto(s)
Laparoscopía/métodos , Pancreatectomía/métodos , Fístula Pancreática/cirugía , Anciano , Estudios de Factibilidad , Femenino , Humanos , Persona de Mediana Edad , Neoplasias Quísticas, Mucinosas y Serosas/cirugía , Fístula Pancreática/prevención & control , Neoplasias Pancreáticas/cirugía , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/cirugía , Colgajos Quirúrgicos , Grapado Quirúrgico/métodos , Técnicas de Sutura , Resultado del TratamientoRESUMEN
Developing a less invasive, practical and cost-effective operative technique for obesity treatment represents a pressing need for our society. In this way, intragastric single port sleeve by endoplication was tested in six pigs during 18 weeks. Celiotomy was performed with animal placed in dorsal decubitus position. Single port gastrostomy was performed and double tobacco pouch sutures were made in fundic region, making a gastric sleeve. At the end, stomach layers and skin were closed in a conventional manner. Means and the standard deviations of surgical time were calculated. The procedure was simple and all animals survived; there were no significant blood loss and no intra and postoperative complications. The procedure was fast (67.4 minutes). The technique has the advantage of not requiring the use of mechanical sutures, making it less costly. The innovation of this procedure was the use of a single port gastrostomy device to perform an intraluminal sleeve. What made this technique less invasive were the use of a single port, nonmanipulation of the stomach intra-abdominally, ease of execution and no need of pneumoperitoneum. The new technique is acceptable and has reproducible viability, had a short procedure time without intra and postoperative complications.
Asunto(s)
Gastrectomía/métodos , Laparoscopía/métodos , Grapado Quirúrgico/métodos , Animales , Estudios de Factibilidad , Gastrectomía/mortalidad , Modelos Animales , Obesidad Mórbida/cirugía , Tempo Operativo , Reproducibilidad de los Resultados , Porcinos , Factores de TiempoRESUMEN
INTRODUCCIÓN: En las últimas décadas es creciente el abordaje por mínima invasión de patologías abdominales debido a sus beneficios evidentes. El cuadro apendicular es la principal emergencia quirúrgica, con diferentes métodos del cierre de la base apendicular. En este artículo comparamos dicho cierre con engrapadora lineal o ligadura con lazo hemostático, para analizar la frecuencia de complicaciones como absceso, dehiscencia y seroma. MÉTODO: Se realizó un estudio prospectivo, observacional y descriptivo, con un total de 703 procedimientos, empleando en 567 pacientes ligadura con lazo hemostático y en 136 engrapadora lineal, operados por los mismos cirujano y equipo quirúrgico, con curva de aprendizaje concluida. RESULTADOS: Las complicaciones referidas en el presente estudio son absceso (n = 5), dehiscencia (n = 3) y seroma (n = 3). De acuerdo con las fases de la patología apendicular: fase 1 o apéndice congestivo, no presentaron complicaciones; fase 2 o supurativo, se reportó un caso de dehiscencia de herida quirúrgica con el uso de ligadura con lazo hemostático; fase 3 o necrótico, se reportó un caso de seroma en un paciente tratado con ligadura con lazo hemostático; y fase 4 o perforado, se encuentra diferencia significativa en el caso de abscesos, reportando cinco con el uso de ligadura con lazo hemostático y ninguno con engrapadora lineal. CONCLUSIONES: En nuestro estudio no existe diferencia estadísticamente significativa entre el uso de engrapadora lineal o ligadura con lazo hemostático en las fases apendiculares 1-3; en la fase 4 es de utilidad significativa el uso de engrapadora lineal ante la incidencia de abscesos. INTRODUCTION: In the last decades, the approach by minimally invasive surgery of abdominal pathologies is growing due to its evident benefits; the appendicular cases being the main surgical emergency, with different methods of closing the appendicular base. In this article, we compared the appendicular base closure with linear stapler and endoloop, to analyze the frequency of complications such as abscess, dehiscence and seroma. METHOD: A prospective, observational and descriptive study was conducted, with a total of 703 procedures, using 567 endoloop patients and 136 linear stapler, operated by the same surgeon and surgical team, with a completed learning curve. RESULTS: The complications referred in the present study were patients with abscess (n = 5), dehiscence (n = 3) and seroma (n = 3). According to the phases of the appendiceal pathology: phase 1 or congestive appendix did not present complications; phase 2 or suppurative was reported one case of surgical wound dehiscence in the use of endoloop; in phase 3 or necrotic, one case of seroma was reported in a patient treated with endoloop; while in phase 4 or perforated there is a significant difference in the case of abscesses, reporting five in the use of endoloop and none in the case of a linear stapler. CONCLUSIONS: In our study there is no statistically significant difference between the use of linear stapler or endoloop in the early appendicular phases; being of significant utility in Phase 4 the use of linear stapler for the incidence of abscesses.
