DATA GOVERNANCE in digital surgery.

Technological and computer advances have led to a "new era" of Surgery called Digital Surgery. In it, the management of information is the key. The development of Artificial Intelligence requires "Big Data" to create its algorithms. The use of digital technology for the systematic capture of data from the surgical process raises ethical issues of privacy, property, and consent. The use of these out-of-control data creates uncertainty and can be a source of mistrust and refusal by surgeons to allow its use, requiring a framework for the correct management of them. This paper exposes the current situation of Data Governance in Digital Surgery, the challenges posed and the lines of action necessary to resolve the areas of uncertainty that have arisen in the process, in which the surgeon must play a relevant role.

Hypercoagulability status, operative mortality, and long-term survival in patients operated on for mesenteric venous thrombosis.

OBJECTIVE: Mesenteric venous thrombosis (MVT) is a rare cause of acute surgical abdomen, with high mortality. The aim of this study was to analyze long-term outcomes and possible factors influencing its prognosis. METHODS: All patients who underwent urgent surgery for MVT from 1990 to 2020 in our center were reviewed. Epidemiological, clinical, and surgical data; postoperative outcomes; origin of thrombosis; and long-term survival were analyzed. Patients were divided into two groups: primary MVT (hypercoagulability disorders or idiopathic MVT) and secondary MVT (underlying disease). RESULTS: Fifty-five patients, 36 (65.5%) men and 19 (34.5%) women, mean age 66.7 years (standard deviation: ±18.0 years), underwent surgery for MVT. Arterial hypertension (63.6%) was the most prevalent comorbidity. Regarding the possible origin of MVT, 41 (74.5%) patients had primary MVT and 14 (25.5%) patients had secondary MVT. From these, 11 (20%) patients had hypercoagulable states, 7 (12.7%) had neoplasia, 4 (7.3%) had abdominal infection, 3 (5.5%) had liver cirrhosis, 1 (1.8%) patient had recurrent pulmonary thromboembolism, and 1 (1.8%) had deep venous thrombosis. Computed tomography was diagnostic of MVT in 87.9% of the cases. Intestinal resection was performed in 45 patients due to ischemia. Only 6 patients (10.9%) had no complication, 17 patients (30.9%) presented minor complications, and 32 patients (58.2%) presented severe complications according to the Clavien-Dindo classification. Operative mortality was 23.6%. In univariate analysis, comorbidity measured by the Charlson index (P = .019) and massive ischemia (P = .002) were related to operative mortality. The probability of being alive at 1, 3, and 5 years was 66.4%, 57.9%, and 51.0%, respectively. In univariate analysis of survival, age (P < .001), comorbidity (P < .001), and type of MVT (P = .003) were associated with a good prognosis. Age (P = .002; hazard ratio: 1.05, 95% confidence interval: 1.02-1.09) and comorbidity (P = .019; hazard ratio: 1.28, 95% confidence interval: 1.04-1.57) behaved as independent prognostic factors for survival. CONCLUSIONS: Surgical MVT continues to show high lethality. Age and comorbidity according to the Charlson index correlate well with mortality risk. Primary MVT tends to have a better prognosis than secondary MVT.

Gastric ischemia secondary to intestinal occlusion due to gallstone ileus.

Gallstone ileus is a rare complication of cholecystoduodenal fistula. Gastric ischemia due to intestinal obstruction is an extremely rare event that, if not diagnosed in time, can have a fatal outcome. We present the case of a patient with intestinal occlusion due to a gallstone obstructing the middle jejunum in which gastric ischemia was diagnosed intraoperatively due to the distension caused by the intestinal obstruction.

Comparative study of postoperative complications after open and laparoscopic surgery of the perforated peptic ulcer: Advantages of the laparoscopic approach.

