Risk factors for complications in acute calculous cholecystitis. Deconstruction of the Tokyo Guidelines

OBJECTIVE

To challenge the risk factors described in Tokyo Guidelines in Acute Calculous Cholecystitis.

METHODS

Retrospective single center cohort study with 963 patients with Acute Cholecystitis during a period of 5 years. Some 725 patients with a "pure" Acute Calculous Cholecystitis were selected. The analysis included 166 variables encompassing all risk factors described in Tokyo Guidelines. The Propensity Score Matching method selected two subgroups of patients with equal comorbidities, to compare the severe complications rate according to the initial treatment (Surgical vs Non-Surgical). We analyzed the Failure-to-rescue as a quality indicator in the treatment of Acute Calculous Cholecystitis.

RESULTS

the median age was 69 years (IQR 53-80). 85.1% of the patients were ASA II or III. The grade of the Acute Calculous Cholecystitis was mild in a 21%, moderate in 39% and severe in 40% of the patients. Cholecystectomy was performed in 95% of the patients. The overall complications rate was 43% and the mortality was 3.6%. The Logistic Regression model isolated 3 risk factor for severe complication: ASA > II, cancer without metastases and moderate to severe renal disease. The Failure-to-Rescue (8%) was higher in patients with non-surgical treatment (32% vs. 7%; P = 0.002). After Propensity Score Matching, the number of severe complications was similar between Surgical and Non-Surgical treatment groups (48.5% vs 62.5%; P = 0.21).

CONCLUSIONS

the recommended treatment for Acute Calculous Cholecystitis is the Laparoscopic Cholecystectomy. Only three risk factors from the Tokyo Guidelines list appeared as independent predictors of severe complications. The failure-to-rescue is higher in non-surgically treated patients.

Atypical double colorectal metastasis: spleen and uterus

Oligometastatic disease is a relatively new concept that refers to an intermediate stage between disseminated and localized cancer. Most frequent locations for colorectal metastasis are lung and liver. We present an a typical case of an 85-year-old woman who was diagnosed with a low-grade adenocarcinoma in left colon; she underwent a left laparoscopic hemicolectomy which resulted in a stage IIIb. After 24 months of follow-up, an increase of carcinoembryonic antigen (CEA) leads to the diagnosis of two metastatic lesions in two uncommon locations: spleen and myometrium. Stepwise surgical resection of both lesions was performed without complications. Spleen and uterus are organs that are rarely affected in colorectal cancer, the affection of both organs being even more infrequent. Despite the atypicality, surgical treatment is a valid strategy in this case of oligometastatic disease, which enables the disease-free survival of the patients.

Closure of Iterative Laparotomy in Patients With Previous Mesh Reinforcement a Cohorts' Study. Short-Term Results

Purpose: Due to extension of prophylactic mesh indications use will become more common to find patients receiving an iterative laparotomy (IL) over a previous reinforced abdominal wall. The aim of this study was to analyze outcomes after IL in patients with previous mesh reinforcement. Methods: This study was a prospective secondary analysis of midline laparotomy closure performed from July 2017 to July 2018 registered in PHACPA study (NCT02658955). IL were included and surgery characteristics and outcomes analyzed. We compared two groups: with (PreM) or without previous prophylactic onlay mesh reinforcement (PreS) Subgroups' analysis, risk factors for complications and survival free hernia analysis were performed. Results: 121 IL were analyzed. Only obesity was associated with higher SSO (OR 2.6; CI 95% 1.02-6.90; p = 0.04) There were 15 incisional hernias (IH) (14.4%). Group with previous mesh reinforcement (pre M) had a higher statistically significative incidence of IH (OR = 1.21; CI 95% 1.05-1.39; p = 0.015). Use of slowly absorbable suture (OR = 0.74; CI 95% 0.60-0.91; p = 0.001), USP 2/0 suture (OR, 0.31; 95% CI, 0.10-0.94; p = 0.033), and small bites technique (OR = 0.81; CI 95% 0.72-0.90; p = 0.011) were associated with less IH. Conclusion: IL has a high percentage of complications and IH. In case of IL without previous reinforcement, a mesh can help to reduce IH. Our data cannot clearly support any technique to close an IL with previous mesh.

Implementing a protocol to prevent incisional hernia in high-risk patients: a mesh is a powerful tool

PURPOSE

The small bites (SB) technique for closure of elective midline laparotomies (EMLs) and a prophylactic mesh (PM) in high-risk patients are suggested by the guidelines to prevent incisional hernias (IHs) and fascial dehiscence (FD). Our aim was to implement a protocol combining both the techniques and to analyze its outcomes.

