Evaluation of the validated intraoperative bleeding scale in liver surgery: study protocol for a multicenter prospective study

Background

Surgical hemostasis has become one of the key principles in the advancement of surgery. Hemostatic agents are commonly administered in many surgical specialties, although the lack of consensus on the definition of intraoperative bleeding or of a standardized system for its classification means that often the most suitable agent is not selected. The recommendations of international organizations highlight the need for a bleeding severity scale, validated in clinical studies, that would allow the selection of the best hemostatic agent in each case. The primary objective of this study is to evaluate the VIBe scale (Validated Intraoperative Bleeding Scale) in humans. Secondary objectives are to evaluate the scale's usefulness in liver surgery; to determine the relationship between the extent of bleeding and the hemostatic agent used; and to assess the relationship between the grade of bleeding and postoperative complications.

Methods

Prospective multicenter observational study including 259 liver resections that meet the inclusion criteria: patients scheduled for liver surgery at one of 10 medium-high volume Spanish HPB centers using an open or minimally invasive approach (robotic/laparoscopic/hybrid), regardless of diagnosis, ASA score <4, age ≥18, and who provide signed informed consent during the study period (September 2023 until the required sample size has been recruited). The participating researchers will be responsible for collecting the data and for reporting them to the study coordinators.

Discussion

This study will allow us to evaluate the VIBe scale for intraoperative bleeding in humans, with a view to its subsequent incorporation in daily clinical practice.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT05369988?term = serradilla&draw = 2&rank = 3, [NCT0536998].

Survey on initial management of acute pancreatitis in Latin America

OBJECTIVE

The population of Latin America harbors the highest incidence of gallstones and acute biliary pancreatitis, yet little is known about the initial management of acute pancreatitis in this large geographic region.

PARTICIPANTS AND METHODS

We performed a post hoc analysis of responses from physicians based in Latin America to the international multidisciplinary survey on the initial management of acute pancreatitis. The questionnaire asked about management of patients during the first 72h after admission, related to fluid therapy, prescription of prophylactic antibiotics, feeding and nutrition, and timing of cholecystectomy. Adherence to clinical guidelines in this region was compared with the rest of the world.

RESULTS

The survey was completed by 358 participants from 19 Latin American countries (median age, 39 years [33-47]; women, 27.1%). The proportion of participants in Latin America vs. the rest of the world who chose non-compliant options with clinical guidelines were: prescription of fluid therapy rate other than moderate (42.2% vs 34.3%, P=.02); prescription of prophylactic antibiotics for severe (10.6% vs 18.0%, P=.002), necrotizing (28.5% vs 36.9%, P=.008), or systemic inflammatory response syndrome-associated (21.2% vs 30.6%, P=.002) acute pancreatitis; not starting an oral diet to patients with oral tolerance (77.9% vs 71.1%, P=.02); and delayed cholecystectomy (16.2% vs 33.8%, P<.001).

CONCLUSIONS

Surveyed physicians in Latin America are less likely to prescribe antibiotics and to delay cholecystectomy when managing patients in the initial phase of acute pancreatitis compared to physicians in the rest of the world. Feeding and nutrition appear to require the greatest improvement.

Textbook Outcome in Bariatric Surgery: Evolution During 15 Years in a Referral Center

BACKGROUND

Textbook outcome (TO) is a multidimensional measure used to assess the quality of care. It is the "ideal" surgical result, based on a series of established indicators. In the field of bariatric surgery (BS), only one publication on TO is available.

OBJECTIVES

To determine TO in our BS unit and identify the factors linked to TO.

SETTING

University public hospital in Alicante (Spain).

METHODS

Retrospective observational study of all primary BS was performed. TO for BS was defined in relation to the following features: no major postoperative complications (Clavien-Dindo >II), hospital stay <75th percentile, and no mortality or readmissions within 30 days of surgery. Comparative analysis of the characteristics of the TO and non-TO groups was performed, as well as univariate and multivariate logistic regressions, to identify the independent factors associated with obtaining TO.

RESULTS

In 970 patients, TO was achieved in 71.5%. The hospital stay was the one that most affected achievement of TO. Analysis according to the type of procedure (sleeve gastrectomy and gastric bypass) did not reveal any differences between both procedures in terms of obtaining TO (71.5 vs 71.26%). Logistic regression identified smoking, heart disease, operative time, and upper gastrointestinal bleeding as independent factors associated with obtaining TO (p<0.05). Analysis of the annual evolution of TO reveals a progressive increase in its achievement (7.7-86.4%).

