Predictors for stone recurrence after a successful common bile duct surgical exploration for choledocholithiasis.

BACKGROUND: Recurrence after common bile duct stone (CBDS) clearance is the major long-term drawback of their management. Its prevalence is significant, and it occurs after all primary therapeutic alternatives. The aim of this study was to determine the predictive factors associated with stone recurrence after surgical common bile duct exploration (CBDE). METHODS: A retrospective cohort study based on patients undergoing CBDE between 2000 and 2018 was conducted. Uni- and multivariate hierarchical regression analyses were performed to assess the independent predictive factors associated with recurrent CBDS in patients with initially successful surgery. RESULTS: A total of 365 patients underwent successful surgical procedures. After a median follow-up of 43.2 (IQR 84) months, 31 (8.4%) patients were diagnosed with CBD stone recurrence. The median time to recurrence was 30.3 (IQR 38) months. The only variable associated with CBDS recurrence was preoperative endoscopic sphincterotomy (HR 2.436, 95% CI: 1.031-5.751, P = 0.042)). CONCLUSION: Patients who undergo preoperative endoscopic sphincterotomy and then cholecystectomy with successful common bile duct clearance may be at increased risk for recurrent stone disease compared to those who go straight to surgery.

Conversion to open surgery during laparoscopic common bile duct exploration: predictive factors and impact on the perioperative outcomes.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is an effective treatment for choledocholithiasis. The aim of this study was to determine the predictive factors associated with conversion during LCBDE and to assess the implications of conversion on the patients' postoperative course. METHODS: A retrospective cohort study based on patients undergoing LCBDE between 2000 and 2018 was conducted. Uni- and multivariate regression analyses were performed. RESULTS: A total of 357 patients underwent LCBDE, and the conversion rate was 14.2%. The main reasons for conversion were lithiasis extraction (21; 41%) and difficult dissection (13; 26%). Independent predictors for conversion were increasing levels of serum bilirubin prior to surgery (OR=4.745, 95% CI: 1.390-16.198; p=0.013), and emergency setting (OR=4.144, 95% CI: 1.449-11.846; p=0.008). Age was independently associated with lower odds of conversion (OR=0.979, 95% CI: 0.960-0.999; p=0.036). Conversion had a negative impact on the patients' postoperative course, including severe complication (21.6% vs. 5.2% p<0.001) and surgical reintervention (11.8% vs. 2.6% p=0.002) rates. CONCLUSION: Conversion to open surgery during LCBDE was associated with increased postoperative morbidity. Emergency surgery and increasing levels of serum bilirubin previous to surgery independently increase the probability of conversion; however age was independently associated with lower odds of conversion.

Predictors for prolonged length of stay after laparoscopic appendectomy for complicated acute appendicitis in adults.

BACKGROUND: Appendicitis-related hospitalizations linked with peritonitis or postoperative complications result in longer lengths of stay and higher costs. The aim of the present study was to assess the independent association between potential predictors and prolonged hospitalization after laparoscopic appendectomy (LA) for complicated acute appendicitis (CAA). METHODS: A retrospective cohort study was conducted on adult patients diagnosed with CAA in which LA was attempted. The primary outcome was a prolonged length of stay (LOS) after surgery, defined as hospitalizations longer than or equal to the 75th percentile for LOS, including the day of discharge. Hierarchical regression models were run to elucidate the independent predictors for the variable of interest. RESULTS: The present study involved 160 patients with a mean age of 50.71 years. The conversion rate was 1.9%, and the overall postoperative morbidity rate was 23.8%. The median length of stay (LOS) was 5 days (75th percentile: 7 days). Multivariate analyses included nine variables that are statistically and/or clinically relevant to assess its relationship with a prolonged LOS: three preoperative (age, sex, and comorbidity), four intraoperative (appendix gangrene, perforation, degree of peritonitis, and drain placement), and two postoperative (immediate ICU admission and complications). The development of postoperative complications (OR 6.162, 95% CI 2.451-15.493; p = 0.000) and the placement of an abdominal drain (OR 3.438, 95% CI 1.107-10.683; p = 0.033) were found to be independent predictors for prolonged LOS. For patients not presenting postoperative complications, drain placement was the only independent predictor for the outcome (OR 7.853, 95% CI 1.520-40.558; p = 0.014). Sensitivity analyses showed confirmatory results. CONCLUSION: The intraoperative process of care has a clear impact on LOS after LA for CAA in adults; therefore, the decision of whether to drain in these situations should be made more restrictively yet with judicious caution.