METHODS

Prospective data of all EMLs were collected for 2 years. Results were analyzed at 1 month and during follow-up. The incidence of HI and FD was compared by groups (M = Mesh vs. S = suture) and by subgroups depending on using SB.

RESULTS

A lower number of FD appeared in the M group (OR 0.0692; 95% CI 0.008-0.56; P = 0.01) in 197 operations. After a mean follow-up of 29.23 months (N = 163; min. 6 months), with a lower frequency of IH in M group (OR 0.769; 95% CI 0.65-0.91; P < 0.0001). (33) The observed differences persisted after a propensity matching score: FD (OR 0.355; 95% CI 0.255-0.494; P < 0.0001) and IH (OR 0.394; 95% CI 0.24-0.61; P < 0.0001). On comparing suturing techniques by subgroups, both mesh subgroups had better outcomes. PM was the main factor related to the reduction of IH (HR 11.794; 95% CI 4.29-32.39; P < 0.0001).

CONCLUSION

Following the protocol using PM and SB showed a lower rate of FD and HI. A PM is safe and effective for the prevention of both HI and FD after MLE, regardless of the closure technique used.

Long-term follow-up of prophylactic mesh reinforcement after emergency laparotomy. A retrospective controlled study

BACKGROUND

Prevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. The present study aimed to analyze the long-term results of prophylactic mesh used for preventing incisional hernia after emergency midline laparotomies.

METHODS

This study was a registered (NCT04578561) retrospective analysis of patients who underwent an emergency midline laparotomy between January 2009 and July 2010 with a follow-up period of longer than 2 years. Long-term outcomes and risk factors for the development of incisional hernias between patients who received a prophylactic reinforcement mesh (Group M) and suture (Group S) were compared.

RESULTS

From an initial 266 emergency midline laparotomies, 187 patients were included. The median follow-up time was 64.4 months (SD 35). Both groups had similar characteristics, except for a higher rate of previous operations (62 vs. 43.2%; P = 0.01) and operation due to a revision laparotomy (32.5 vs.13%; P = 0.02) in the M group. During follow-up, 29.9% of patients developed an incisional hernia (Group S 36.6% vs. Group M 14.3%; P = 0.002). Chronic mesh infections were diagnosed in 2 patients, but no mesh explants were needed, and no patient in the M group developed chronic pain. Long-term risk factors for incisional hernia were as follows: smoking (HR = 2.47; 95% CI 1.318-4.624; P = 0.05), contaminated surgery (HR = 2.98; 95% CI 1.142-7.8; P = 0.02), surgical site infection (SSI; HR = 3.83; 95% CI 1.86-7.86; P = 0.001), and no use of prophylactic mesh (HR = 5.09; 95% CI 2.1-12.2; P = 0.001).

CONCLUSION

Incidence of incisional hernias after emergency midline laparotomies is high and increases with time. High-risk patients, contaminated surgery, and surgical site infection (SSI) benefit from mesh reinforcement. Prophylactic mesh use is safe and feasible in emergencies with a low long-term complication rate.

TRIAL REGISTRATION

NCT04578561. www.clinicaltrials.gov.

Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines

BACKGROUND

Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The recommended treatment is the early laparoscopic cholecystectomy; however, the Tokyo Guidelines (TG) advocate for different initial treatments in some subgroups of patients without a strong evidence that all patients will benefit from them. There is no clear consensus in the literature about who is the unfit patient for surgical treatment. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification.

METHODS

Retrospective unicentric cohort study of patients emergently admitted with and ACC during 1 January 2011 to 31 December 2016. The study comprised 963 patients. Primary outcome was the mortality after the diagnosis. A propensity score method was used to avoid confounding factors comparing surgical treatment and non-surgical treatment.

RESULTS

The overall mortality was 3.6%. Mortality was associated with older age (68 + IQR 27 vs. 83 + IQR 5.5; P = 0.001) and higher Charlson Comorbidity Index (3.5 + 5.3 vs. 0+2; P = 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.7-12.8 P = 0.001), dementia (OR 4.12; 95% CI 1.34-12.7, P = 0.001), age > 80 years (OR 1.12: 95% CI 1.02-1.21, P = 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.5-28.3, P = 0.001) which predicted the mortality in a 92% of the patients. The receiver operating characteristic curve yielded an area of 88% significantly higher that 68% (P = 0.003) from the TG classification. When comparing subgroups selected using propensity score matching with the same morbidity and severity of ACC, mortality was higher in the non-surgical treatment group. (26.2% vs. 10.5%).