CONCLUSION

In our series, TO was obtained in 71.5% of patients. The standardization of the technique and the experience gained over the years has improved our TO results.

Surgery of Colorectal Liver Metastases Involving the Inferior Vena Cava: A Systematic Review

Combined hepatic and inferior vena cava (IVC) resection is the only potentially curative treatment for patients with colorectal liver metastases (CRLM) involving the IVC. Most of the existing data come from case reports or small case series. In this paper, a systematic review based on the PICO strategy was performed in accordance with the PRISMA statement. Papers from January 1980 to December 2022 were searched in Embase, PubMed, and the Cochrane Library databases. Articles considered for inclusion had to present data on simultaneous liver and IVC resection for CRLM and report surgical and/or oncological outcomes. From a total of 1175 articles retrieved, 29, including a total of 188 patients, met the inclusion criteria. The mean age was 58.3 ± 10.8 years. The most frequent techniques used were right hepatectomy ± caudate lobe for hepatic resections (37.8%), lateral clamping (44.8%) for vascular control, and primary closure (56.8%) for IVC repair. The thirty-day mortality reached 4.6%. Tumour relapse was reported in 65.8% of the cases. The median overall survival (OS) was 34 months (with a confidence interval of 30-40 months), and the 1-year, 3-year, and 5-year OS were 71.4%, 19.8%, and 7.1%, respectively. In the absence of prospective randomized studies, which are difficult to perform, IVC resection seems to be safe and feasible.

International multidisciplinary survey on the initial management of acute pancreatitis: Perspective of point-of-care specialists focused on daily practice

BACKGROUND

The initial management of patients with acute pancreatitis impacts both morbidity and mortality. Point-of-care decisions have been reported to differ from clinical guideline recommendations.

METHODS

An online anonymous questionnaire was distributed through scientific associations and social media using REDCap. Multivariable logistic regression was used to identify the characteristics of participants associated with compliance with the recommendations.

RESULTS

A total of 1054 participants from 94 countries completed the questionnaire; median age (IQR) was 39 (32-47) years; 30.7% were women. Among the participants, 37% opted for nonmoderate flow of i.v. fluid, 31% for fluid type other than Ringer's lactate; 73.4% were in favor of nil per os to patients who could eat, 75.5% for other than enteral feeding to patients with oral intolerance; 15.5% used prophylactic antibiotic in patients with severe acute pancreatitis, 34.1% in necrotizing acute pancreatitis, and 27.4% in patients with systemic inflammatory response syndrome; 27.8% delayed cholecystectomy after biliary acute pancreatitis. Participants with publications in PubMed on acute pancreatitis showed better compliance (OR, 1.62; 95% CI: 1.15-2.32; P = .007) with recommendations of the clinical guidelines.

CONCLUSIONS

Feeding and nutrition require the greatest improvement efforts, but also the use of prophylactic antibiotics and timing of cholecystectomy should be improved.

A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation

PURPOSE

A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort.

METHODS

An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included.

RESULTS

A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score ≥ 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%.

CONCLUSION

Patients with a Shin score ≤ 1 should undergo surveillance, while patients with a score ≥ 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines.

Benefica chirurgia. A global surgery project focusing on hernia surgery

BACKGROUND

The aim of international health cooperation projects is to alleviate the deficiencies in the area of health in low resource settings. Hernia surgery is a procedure that is well suited to these missions, due to its low morbidity, the fact that it can be performed on an outpatient basis, and the improvement in quality of life that it provides.

OBJECTIVE

To describe the results of Benefica Chirurgia (BC), a Spanish non-profit humanitarian association in hernia pathology.

METHODS

Five one-week surgical campaigns were carried out in Ecuador between 2015 and 2019, involving anesthetists, general and pediatric surgeons. Surgical and medical equipment was provided and transported by BC. ASA I/II patients underwent surgery.