BACKGROUND: Despite the acceptance of the laparoscopic approach for the treatment of perforated peptic ulcers, its definitive implantation is still a matter of discussion. We performed a comparative study between the open and laparoscopic approach focused on postoperative surgical complications. METHODS: Retrospective observational study in which patients operated on for perforated peptic ulcus in our center between 2001 and 2017 were analyzed. Only those in whom suture and/or omentoplasty had been performed were selected, either for open or laparoscopic approach. Demographic, clinical, and intraoperative variables, complications, mortality and length of stay were collected. Both groups, open and laparoscopic surgery patients, were compared. RESULTS: The final study sample was 250 patients, 190 (76%) men and 60 (24%) women, mean age 54 years (SD ± 16.7). In 129 cases (52%), the surgical approach was open, and in 121 (48%) it was laparoscopic. Grades III-V complications of the Clavien-Dindo Classification occurred in 23 cases (9%). Operative mortality was 1.2% (3 patients). Laparoscopically operated patients had significantly fewer complications (p = 0.001) and shorter hospital stay (p < 0.001). In multivariate analysis, laparoscopic approach (p = 0.025; OR:0.45-95%CI: 0.22-0.91), age (p = 0.003; OR:1.03-95%CI: 1.01-1.06), and Boey score (p = 0.024 - OR:1.71 - CI95%: 1.07-2.72), were independent prognostic factors for postoperative surgical complications. CONCLUSION: Laparoscopic surgery should be considered the first-choice approach for patients with perforated peptic ulcer. It is significantly associated with fewer postoperative complications and a shorter hospital stay than the open approach.

Impact of frailty on 5-year survival in patients older than 70 years undergoing colorectal surgery for cancer.

BACKGROUND: Frailty has been shown to be a good predictor of post-operative complications and death in patients undergoing gastrointestinal surgery. The aim of this study was to analyze the differences between frail and non-frail patients undergoing colorectal cancer surgery, as well as the impact of frailty on long-term survival in these patients. METHODS: A cohort of 149 patients aged 70 years and older who underwent elective surgery for colorectal cancer was followed-up for at least 5 years. The sample was divided into two groups: frail and non-frail patients. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) was used to detect frailty. The two groups were compared with regard to demographic data, comorbidities, functional and cognitive statuses, surgical risk, surgical variables, tumor extent, and post-operative outcomes, which were mortality at 30 days, 90 days, and 1 year after the procedure. Univariate and multivariate analyses were also performed to determine which of the predictive variables were related to 5-year survival. RESULTS: Out of the 149 patients, 96 (64.4%) were men and 53 (35.6%) were women, with a median age of 75 years (IQR 72-80). According to the CSHA-CFS scale, 59 (39.6%) patients were frail, and 90 (60.4%) patients were not frail. Frail patients were significantly older and had more impaired cognitive status, worse functional status, more comorbidities, more operative mortality, and more serious complications than non-frail patients. Comorbidities, as measured by the Charlson Comorbidity Index (p = 0.001); the Lawton-Brody Index (p = 0.011); failure to perform an anastomosis (p = 0.024); nodal involvement (p = 0.005); distant metastases (p < 0.001); high TNM stage (p = 0.004); and anastomosis dehiscence (p = 0.013) were significant univariate predictors of a poor prognosis on univariate analysis. Multivariate analysis of long-term survival, with adjustment for age, frailty, comorbidities and TNM stage, showed that comorbidities (p = 0.002; HR 1.30; 95% CI 1.10-1.54) and TNM stage (p = 0.014; HR 2.06; 95% CI 1.16-3.67) were the only independent risk factors for survival at 5 years. CONCLUSIONS: Frailty is associated with poor short-term post-operative outcomes, but it does not seem to affect long-term survival in older patients with colorectal cancer. Instead, comorbidities and tumor stage are good predictors of long-term survival.

Severe respiratory failure secondary to megaesophagus due to terminal achalasia.

We present the case of a 56-year-old male diagnosed with achalasia ten years previously without follow-up. He presented with fever, dysphonia and dyspnea associated with a constitutional syndrome of one month of evolution. Laboratory tests showed leucocytosis of 15,870/ul. The chest radiography confirmed mediastinal widening and a chest computed tomography (CT) showed full esophageal dilation up to 10 cm compressing the trachea and right main bronchus, with tapering at the esophagogastric junction.

Surgical Outcomes in Acute Mesenteric Ischemia: Has Anything Changed Over the Years?