CONCLUSIONS

Mortality was higher in ACC patients treated with non-surgical treatment. ACME identifies high-risk patients. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC.

TRIAL REGISTRATION

Retrospectively registered and recorded in Clinical Trials. NCT04744441.

Caecal volvulus and jejunostomy: challenging diagnostic

Caecal volvulus represent the 20–40% of colonic volvulus, being the second most frequent localization. It causes intestinal occlusion symptomatology (nausea, vomiting, abdominal distension). We present a case of 45-year-old women with feeding jejunostomy tube due to connatal anoxia. She arrives at A&E after 12 h of vomits and abdominal pain. The CT scan shows a small intestine dilation that suggested a small intestine volvulus. A laparotomy is performed showing a caecal volvulus, so ileo-cequectomy with primary anastomosis is performed. After several complications, she was discharged after 60 days of hospital stay. Caecal volvulus can be challenging to diagnose by clinic, because it can be hardly differenced from other intestinal occlusion causes. CT scan can be useful to reach the diagnostic and see signs of tissue suffering. In contrast with sigma volvulus, endoscopic treatment has not shown any benefit to solve it.

Small bites technique for midline laparotomy closure: From theory to practice: Still a long way to go

BACKGROUND

The closure technique of the abdominal wall is a key factor in the development of incisional hernia. Our aim was to implement a protocol for closure of median laparotomy, to evaluate the grade of implementation, as well as to assess the results and safety of the technique.

METHODS

A series of formative activities to implement the small bites technique for closure of median laparotomy in elective operations were designed. After 1 year, a survey was conducted on knowledge and use of the technique. Prospective compilation of data of all median laparotomy in elective operations and their follow-up was done for 1 year. The incidence of incisional hernia depending on the fulfilment of the protocol was compared.

RESULTS

A total of 74 surgeons participated in the activities. All the participants accomplished the technique perceiving low difficulty (1.9/10). After 1 year, 44 surgeons answered the survey; 95% stated that they knew the small bites technique and used it always or almost always, but only 52% performed the calculation of the suture length and the incision length ratio. A total of 114 median laparotomy in elective operations were analyzed; among them, 30.7% were closed with small bites presenting a lower frequency of incisional hernia and burst abdomen (small bites 3.6% vs large bites 12.1%; odds ratio 1.30; confidence interval, 0.992--1.711; P = .20).

CONCLUSION

The measures were effective for learning, but education alone was not enough to implement the technique in the real scenario. Small bites technique is reproducible, has no risks, and provides low incidence of incisional hernia. More incentives and actions are needed to improve laparotomy closure.

Incidence of Incisional Hernia After Emergency Subcostal Unilateral Laparotomy: Does Augmentation Prophylaxis Play a Role?

BACKGROUND

Few data are available about the frequency of incisional hernia in an emergency subcostal laparotomy. Our objective is to analyze the incidence of incisional hernia after emergency subcostal laparotomy and evaluate if prophylactic mesh could help prevent it.

METHODS

This study is a monocentric retrospective analysis following STROBE guideline statements of all patients who underwent an emergency subcostal laparotomy between January 2011 and July 2017 in our University Hospital. We compared complications and incidence of incisional hernia between patients who received sutures (Group S; N = 203) and patients with prophylactic onlay mesh (Group M; N = 80). A multivariate risk factor analysis of incisional hernia was performed. An incisional hernia-estimated risk calculator equation was created.

RESULTS

A total of 283 patients were analyzed. There were 80 patients in Group M and 203 in Group S. In short-term outcomes, length of surgery (213 ± 115 min vs 165 ± 73.3 min, P = 0.001) and hospital stay (16.4 ± 18.7 vs 11.6 days ± 13.4, P = 0.038) were longer in Group M. Long-term follow-up was conducted in 207 patients with a mean follow-up time of 39.3 ± 23 months. Incisional hernia was detected in 29 (19.1%) patients in Group S but in only two (3.8%) patients in Group M (P = 0.008). In the multivariate analysis, a risk factor analysis included wound infection (4.91 HR (2.12-11.4); P < 0.001), previous hernia repair (2.86 HR (1.24-6.61); P = 0.014), and shock (2.64 HR (1.01-6.93); P = 0.048).

CONCLUSIONS

The incidence of incisional hernia after emergency subcostal laparotomy is high. Risk factors are wound infection, shock, and previous hernia surgery. The use of prophylactic mesh augmentation was safe and reduced the incidence of incisional hernia.