RESULTS

Surgery was performed on 240 patients with hernia pathology on 27 days. Sixty-three per cent of patients were male and the mean age was 48.2 years (range: 1-83). Hernia location was inguinal in 113 patients, umbilical in 101, and other in 26. The anesthetic technique used was spinal in 185 patients (77.1%), local plus intravenous sedation in 31 (12.9%), and general in 24 (10%). The surgical technique used was hernioplasty in 191 patients, herniorrhaphy in 31, incisional hernia repair in 15 and herniotomy in three. Surgery was performed on an outpatient basis in 98.4% of cases. Morbidity was 2%. Long-term postoperative evaluation is very complex.

CONCLUSION

These campaigns make a significant contribution to health in low resource settings and provide great personal satisfaction for those involved. Standards achieved in the immediate postoperative period were similar to those obtained at the surgeons' centers in Europe. However, it is difficult to establish the rates of recurrence and chronic pain.

Applicability and reproducibility of the validated intraoperative bleeding severity scale (VIBe scale) in liver surgery: A multicenter study

BACKGROUND

Bleeding is an intraoperative and postoperative complication of liver surgery of concern, and yet evidence to support utility and reproducibility of bleeding scales for liver surgery is limited. We determined the reproducibility of the clinician-reported validated intraoperative bleeding severity scale and its clinical value of implementation in liver surgery.

METHODS

In this descriptive and observational multicenter study, we assessed the performance of liver surgeons instructed on the clinician-reported intraoperative bleeding severity scale using training videos that covered all 5 grades of bleeding severity. Surgeons were stratified according to years of surgical experience and number of surgeries performed per year based on a median split in low and high values. Intraobserver and interobserver agreement was assessed using Kendall's coefficient of concordance (Kendall's W).

RESULTS

Forty-seven surgeons from 10 hospitals in Spain participated in the study. The overall intraobserver concordance was 0.985, and the overall interobserver concordance was 0.929. For "high experience" surgeons, the intraobserver and interobserver agreement values were 0.990 and 0.941, respectively. For "low experience" surgeons, the intraobserver and interobserver agreement was 0.981 and 0.922, respectively. Regarding the annual number of surgeries, intraobserver and interobserver agreement values were 0.995 and 0.940, respectively, for surgeons performing >35 surgeries per year, with 0.979 and 0.923, respectively, for surgeons who perform ≤35 surgeries year.

CONCLUSION

The clinician-reported intraoperative bleeding severity scale shows high interobserver and intraobserver concordance, suggesting it is a useful tool for assessing severity of bleeding during liver surgery; years of surgical experience and number of annual procedures performed did not affect the applicability of the clinician-reported intraoperative bleeding severity scale.

Prediction of peritoneal soiling in acute appendicitis with simple clinical and laboratory data. Prospective, multicenter, cohort study of 2,645 adult patients nationwide

BACKGROUND AND AIMS

In order to facilitate the preoperative prediction of complicated appendicitis, we propose a complementary approach by selecting an endpoint defined by the intraoperative finding of peritoneal soiling (PS).

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending emergency general surgery patients on a 24-hour, 7-days a week basis, enrolled consecutive adult patients requiring appendectomy. Patients were stratified according to the absence or the finding of PS during the surgical procedure.

RESULTS

A total of 2645 patients were included; median age (IQR) was 35 (22-51) years, 44.3% were female. The laparoscopic approach was used in 70.8% of appendectomies. In a third of patients (31.7%), there was PS with pus around the appendix, or bowel contents, free pus, or blood in the peritoneal cavity. To develop the prediction model, 1764 patients were randomly selected for the derivation cohort and the remaining 881 patients were assigned to the validation cohort. On multivariable logistic regression analysis of all patients, two clinical variables (age, and pulse) and three laboratory variables (serum urea, serum sodium, and white blood cell count) were individually associated (P < .05) with a greater probability of having PS (Hosmer-Lemeshow chi, 1.63; P = .99; C-statistic, 0.7). Based on the multivariable regression model, both static and dynamic nomograms were developed for the prediction of PS in patients with acute appendicitis.

CONCLUSIONS

The entry of simple clinical and laboratory variables in the dynamic nomogram may be useful in guiding the initial management of patients with acute appendicitis in resource-limited settings.

Reaching a consensus on the definition of "difficult" cholecystectomy among Spanish experts. A Delphi project. A qualitative study

BACKGROUND

Being able to predict preoperatively the difficulty of a cholecystectomy can increase safety and improve results. However, there is a need to reach a consensus on the definition of a cholecystectomy as "difficult". The aim of this study is to achieve a national expert consensus on this issue.