Gastric syphilis and its importance for a differential diagnosis in HIV patients.

A 41-year-old male, with history of HIV presented to emergency department with two months of abdominal pain and a weight loss. Radiological and endoscopic examinations where suggestive of gastric cancer. However, biopsies ruled out malignancy. The reaginic and anti-treponemal tests were positive, so the histological study was repeated with anti-Treponema pallidum monoclonal antibodies. The presence of spirochetes was confirmed. After three weeks of penicillin-based treatment, the gastric lesions and symptoms were resolved.

The impact of age and comorbidity on the postoperative outcomes after emergency surgical management of complicated intra-abdominal infections.

Age-adjusted Charlson Comorbidity Index (a-CCI) score has been used to weight comorbid conditions in predicting adverse outcomes. A retrospective cohort study on adult patients diagnosed with complicated intra-abdominal infections (cIAI) requiring emergency surgery was conducted in order to elucidate the role of age and comorbidity in this scenario. Two main outcomes were evaluated: 90-day severe postoperative complications (grade ≥ 3 of Dindo-Clavien Classification), and 90-day all-cause mortality. 358 patients were analyzed. a-CCI score for each patient was calculated and then divided in two comorbid categories whether they were ≤ or > to percentile 75 ( = 4): Grade-A (0-4) and Grade-B ( ≥ 5). Univariate and multivariate regression analyses were performed, and the predictive validity of the models was evaluated by the area under the receiver operating characteristics (AUROC) curve. Independent predictors of 90-day severe postoperative complications were Charlson Grade-B (Odds Ratio [OR] = 3.49, 95% confidence interval [95%CI]: 1.86-6.52; p < 0.0001), healthcare-related infections (OR = 7.84, 95%CI: 3.99-15.39; p < 0.0001), diffuse peritonitis (OR = 2.64, 95%CI: 1.45-4.80; p < 0.01), and delay of surgery > 24 hours (OR = 2.28, 95%CI: 1.18-4.68; p < 0.02). The AUROC was 0.815 (95%CI: 0.758-0.872). Independent predictors of 90-day mortality were Charlson Grade-B (OR = 8.30, 95%CI: 3.58-19.21; p < 0.0001), healthcare-related infections (OR = 6.38, 95%CI: 2.72-14.95; p < 0.0001), sepsis status (OR = 3.98, 95%CI: 1.04-15.21; p < 0.04) and diffuse peritonitis (OR = 3.06, 95%CI: 1.29-7.27; p < 0.01). The AUROC for mortality was 0.887 (95%CI: 0.83-0.93). Post-hoc sensitivity analyses confirmed that the degree of comorbidity, estimated by using an age-adjusted score, has a critical impact on the postoperative course following emergency surgery for cIAI. Early assessment and management of patient's comorbidity is mandatory at emergency setting.

Laparoscopic approach of the left side of the pancreas. / Abordaje laparoscópico del páncreas izquierdo.

INTRODUCTION: Laparoscopic left-sided pancreatectomy (LLP) is an increasingly used surgical technique for the treatment of benign and malignant lesions of the left side of the pancreas. The results of LLP as a treatment for primary pancreatic lesions of the head and tail of the pancreas were evaluated. METHODS: From November 2011 to November 2017, 18 patients underwent surgery for primary lesions of the pancreas by means of a laparoscopic distal pancreatectomy. An intra-abdominal drain tube was used in all cases, and the recommendations of the International Study Group for Pancreatic Fistula (ISGPF) were followed. RESULTS: The mean age was 66.5years (IQR 46-74). Among the 18 left pancreatectomies performed, four were with splenic preservation, and one was a central pancreatectomy. There were two conversions. The median surgical time was 247.5minutes (IQR 242-275). The median postoperative hospital stay was 7days (IQR 6-8). After 90days, complications were detected in five patients: three gradeII, one gradeIII and one gradeV according to the modified Clavien-Dindo classification. There was one gradeB pancreatic fistula, and four patients had to be readmitted to hospital because of peripancreatic collections. The anatomic pathology diagnosis was malignant neoplasm in 38.9% of cases, all of them with negative resection margins. CONCLUSIONS: LLP can be considered the technique of choice in the treatment of primary benign pancreatic lesions and an alternative to the open approach in selected patients diagnosed with malignant pancreatic lesions.