Asunto(s)
Técnicas de Cierre de Herida Abdominal , Apendicectomía/métodos , Laparoscopía/métodos , Ligadura/métodos , Complicaciones Posoperatorias/etiología , Grapado Quirúrgico/métodos , Absceso Abdominal/epidemiología , Absceso Abdominal/etiología , Técnicas de Cierre de Herida Abdominal/economía , Técnicas de Cierre de Herida Abdominal/instrumentación , Apendicectomía/economía , Hospitales Privados , Humanos , Laparoscopía/economía , Ligadura/economía , Ligadura/instrumentación , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Seroma/epidemiología , Seroma/etiología , Grapado Quirúrgico/economía , Grapado Quirúrgico/instrumentación , Dehiscencia de la Herida Operatoria/epidemiología , Dehiscencia de la Herida Operatoria/etiología , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiologíaRESUMEN
PURPOSE: To perform technically the laparoscopic sleeve gastrectomy (LSG) using a unique Intragastric Single Port (IGSG) in animal swine model, evidencing an effective and safe procedure, optimizing the conventional technique. METHODS: IGSG was performed in 4 minipigs, using a percutaneous intragastric single port located in the pre-pyloric region. The gastric stapling of the greater curvature started from the pre-pyloric region towards the angle of His by Endo GIA™ system and the specimen was removed through the single port. In the postoperative day 30, the animals were sacrificed and submitted to autopsy. RESULTS: All procedures were performed without conversion, and all survived 30 days. The mean operative time was 42 min. During the perioperative period no complications were observed during invagination and stapling. No postoperative complications occurred. Post-mortem examination showed no leaks or infectious complications. CONCLUSION: Intragastric Single Port is a feasible procedure that may be a suitable alternative technique of sleeve gastrectomy for the treatment of morbid obesity.
Asunto(s)
Gastrectomía/métodos , Laparoscopía/métodos , Animales , Estudios de Factibilidad , Gastrectomía/mortalidad , Laparoscopía/mortalidad , Ilustración Médica , Modelos Animales , Obesidad Mórbida/cirugía , Tempo Operativo , Reproducibilidad de los Resultados , Grapado Quirúrgico/métodos , Porcinos , Factores de TiempoRESUMEN
Abstract Purpose: To perform technically the laparoscopic sleeve gastrectomy (LSG) using a unique Intragastric Single Port (IGSG) in animal swine model, evidencing an effective and safe procedure, optimizing the conventional technique. Methods: IGSG was performed in 4 minipigs, using a percutaneous intragastric single port located in the pre-pyloric region. The gastric stapling of the greater curvature started from the pre-pyloric region towards the angle of His by Endo GIA™ system and the specimen was removed through the single port. In the postoperative day 30, the animals were sacrificed and submitted to autopsy. Results: All procedures were performed without conversion, and all survived 30 days. The mean operative time was 42 min. During the perioperative period no complications were observed during invagination and stapling. No postoperative complications occurred. Post-mortem examination showed no leaks or infectious complications. Conclusion: Intragastric Single Port is a feasible procedure that may be a suitable alternative technique of sleeve gastrectomy for the treatment of morbid obesity.