BACKGROUND: Despite increases in knowledge and advances in the management of acute mesenteric ischemia syndrome (AMI), there have been no significant improvements in mortality in recent years. The objective of this study was to assess the changes in clinical characteristics and surgical outcomes in patients who underwent AMI over time. METHODS: A total of 323 consecutive patients who underwent acute mesenteric ischemia at our institution between 1990 and 2015 were examined. The occurrence of significant changes over this 25-year period in demographic data, comorbidity, clinical characteristics, laboratory results, operative findings, etiology of the AMI, and operative mortality were evaluated. The evolution mortality rates for the studied period were analyzed using the additive logistic regression, and the significant effect was determined using the Akaike Information Criterion (AIC). RESULTS: A significant increasing linear trend was observed in recent years in Charlson score values (p = 0.008), antiplatelet drug intake (p < 0.001), use of CT scan (p < 0.001), arterial thrombosis (p < 0.001), and intestinal resection (p = 0.047), while a decreasing linear trend was observed in digoxin intake (p < 0.001), angiography use (p = 0.004), and embolia (p < 0.001). The rest of the parameters did not present changes over time. Regarding the evolution of the adjusted surgical mortality, a significant decrease according the AIC criterion was observed. CONCLUSIONS: In recent years, the characteristics of patients with AMI requiring surgery have changed. Changes in operative mortality have also been detected, showing a tendency toward a progressive and significant decrease.

Major ambulatory surgery for the treatment of breast cancer: Factors conditioning conversion to conventional hospitalization. / Cirugía mayor ambulatoria del cáncer de mama: factores relacionados con la conversión a hospitalización convencional.

INTRODUCTION: The main step in curative treatment for breast cancer is surgery. Its use in an ambulatory setting can contribute towards more efficient healthcare, providing additional benefits for patients. In this study, we analyze the results obtained with this treatment method and identify factors related with conversion to hospitalization. METHODS: Results were analyzed from the 206 surgeries performed for breast cancer in 2016, using three different methods: day surgery, overnight ambulatory (23h) and conventional hospitalization. The ambulatory success and conversion rates were calculated for the global sample and stratified, distinguishing between conservative surgery, mastectomy and axillary surgery. A univariate analysis was performed to identify the factors involved in conversion. RESULTS: For the global sample, the ambulatory surgery rate was 61.2%, 16.5% conversions and a success rate of 83.4%. For conservative surgery, ambulatory, success and conversion rates were 78.8%, 88.6 and 11.4%, respectively. For mastectomies, the ambulatory rate was 28.6%, with 62.9% success and 37.1% conversions. The 11 axillary surgeries were performed as day surgeries. Factors associated with conversion were mastectomy vs. vs. conservative surgery and the appearance of postoperative complications. CONCLUSIONS: Ambulatory surgery for the surgical treatment of breast cancer should be standard care. Optimized results require adequate patient selection and the performance of surgical technique that needs to be as careful and as conservative as possible.

Intrathoracic leak after an Ivor Lewis procedure for an esophageal neoplasm treated with a stent.

A 75-year-old male who underwent an Ivor Lewis esophagectomy due to a distal adenocarcinoma had a leak at the gastroplasty on the 5th day after surgery, which required two surgeries and a primary suture. He was transferred to our hospital due to a poor outcome and endoscopy revealed a 2.5cm gap perianastomotically on the gastroplasty wall, for which a stent was placed. Due to hemodynamic impairment, a thoracotomy procedure was performed, which revealed stent protrusion into the cavity. The patient underwent an esophagogastric anastomosis resection, cervical esophagostomy and gastrostomy. Sepsis was resolved postoperatively and the patient had a protracted stay in the PACU due to poor respiratory dynamics following a prolonged intubation.

Perioperative Blood Transfusion is Associated with an Increased Mortality in Older Surgical Patients.

BACKGROUND: More surgical interventions are being performed on octogenarian patients. The aim of this study was to identify factors associated with operative mortality and to determine if perioperative transfusions could affect mortality outcomes in a nonselected series of octogenarian patients undergoing surgery. METHODS: A descriptive cross-sectional study was performed on a population of 413 consecutive patients over 80 years old, treated surgically, and divided into two groups: transfused and nontransfused patients. The following variables were recorded: sociodemographic characteristics, main diagnoses, surgical procedure and its characteristics, ASA score, Charlson comorbidity index (CCI), National Nosocomial Infection Surveillance (NNIS) index, transfusion requirements, the Clavien-Dindo classification of surgical complications, and operative mortality. RESULTS: The mean age of the patients was 84.5 years (SD + 3.6). Transfused (25.2 %) and nontransfused patients had similar characteristics; except for neoplasia (P <0.001), NNIS (P = 0.008), operative mortality (P = 0.004), and complications according to Clavien-Dindo score (P <0.001). Operative mortality was 20.1 % (83 patients). The predictive variables associated with operative mortality were ASA score (P <0.001), emergency surgery (P <0.001), and blood transfusion (P = 0.004). After adjusting for the variables age, ASA class, NNIS, emergency surgery, and neoplasia, the multivariate analysis showed that the perioperative transfusion in octogenarian patients continued to be significantly associated with operative mortality (P = 0.019; OR 1.97, 95 % CI 1.12-3.47). CONCLUSION: Perioperative transfusion is an independent predictor of postoperative mortality in surgical octogenarian patients.