METHODS

A two-round Delphi study was performed. Based on the previous literature, history of biliary pathology, preoperative clinical, analytical, and radiological data, and intraoperative findings were selected as variables of interest and rated on a Likert scale. Inter-rater agreement was defined as "unanimous" when 100% of the participants gave an item the same rating on the Likert scale; as "consensus" when ≥80% agreed; as "majority" when the agreement was ≥70%. The delta of change between the two rounds was calculated.

RESULTS

After the two rounds, the criteria that reached "consensus" were bile duct injury (96.77%), non-evident anatomy (93.55%), Mirizzi syndrome (93.55%), severe inflammation of Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since last acute cholecystitis (83.87%), scleroatrophic gallbladder (80.65%) and pericholecystic abscess (80.65%).

CONCLUSION

The ability to predict difficulty in cholecystectomy offers important advantages in terms of surgical safety. As a preliminary step, the items that define a surgical procedure as difficult should be established. Standardization of the criteria can provide scores to predict difficulty both preoperatively and intraoperatively, and thus allow the comparison of groups of similar difficulty.

Liver and lung hydatid cysts with transdiaphragmatic rupture treated by radical surgery

Hydatidosis is a parasitic disease caused by Echinococcus granulosus, a tapeworm that is endemic in certain parts of the world. We present a case of hepatopulmonary hydatidosis with diaphragm involvement and close contact with the suprahepatic inferior vena cava treated with radical surgery. We discuss therapeutical surgical options (approach and type of surgery).

Textbook outcome among patients undergoing enhanced recovery after liver transplantation stratified by risk. A single-center retrospective observational cohort study

BACKGROUND & AIMS

Liver transplantation (LT) is one of the most complex surgical procedures. Enhanced recovery after surgery (ERAS) aims to reduce the risk of postoperative complications. When patients achieve all desirable outcomes after a procedure, they are considered to have experienced a textbook outcome (TO).

METHODS

Two cohorts of patients undergoing low (n = 101) or medium risk (n = 15) LT were identified. The remaining patients (n = 65) were grouped separately. The ERAS protocol included pre-, intra-, and post-operative steps. TO was defined as the absence of complications, prolonged length of hospital stays, readmission and mortality during the first 90 days.

RESULTS

One third of patients who underwent ERAS after LT experienced a TO. On multivariable analysis, age (OR, 1.05 [95% CI, 1.01-1.09]; P = .02), and having hepatocellular carcinoma (OR, 2.83 [95% CI, 1.37-6.03]; P = .005) were individually associated with a greater probability of achieving a TO. Belonging to the cohorts of medium risk or outside the selection criteria was associated with a lower probability of achieving a TO (OR, 0.46 [96% CI, 0.22-0.93]; P = .03). Patients less likely to experience TO required more hospital resources. Patients who achieved TO were more likely to remain free of chronic kidney disease (achieved TO, 83.8% [82.7-85.6]; failed TO, 67.9% [66.9-70.2]; P < .05). Tacrolimus dose and trough levels were similar.

CONCLUSIONS

A novel finding of our study is that short and medium-term kidney function is better preserved in patients who experience a TO. Better kidney function of patients who achieve TO is not due to lower tacrolimus dosage.

Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

BACKGROUND AND AIMS

Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures.

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator.

RESULTS

A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity.

CONCLUSIONS

This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

Liver resection and ablation for squamous cell carcinoma liver metastases

Background

Limited evidence exists to guide the management of patients with liver metastases from squamous cell carcinoma (SCC). The aim of this retrospective multicentre cohort study was to describe patterns of disease recurrence after liver resection/ablation for SCC liver metastases and factors associated with recurrence-free survival (RFS) and overall survival (OS).

Method

Members of the European–African Hepato-Pancreato-Biliary Association were invited to include all consecutive patients undergoing liver resection/ablation for SCC liver metastases between 2002 and 2019. Patient, tumour and perioperative characteristics were analysed with regard to RFS and OS.