Asunto(s)
Animales , Laparoscopía/métodos , Gastrectomía/métodos , Porcinos , Factores de Tiempo , Obesidad Mórbida/cirugía , Estudios de Factibilidad , Reproducibilidad de los Resultados , Grapado Quirúrgico/métodos , Modelos Animales , Tempo Operativo , Gastrectomía/mortalidad , Ilustración MédicaRESUMEN
INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures performed worldwide. However, staple line-related complications have become a major challenge for bariatric surgeons. The aim of this study was to evaluate the morbidity in a cohort of patients who underwent LSG with imbricated oversewing of the staple line at a single high-volume center. MATERIALS AND METHODS: We retrospectively reviewed prospectively collected data for all patients who underwent LSG to treat obesity at our institution from January 2010 to September 2016. All practitioners had undergone training with a single senior bariatric surgeon using oversewing as staple line reinforcement (SLR). RESULTS: In total, 1023 LSGs were performed (female, 67.3%; mean age, 40.6 ± 10.8 years; median preoperative body mass index, 37 ± 4.5 kg/m2). The mean operative time was 67.6 ± 23.4 min (range, 30-150 min). The rate of conversion to open surgery was 0.3%. Early complications were noted in 18 patients (1.8%), including 5 cases of bleeding (0.5%). No leaks, stenosis, or mortality occurred. CONCLUSIONS: LSG is a safe technique, but staple line-associated complications can be life-threatening. In this series, no leaks occurred from the very beginning of the surgeons' experience in LSG. Imbricated oversewing of the staple line, proper mentoring, and performance of surgery in appropriate settings are good approaches to decreasing complications.
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Fuga Anastomótica/prevención & control , Obesidad Mórbida/cirugía , Grapado Quirúrgico/métodos , Adolescente , Adulto , Anciano , Chile , Estudios de Cohortes , Conversión a Cirugía Abierta , Femenino , Gastrectomía/métodos , Humanos , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Chronic leaks after laparoscopic sleeve gastrectomy (LSG) are often difficult to treat by endoscopy metallic stent. Septotomy has been indicated as an effective procedure, but the technical aspects have not been detailed in previous publications (Campos JM, Siqueira LT, Ferraz AA, et al., J Am Coll Surg 204(4):711, 2007; Baretta G, Campos J, Correia S, et al., Surg Endosc 29(7):1714-20, 2015; Campos JM, Pereira EF, Evangelista LF, et al., Obes Surg 21(10):1520-9, 2011). We herein present a video (6 min) demonstrating the maneuver principles of this technique, showing it as a safe and feasible approach. METHODS: A 32-year-old male, with BMI 43.4 kg/m(2), underwent LSG. On the tenth POD, he presented with a leak and initially was managed with the following approach: laparoscopic exploration, drainage, endoclips, and 20-mm balloon dilation. However, the leak remained for a period of 6 months. On the endoscopy, a septum was identified between the leak site and gastric pouch, so it was decided to "reshape" this area by septotomy. Septotomy procedure: Sequential incisions were performed using argon plasma coagulation (APC) with 2.5 flow and 50 W (WEM, SP, Brazil) over the septum in order to allow communication between the perigastric cavity (leak site) and the gastric lumen. The principles below must be followed: (1) Scope position: the endoscopist's left hand holds the control body of the gastroscope while the right hand holds the insertion tube; the APC catheter has no need to be fixed. This avoids movements and unprogrammed maneuvers. (2) Before cutting, the septum is placed in the six o'clock position on the endoscopic view, by rotating the gastroscope. (3) The septum is sectioned until the bottom of the perigastric cavity (leak site). (4) That section is made towards the