The age-adjusted Charlson Comorbidity Index as an outcome predictor of patients with acute mesenteric ischemia.

Acute mesenteric ischemia (AMI) is a catastrophic surgical condition, especially in older patients with multiple comorbidities. The aim of this study was to evaluate the impact of comorbidity on perioperative mortality and overall survival in patients surgically treated for AMI. A series of 186 consecutive patients (106 men and 80 women) who underwent surgery because of AMI in a university tertiary care center between 1990 and 2006 were retrospectively studied. The Charlson Comorbidity Index (CCI) score, unadjusted and adjusted by age, was preoperatively calculated in each patient. Perioperative mortality and overall survival were also recorded. The association between unadjusted and adjusted by age CCI and perioperative mortality and overall survival were analyzed. The mean age of the studied population was 72.1 years (SE +/-13.7 years). Hospital mortality was 64.5%. One-year, 3-year, and 5-year overall estimated survival by the Kaplan-Meier method after surgery for AMI was 26%, 23% and 21%, respectively. Perioperative mortality was not related to the unadjusted preoperative CCI (p = 0.093). Nevertheless, a statistically significant association was found between mortality and preoperative adjusted CCI (p = 0.007). Likewise, CCI unadjusted was almost related to overall survival (p = 0.055), but the values of the categorized CCI adjusted by age showed a statistically significant difference in overall survival (p = 0.012). In multivariate analysis, CCI adjusted by age remained independent prognostic factor of mortality. Comorbidity adjusted by age may play a role as a predictive factor for perioperative mortality and long-term survival in patients operated on for AMI.

[Predictive factors of massive intestinal necrosis in acute mesenteric ischemia]. / Factores predictivos de necrosis masiva intestinal en la isquemia mesentérica aguda.

INTRODUCTION: Suspicion of intestinal necrosis in patients with mesenteric ischemia is mandatory in surgery. Many patients develop massive necrosis after open surgery. However, in some frail, elderly patients, preoperative prediction of massive intestinal necrosis could avoid an unnecessary laparotomy. The aim of this study was to assess predictive factors of massive intestinal necrosis in acute mesenteric ischemia. PATIENTS AND METHOD: We retrospectively evaluated a consecutive sample of 155 patients, 88 men and 67 women, with a mean age of 71.9 years (SD +/- 13.6), who underwent surgery for acute mesenteric ischemia in our institution from 1990 to 2004. Age, sex, clinical features, laboratory findings, and delay to surgery were recorded and assessed as possible risk factors for massive intestinal necrosis. A logistic regression model was used to identify independent prognostic factors. RESULTS: Of the 155 patients, massive intestinal necrosis was recorded in 48 (31%; 95% CI: 23.4-38.6). A statistically significant association was found between massive intestinal necrosis and age (p = 0.04), previous digoxin use (p = 0.01), shock (p = 0.009), hemoconcentration (hemoglobin levels > 16 g/dL) (p = 0.02), hyperamylasemia (p < 0.001), acidosis (p = 0.012), and alkalosis (p = 0.048). Multiple stepwise logistic regression analysis identified three independent prognostic factors that were significantly associated with a higher risk of massive intestinal necrosis: shock (OR = 3.4; 95% CI: 1.1-10), hemoconcentration (OR = 6; 95% CI: 1.6-22.8), and hyperamylasemia (OR = 4.2; 95% CI: 1.5-12.2). CONCLUSIONS: Massive intestinal necrosis can be observed in at least 25% of patients undergoing surgery for acute mesenteric ischemia. Within the limitations of a retrospective study, the variables of shock, hemoconcentration and elevated serum amylase levels may be considered as independent predictive factors of fatal necrosis of the bowel.