Results

Among the 102 patients included from 24 European centres, 56 patients had anal cancer, and 46 patients had SCC from other origin. RFS in patients with anal cancer and non-anal cancer was 16 and 9 months, respectively (P = 0.134). A positive resection margin significantly influenced RFS for both anal cancer and non-anal cancer liver metastases (hazard ratio 6.82, 95 per cent c.i. 2.40 to 19.35, for the entire cohort). Median survival duration and 5-year OS rate among patients with anal cancer and non-anal cancer were 50 months and 45 per cent and 21 months and 25 per cent, respectively. For the entire cohort, only non-radical resection was associated with worse overall survival (hazard ratio 3.21, 95 per cent c.i. 1.24 to 8.30).

Conclusion

Liver resection/ablation of liver metastases from SCC can result in long-term survival. Survival was superior in treated patients with liver metastases from anal versus non-anal cancer. A negative resection margin is paramount for acceptable outcome.

Jaundice as a clinical presentation in liver hydatidosis increases the risk of postoperative biliary fistula

PURPOSE

Echinococcosis, also known as hydatidosis, is a zoonosis that is endemic in many countries worldwide. Liver hydatid cysts have a wide variety of clinical manifestations, among which obstructive jaundice is one of the rarer forms. The aims of the study were to analyze the preoperative management of these patients and to record the kind of surgical treatment performed and the short- and long-term postoperative results.

METHODS

A retrospective two-center observational study of patients operated upon for liver hydatidosis with initial symptoms of obstructive jaundice. Preoperative characteristics, surgical data, and postoperative complications, including biliary fistula, were recorded.

RESULTS

Of 353 patients operated upon for liver hydatidosis, 44 were included in the study. Thirty-five patients (79.6%) were defined as CE2 or CE3 in the World Health Organization (WHO) classification. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 25 patients (56.8%) and identified intrabiliary communication in 29. Radical surgery was carried out in 29 of the total sample (65.9%). Severe postoperative complications (Clavien-Dindo grade IIIA or higher) were recorded in 25% of patients. The factors associated with greater postoperative morbidity were age above 65 (HR 8.76 [95% CI 0.78-97.85]), cyst location (HR 4.77 [95% CI 0.93-24.42]), multiple cysts (HR 14.58 [95% CI 1.42-149.96]), and cyst size greater than 5 cm (HR 6.88 [95% CI 0.95-50]).

CONCLUSION

The presentation as obstructive jaundice causes greater postoperative morbidity. The main postoperative complication in these cases, despite radical surgery, is biliary fistula. In our series, routine preoperative ERCP did not show any benefit.

[National survey on the treatment of cholelitiasis in Spain during the initial period of the COVID-19 pandemic]

Introduction

The extraordinary impact of COVID-19 pandemic on Spanish hospitals has led to a redistribution of resources for the treatment of these patients, with a decreased capacity of care for other common diseases. The aim of the present study is to analyse how this situation has affected the treatment of cholecystitis and cholelythiasis.

Methods

It is a descriptive national study after online voluntary distribution of a specific questionnaire with Google Drive™ to members of the Spanish Association of Surgeons (AEC).

Results

We received 153 answers (one per hospital). Elective cholecystectomies have been cancelled in 96.7% of centres. Conservative treatment for acute cholecystitis has been selected in 90% (previously 18%), and if operated, 95% have been performed laparoscopically. Globally, only 49% perform preoperative diagnostic tests for SARS-CoV-2, and 58.5% recognize there have been cases confirmed postoperatively after other surgeries, with worse surgical outcomes in 54%.

Conclusions

This survey shows that most of the Spanish centers are following the surgical societies suggestions during the pandemic. However, some data requires to be taken into account for the next phase of the pandemic.

National survey on the treatment of cholelitiasis in Spain during the initial period of the COVID-19 pandemic

Introduction

The extraordinary impact of COVID-19 pandemic on Spanish hospitals has led to a redistribution of resources for the treatment of these patients, with a decreased capacity of care for other common diseases. The aim of the present study is to analyse how this situation has affected the treatment of cholecystitis and cholelythiasis.

Methods

It is a descriptive national study after online voluntary distribution of a specific questionnaire with Google Drive™ to members of the Spanish Association of Surgeons (AEC).

Results

We received 153 answers (one per hospital). Elective cholecystectomies have been cancelled in 96.7% of centres. Conservative treatment for acute cholecystitis has been selected in 90% (previously 18%), and if operated, 95% have been performed laparoscopically. Globally, only 49% perform preoperative diagnostic tests for SARS-CoV-2, and 58.5% recognize there have been cases confirmed postoperatively after other surgeries, with worse surgical outcomes in 54%.