staple line. (5) Just after the septotomy, a Savory-Gilliard guidewire (Cook Medical, Indiana, USA) through the scope must be inserted until the duodenum, followed by 30-mm balloon (Rigiflex®, Boston Scientific, MA, USA) insertion. The balloon catheter must be firmly held during gradual inflation (maximum 10 psi) to avoid slippage and laceration. This allows increasing the gastric lumen. (6) Septotomy by electrocautery with a needle knife (Boston Scientific, MA, USA) can be made when an intensive fibrotic septum is present; bleeding is rare in this case. In this case, the endoclip previously used was removed from the septum with forceps to avoid heat transmission. Small staples visualized in the fistula orifice were not completely removed due to technical difficulties and friable tissue. RESULTS: Two sessions were performed in 15 days, resulting in leak closure. The patient was submitted to radiological control 1 week after the second session, which revealed fistula healing, without gastric stenosis. The nasoduodenal feeding tube remained for 7 days, when the patient started oral diet. This patient was followed for 18 months without recurrence. CONCLUSIONS: Septotomy and balloon dilation were initially performed on a difficult-to-treat chronic fistula after gastric bypass and named before as stricturotomy (Campos JM, Siqueira LT, Ferraz AA, et al., J Am Coll Surg 204(4):711, 2007). This procedure allows internal drainage of the fistula and deviates oral intake to the pouch. In addition, achalasia balloon dilation treats strictures and axis deviation of the gastric chamber, promoting reduction of the intragastric pressure. Septotomy and balloon dilation are technically feasible and might be useful in selected cases for closure of chronic leaks after LSG.
Asunto(s)
Fuga Anastomótica/terapia , Dilatación/métodos , Gastrectomía/efectos adversos , Balón Gástrico , Obesidad Mórbida/cirugía , Estómago/cirugía , Adulto , Enfermedad Crónica , Drenaje/métodos , Gastrectomía/métodos , Humanos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Masculino , Reoperación/métodos , Estómago/patología , Grapado Quirúrgico/métodosRESUMEN
INTRODUCTION: Repair of inguinal hernia is one of the most common elective operations performed in general surgery practice. Mesh hernia repair became the gold standard because of its low recurrence rate in comparison with non-tension-free repair. Laparoscopic approach seems to have potential advantages over open techniques, including faster recovery and reduced acute and chronic pain rate. Laparoscopic mesh fixation is usually performed using staples, which is associated with higher cost and risk for chronic pain. Recently, the role of mesh fixation has been questioned by several surgeons. AIM: To evaluate mesh displacement in patients undergoing laparoscopic inguinal hernia repair comparing mesh fixation with no fixation. METHODS: From January 2012 to May 2014, 60 consecutive patients with unilateral inguinal hernia were randomized into two groups: control group--10 patients underwent totally extraperitoneal (TEP) repair with mesh fixation; NO FIX group-50 patients underwent TEP repair with no mesh fixation. Mesh was marked with three 3-mm surgical clips at its medial inferior, medial superior and lateral inferior corners. Mesh displacement was measured by comparing an initial X-ray, performed in the immediate postoperative period, with a second X-ray obtained 30 days later. RESULTS: The mean displacement of all three clips in control group was 0.1-0.35 cm (range 0-1.2 cm), while in NO FIX group was 0.1-0.3 cm (range 0-1.3 cm). The overall displacement of control and NO FIX group did not show any difference (p = 0.50). CONCLUSION: Fixation of the mesh for TEP repair is unnecessary. TEP repair with no mesh fixation is safe and is not associated with increased risk of mesh displacement.