Accuracy of malignancy criteria for an intraductal papillary mucinous neoplasm. Should we have blind faith in consensus guidelines?

Based on a recent review about intraductal papillary mucinous neoplasm (IPMN), we want to reflect some important issues referring to the different consensus guidelines, criteria anda algorithms that are a starting point to manage this neoplasm as well as their limitations.

Laparoscopic management of gastric perforation secondary to mesenteroaxial volvulus in a patient with laparoscopic adjustable gastric banding.

A 54-year-old woman was admitted to the emergency department with a 2-week history of alimentary vomiting. She had undergone laparoscopic adjustable gastric banding 6 years earlier. CT revealed a mesenteroaxial gastric volvulus and ischemia on the gastric wall. Emergent diagnostic laparoscopy was performed, and severe peritonitis and gastric necrosis caused by volvulation was found. After band removal, a fundal perforation was noted, but a viable lesser curvature enabled laparoscopic sleeve gastrectomy to be performed. The postoperative course was uneventful. Laparoscopic adjustable gastric banding is considered a safe and effective method for the surgical treatment of obesity, but it is associated with a number of complications, such as pouch dilatation and band slippage. Although infrequent, ischemic complications are life-threatening conditions that require urgent surgery. This is the first report of this unusual complication managed laparoscopically.

Mirizzi syndrome: a new insight provided by a novel classification.

BACKGROUNDS/AIMS: Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis. The aim of this study is to evaluate our 15-year experience in this challenging entity and to propose a new classification for this disease. METHODS: A retrospective study including patients diagnosed with Mirizzi syndrome and undergoing surgical procedures for Mirizzi syndrome between January 2000 and October 2015 was conducted. Data collected included clinical, surgical procedure, postoperative morbidity. Patients were evaluated according to the Csendes classification and the proposed system, in which patients were divided into three types and three subtypes. RESULTS: 28 patients were included for analysis. They accounted as the 0.5% of a total of 4853 cholecystectomies performed in the study period. There were 21 women and 7 men. Initial laparotomic approach was performed in 12 patients and in 16 patients laparoscopic procedures were attempted. The procedure was completed in only 6 patients, 5 presenting type I and 1 type II Mirizzi syndrome. Mean postoperative stay was 15±9 days. Postoperative morbidity rate was 28%. Postoperative mortality was none. CONCLUSIONS: Laparoscopic surgery for Mirizzi syndrome has been shown succesful only in early stages. A novel classification is proposed, based on the types of common bile duct injuries and in the presence cholecystoenteric fistula.

Laparoscopic vs. open surgery for the treatment of iatrogenic colonoscopic perforations: a systematic review and meta-analysis.

AIMS: Iatrogenic colonoscopy perforations (ICP) are a rare but severe complication of diagnostic and therapeutic colonoscopies. The present systematic review and meta-analysis aims to investigate the operative and post-operative outcomes of laparoscopy vs. open surgery performed for the management of ICP. METHODS: A literature search was carried out on Medline, EMBASE, and Scopus databases from January 1990 to June 2016. Clinical studies comparing the outcomes of laparoscopic and open surgical procedures for the treatment for ICP were retrieved and analyzed. RESULTS: A total of 6 retrospective studies were selected, including 161 patients with ICP who underwent surgery. Laparoscopy was used in 55% of the patients, with a conversion rate of 10%. The meta-analysis shows that the laparoscopic approach was associated with significantly fewer post-operative complications compared to open surgery (18.2% vs. 53.5% respectively; Relative risk, RR: 0.32 [95%CI: 0.19-0.54; p < 0.0001; I2 = 0%]) and shorter hospital stay (mean difference -5.35 days [95%CI: -6.94 to -3.76; p < 0.00001; I2 = 0%]). No differences between the two surgical approaches were observed for postoperative mortality, need of re-intervention, and operative time. CONCLUSION: The present study highlights the outcomes of the surgical management of an endoscopic complication that is not yet considered in clinical guidelines. Based on the current available literature, the laparoscopic approach appears to provide better outcomes in terms of postoperative complications and length of hospital stay than open surgery in the case of ICP surgical repair. However, the creation of large prospective registries of patients with ICP would be a step forward in addressing the lack of evidence concerning the surgical treatment of this endoscopic complication.