Conclusions

This survey shows that most of the Spanish centers are following the surgical societies suggestions during the pandemic. However, some data requires to be taken into account for the next phase of the pandemic.

Evaluation of Preoperative Clinical and Serological Determinations in Complicated Acute Appendicitis: A Score for Predicting Complicated Appendicitis

BACKGROUND

To analyze whether clinical and analytical parameters differ according to histopathology in cases of acute appendicitis (AA).

METHODS

This is a retrospective, observational study including patients (>14 years of age) admitted for suspicion of AA from 1 April 2014 to 31 July 2016. Histopathology was divided into complicated (including perforated and gangrenous AA) and uncomplicated appendicitis (phlegmonous). Sex, age, temperature of patients on admission to the Emergency Department, symptom duration, preoperative white blood cell (WBC) count, neutrophil percentage, mean platelet volume (MPV), platelet distribution width (PDW), C-reactive protein (CRP) and hospital stay were compared in the two groups.

RESULTS

Three hundred and thirty-five patients were analyzed, and 284 were included. Appendicitis was uncomplicated in 194 (68.3%) and complicated in 90 (31.7%). Age, symptom duration, neutrophil percentage, CRP and hospital stay were higher in the complicated AA group (P < .05). The mean differences between uncomplicated and complicated AA were: age 13.2 years (95% CI: 8.2-18.2), symptom duration 14.1hours (95% CI: 6.3-21.9), neutrophil percentage 5.0% (95% CI: 3.2-6.8), CRP 73.6mg/l (95% CI: 50.0-97.2) and hospital stay 2.2 days (95% CI: 1.4-3.0), with p<0.05 for all these variables. A model based on the preoperative parameters (age, symptom duration, neutrophil percentage and CRP) was calculated to predict the likelihood of complicated AA. The receiver operating characteristic (ROC) of the model had an area under the curve of 0.80 (95% CI 0.75-0.85).

CONCLUSION

This model is able to diagnose complicated AA without the need for imaging techniques, although it must be validated with prospective analysis.

Spanish multicenter study of surgical resection of pancreatic tumors infiltrating the celiac axis: does the type of pancreatectomy affect results?

BACKGROUND

Pancreatectomy plus celiac axis resection (CAR) is performed in patients with locally advanced pancreatic cancer. The morbidity rates are high, and no survival benefit has been confirmed. It is not known at present whether it is the type of pancreatectomy, or CAR itself, that is the reason for the high complication rates.

METHODS

Observational retrospective multicenter study.

INCLUSION CRITERIA

patient undergoing TP, PD or DP plus CAR for a pancreatic cancer.

RESULTS

Sixty-two patients who had undergone pancreatic cancer surgery (PD,TP or DP) plus CAR were studied. Group 1: 17 patients who underwent PD/TP-CAR (13TP/4PD); group 2: 45 patients who underwent DP-CAR. Groups were mostly homogeneous. Operating time was longer in the PD/TP group, while operative complications did not differ statistically in the two groups. The number of lymph nodes removed was higher in the PD/TP group (26.5 vs 17.3), and this group also had a higher positive node ratio (17.9% vs 7.6%). There were no statistical differences in total or disease-free survival between the two groups.

CONCLUSION

It seems that CAR, and not the type of pancreatectomy, influences morbidity and mortality in this type of surgery. International multicenter studies with larger numbers of patients are now needed to validate the data presented here.

The top 100. Review of the most cited articles on pancreas and laparoscopy

INTRODUCTION

The number of citations is considered as an indirect indicator of the merit of an article, journal or researcher, although it is not an infallible method to determine scientific quality. Our goal is to determine the characteristics of the articles most cited about pancreas and laparoscopy.

METHODS

We performed a search of all articles published in any journal about pancreas and laparoscopy until September 2019 and selected the 100 most cited papers. We recorded number of citations, journal, year of publication, quartil, impact factor, institution, country, authors type of paper, type of surgery, topic and area.

RESULTS

The top 100 citations account 10,970 citations in total. The journal with the most articles is Surgical Endoscopy and 2007 is the year with the highest number of articles in the top 100 citations. The percentage of publications from America and Europe are similar. Case series is the most frequently paper, outcomes/morbidity is the most frequently discussed topic, and distal pancreatectomy is the most frequently type of surgery.