Asunto(s)
Hernia Inguinal/cirugía , Herniorrafia , Laparoscopía , Complicaciones Posoperatorias/cirugía , Grapado Quirúrgico/efectos adversos , Adulto , Anciano , Procedimientos Quirúrgicos Electivos/efectos adversos , Femenino , Herniorrafia/métodos , Humanos , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/etiología , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Recurrencia , Mallas Quirúrgicas/efectos adversos , Grapado Quirúrgico/métodos , Resultado del TratamientoRESUMEN
STUDY OBJECTIVE: To demonstrate the technique of laparoscopic double discoid resection with a circular stapler for bowel endometriosis. DESIGN: Case report (Canadian Task Force classification III). SETTING: Private hospital in Curitiba, Paraná, Brazil. PATIENT: A 33-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 6-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the submucosa, 5 cm far from the anal verge. INTERVENTIONS: Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veres needle placed at the umbilicus. Four trocars were placed: a 10-mm trocar at the umbilicus for the zero-degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions, and all implants in the anterior compartment of the pelvis were resected. The lesions located at the ovarian fossae were completely removed. The ureters were identified bilaterally, and both para-rectal fossae were dissected. The right hypogastric nerve was released from the disease laterally. The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum. The lesion was shaved off the anterior rectal wall using a harmonic scalpel. A x-shaped stitch was placed at the anterior rectal wall using 2-0 mononylon suture. A 33-mm circular stapler was placed transanally under laparoscopic control, and once it reached the area to be resected, it was opened. A gap was created between the envil and the stapler. The anterior rectal wall was placed inside this gap with the aid of the stitch at the anterior rectal wall. The stapler was fired, and a piece of the anterior rectal wall was resected. The same procedure was performed using a 29-mm circular stapler, which allowed for the complete removal of the lesion. We usually perform the second discoid resection using a 29-mm circular stapler to allow an easy progression of the stapler through the rectum beyond the first stapler line, so not to put too much pressure on it. In our experience, the first discoid resection removes most of the disease, and the second discoid resection is only needed to remove a small amount of residual disease, along with the first staple line. MEASUREMENTS AND MAIN RESULTS: The procedure took 177 min, and the estimated blood loss was 100 mL. The patient started clear liquids 6 hours after the procedure, and was discharged 19 hours after that [1]. Pathological examination of the 2 strips of the anterior rectal wall revealed infiltration of the bowel wall by endometriotic tissue. She had an uneventful postoperative course, and was able to re-start sexual intercourse 50 days after surgery. Between January 2010 and January 2015, 315 women underwent laparoscopic surgery for the treatment of bowel endometriosis in our service. Among them, 16 (5.1%) were operated on by using the double discoid resection technique. Median age of the patients was 34 years, and median body mass index was 25.9 kg/m(2). Median preoperative cancer antigen-125 level was 26.5 U/mL (normal value is <35 U/mL). Median size of the rectosigmoid nodule was 35 mm (range: 30-60), and median distance from the anal verge was 10.5 cm (range: 5-15 cm). Median surgical time was 160 min (range: 54-210 min). Concomitant procedures included hysterectyomy (n = 5), partial cystectomy (n = 3), resection of the posterior vaginal fornix (n = 4), and appendectomy (n = 1). Median estimated intraoperative bleeding was 32.5 mL (range: 30-100), and median time of hospitalization was 19 hours (range: 10-41). Median American Fertility Society score was 46 (10-102). Two minor complications (12.5%) occurred in this initial series: 1 patient required bladder catheterization for urinary retention; and 1 patient developed a urinary tract infection that required oral antibiotic treatment. One major complication (6.2%) was observed; the patient developed fever and abdominal pain on the fourth postoperative day. She was re-operated, and the intraoperative diagnosis was pelviperitonitis. The abdominal cavity was inspected for any dehiscence of the bowel and then washed. She was discharged on the second day after re-operation with oral antibiotic therapy. In our daily practice, we are used to discharging our patients soon in the postoperative setting (19 hours for rectal shaving or discoid resection and 28 hours for segmental bowel resection) [1] because the rate of postoperative fistula seems to be low [2]. Because we still have not seen any fistulas after conservative surgery (rectal shaving, discoid resection, and double discoid resection), we usually prefer to perform this type of surgery compared with segmental bowel resection, when possible. CONCLUSIONS: Laparoscopic double discoid resection with circular stapler may be an alternative to segmental bowel resection in selected patients with bowel endometriosis.