CONCLUSIONS

This bibliometric study on pancreas and laparoscopy is conditioned by the time factor, since laparoscopy has arrived later at pancreatic surgery, probably due to the morbidity and mortality associated with pancreatic surgery and the need for a high specialization in this field. The literature is recent and scarce. More and better-quality studies are needed in this field.

Inguinal abscess as presentation of a right colon cancer. A systematic review

Perforation in colorectal cancer is an uncommon condition, and neoplastic invasion of the abdominal wall with local infection is even rarer. Our objective is to present the case of an 84-year-old male with right colon cancer that manifested as an inguinal abscess, and also to perform a systematic review of the literature in PubMed, EMBASE, and Web of Science. A total of 59 cases in retrospective studies were found. Median age was 64 years, thirty cases were men and twenty-nine were women (51% and 49%, respectively). The most common location was the right colon with 27 cases (46%), followed by the left colon with 18 cases (31%), 12 cases in the transverse colon (20%), and 2 cases with colonic synchronous neoplasm (3%). Surgery was performed in two or more occasions for 33 cases (60%), and on one occasion for 21 cases (38%); medical treatment alone was administered in one case (2%). The most common histological type was adenocarcinoma (64%), followed by its mucinous variant (22%). There was recurrence in 33% of cases. Mortality at follow-up was 47%. As a limitation of our study, follow-up was heterogeneous, making it impossible to interpret long-term results regarding the influence of treatment on patient survival, also difficulted by the urgent nature of the condition and its exceptional incidence. Further studies are needed with prospective data collection on the management of colorectal cancer in the emergency setting, standardizing follow-up in order to facilitate an adequate analysis of the prognosis of the disease.

Antimicrobial Stewardship Programs Are Required in a Department of Surgery: "How" Is the Question A Quasi-Experimental Study: Results after Three Years

Objective: Our aim was to describe our antimicrobial stewardship program and the methodology based on the results in a surgical department. Methods: Our study was a quasi-experimental study conducted from January 1, 2009, through September 30, 2017. The site was the General and Digestive Surgery Department in a public primary referral center, the University Hospital of Getafe (Madrid, Spain). We implemented the antimicrobial stewardship program following a prospective audit and feedback model, with a surgeon incorporated into the manaagement group. We studied the deaths and 30-day re-admission rates, length of stay, prevalence of gram-negative bacilli, meropenem resistance, and days of treatment with meropenem. Results: After three years of the program, we recorded a significant decrease in Pseudomonas aeruginosa prevalence, a significant increase in Klebsiella pneumoniae prevalence, a decrease in meropenem resistance, and a reduction in meropenem days of treatment. Conclusions: Antimicrobial stewardship programs have a desirable effect on patients. In our experience, the program team should be led by a staff from the particular department. When human resources are limited, the sustainability, efficiency, and effectiveness of interventions are feasible only with adequate computer support. Finally, but no less important, the necessary feedback between the prescribers and the team must be based on an ad hoc method such as that provided by statistical control charts, a median chart in our study.

Hepatic gastrointestinal stromal tumor: Systematic review of an exceptional location

BACKGROUND

A minor subset of primary gastrointestinal stromal tumors (GIST) can also arise outside the gastrointestinal tract, which is known as an extra-GIST (E-GIST). Primary GIST of the liver is an exceptional location.

AIM

To characterize epidemiological, clinical and pathological features and options of treatments.

METHODS

We performed a systematic review to search for articles on primary hepatic GIST.

RESULTS

This review shows that right hepatic lobe was the most frequent location. Regarding pathological and immunohistochemical features, mitotic count was ≥ 5/50 High Power Fields in more than 50%; and CD117 was negative in only 1 patient. More than 70% of patients had a lesion with high risk of malignancy.

CONCLUSION

The diagnosis of E-GIST must be considered in a liver mass. Rendering an accurate diagnosis is a challenge, as well as the confirmation of their primary or metastatic nature.

National survey on Pancreatic Surgery Units

INTRODUCTION

The technical, human, scientific and treatment characteristics of the Units that manage complex pathologies have not been studied in depth.

METHODS

Multi-institutional descriptive study (survey) developed jointly by the Hepatobiliary-Pancreatic Division of the Spanish Association of Surgeons and the Spanish Chapter of the IHPBA (International Hepatopancreatobiliary Association) on the characteristics of the Units where pancreatic surgery is performed in Spain.

RESULTS

82 surveys were sent. 69 medical centers responded (84%), belonging to 16 autonomous regions of Spain. The total population of these regions was 23,183,262 (50% of the Spanish population). The average number of beds per hospital was 673. The unit that performs pancreatic surgery is a Hepatobiliary-Pancreatic Surgery Unit or HPB and Liver Transplant Surgery Unit in 56 hospitals (77%). The average number of surgeons is 4.5 per Unit. Fifty-five Units (80%) lack specific anesthetists. The number of pancreatectomies performed during 2017 at the hospitals surveyed was 1,315 pancreaticoduodenectomies (PD), 566 distal pancreatectomies (DP) and 178 total pancreaticoduodenectomies (TPD). The mean per hospital was 19.1 PD, 8.2 DP and 2.6 TPD. PD was usually performed using a classic approach, with pancreatojejunostomy, single-loop technique, antecolic gastrojejunostomy and using two drain tubes. Only 7 Units performed PD laparoscopically and only 13 units did not perform laparoscopic DP.

CONCLUSIONS

This survey provides updated information about the majority of the Units where pancreatic surgery is performed in Spain and could also serve as a starting point for prospective multicenter studies.

The top 100: A review of the most cited articles in Surgery

INTRODUCTION

We performed a study of the top 100 most cited articles in the five general surgery journals with the highest impact according to Journal Citation Report.

METHODS

We selected the five journals with the highest impact in 2015: Annals of Surgery, British Journal of Surgery, JAMA Surgery, Surgery, and Journal of the American College of Surgeons. In January 2017, using the Web of Science application, we performed a search of all articles published by these journals and identified the 100 most cited articles (top 100). We evaluated the number of citations, year of publication, type of article, country and hospital of the article, area of interest and number of authors.

RESULTS

The median number of citations per top 100 paper was 490. Twenty percent of the top 100 papers have been published since 2000. Overall, 70% are original papers, 8% randomized control trials, 11% reviews, 1% meta-analyses and 11% other subtypes. There are 13% proceedings papers. Sixty-one percent are from the US. The most frequently discussed topic is hepato-pancreato-biliary surgery (33%).

CONCLUSIONS

The top 100 most cited articles tend to be original articles describing studies carried out in the US, reporting significant surgical breakthroughs. Hepato-pancreato-biliary surgery is the most common subject area. Annals of Surgery had twice as many citations as the other journals studied. The archetypal article of the Top15 most cited is an original paper published in the twentieth century, with an average of 2000 citations.

Pelvic hydatidosis: an exceptional location

Hydatid disease is a zoonosis, still endemic in some Spanish geographical areas. Extrahepatic-extrapulmonary lesions account for only 10%, with pelvic lesions being exceptional. We present two patients with pelvic hydatidosis, with or without concomitant liver injury. Treatment depends on the cyst, location and symptoms. Surgery is mandatory if there is any complication.

Systematic review of the mesopancreas: concept and clinical implications

BACKGROUND

In 2007, Gockel et al. coined the term mesopancreas (MP). In the next 10 years, a limited number of publications about MP have been published, but little is known about the oncological benefit of MP resection. We performed a systematic review of the literature on MP.

METHODS

An electronic search was performed in PubMed, EMBASE, Cochrane, Latindex, Scielo, and Koreamed databases until 15 June 2017 to identify all published articles dealing with the subject of MP. Some language restriction was done (Chinese and Rumanian).

RESULTS

The search yielded 51 articles; 28 articles were selected as relevant. All were retrospective studies focused more on describing technical variants, feasibility and safety than on the cancer results. The R0 rate in patients with MP resection ranged between 57 and 96.7%. In all the articles with a control group, the R0 rate was higher in the MP excision group. Survival data were explicitly stated only in five series.

CONCLUSION

MP is a difficult-to-excise retropancreatic area. In theory, it is agreed that MP excision raises the rate of R0 resections, which in turn reflected in an improvement in the oncological results; however, at present there are no randomized studies to prove this. Achieving a worldwide consensus on its concept, landmarks, excision technique and oncological results is essential.