Benchmark Outcomes for Distal Pancreatectomy: A Multicenter Prospective Snapshot Study (SPANDISPAN).

BACKGROUND: Improving the quality of care is a priority for health systems to obtain better care and reduce costs. One of the tools for measuring quality is benchmarking (BM). We presented a one-country prospective study of distal pancreatectomies (DP) and determined BM. STUDY DESIGN: Prospective, multicenter, observational snapshot study of DP carried out at Spanish HPB centers for a year (February 22-January 23). HPB centers were defined as high-volume if they performed > 10 DP per year. Inclusion criteria: any scheduled DP for any diagnosis and age > 18 years. The low-risk group was defined following the Durin et al. criteria and major complications as Clavien-Dindo ≥ III. RESULTS: 313 patients from 42 centers and 46.6% from high-volume centers were included. Median DP by center was 7 (IQR: 5-10), median age was 65 years (IQR: 55-74), and 53.4% were female. The surgical approach was minimally invasive (MIS) in 69.3%. Major complications were 21.1%. Postoperative pancreatic fistula (POPF) grade B/C rate was 20.1%, and 90-day mortality was 1.6%. One hundred and forty-three were low-risk group patients (43.8%). Compared with previous BM data, an increasing MIS rate and fewer hospital stay was obtained. CONCLUSION: We present the first determination of DP-BM in a prospective series, obtaining similar results to the previous ones, but our BM values include a shorter hospital stay and a higher percentage of MIS probably related to ERAS protocols and prospective data collection. BM is a multiparameter valuable tool for reporting outcomes, comparing centers, and identifying the points to improve surgical care.

Application of the REAL-score prognostic index in decision making in rectal cancer surgery.

BACKGROUND: Colorectal anastomosis leak (AL) is the most feared complication of rectal cancer surgery (1-19%) as it increases morbidity and mortality and worsens oncological outcomes in terms of local recurrence and survival. The publication of the REAL-score index makes it possible to predict the risk of AL and compare the expected results with those obtained. METHOD: Observational, descriptive, longitudinal and retrospective study of patients operated on for rectal cancer at the Miguel Servet University Hospital, in Zaragoza, Spain, in 2019. Statistical analysis of morbidity and mortality outcome variables and the REAL-score index using ROC curves. RESULTS: Of 80 patients operated on for rectal cancer, colorectal anastomosis was performed in 52 and temporary ileostomy in 11 (21.2%). Morbidity was high (38.4%), but severe only in 7.7% (Clavien-Dindo IIIb), with no deaths. There were four dehiscences: one type B and three type C. A direct relationship between high risk of AL and the practice of temporary stoma is observed when the cut-off point of the REAL-score exceeds 14.74%. CONCLUSIONS: REAL-score can help in decision-making in rectal cancer surgery. Above a cut-off point, the risk of AL would imply a selective ileostomy.

ANTECEDENTES: La dehiscencia de la anastomosis colorrectal (DA) es la complicación más temida de la cirugía del cáncer de recto (1-19%), pues incrementa la morbimortalidad y empeora los resultados oncológicos en términos de recidiva local y supervivencia. La publicación del índice REAL-score permite predecir el riesgo de DA y comparar los resultados esperados con los obtenidos. MÉTODO: Estudio observacional, descriptivo, longitudinal y retrospectivo, de pacientes intervenidos de cáncer de recto en el Hospital Universitario Miguel Servet, en Zaragoza, España, en 2019. Análisis estadístico de variables resultado de morbimortalidad y del índice REAL-score mediante curvas ROC. RESULTADOS: De 80 pacientes intervenidos de cáncer de recto, se realizó anastomosis colorrectal en 52 e ileostomía temporal en 11 (21.2%). La morbilidad fue alta (38.4%), pero grave solo en el 7.7% (Clavien-Dindo IIIb), sin ningún fallecimiento. Hubo cuatro dehiscencias: una de tipo B y tres de tipo C. Se observa una relación directa entre alto riesgo de DA y la práctica de estoma temporal cuando el punto de corte del REAL-score supera el 14.74%. CONCLUSIONES: El REAL-score puede ayudar en la toma de decisiones en la cirugía del cáncer de recto. Por encima de un punto de corte, el riesgo de DA implicaría ileostomía selectiva.

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].

Tratamiento quirúrgico del leiomiosarcoma de vena cava inferior

Introducción: La baja incidencia del leiomiosarcoma de la vena cava inferior dificulta tanto la estandarización del diagnóstico como el tratamiento. Objetivo: Presentar el manejo realizado en nuestro centro de un paciente que desarrolló un leiomiosarcoma de vena cava inferior, una patología de baja incidencia y que las posibilidades de realizar un rescate quirúrgico son muy bajas. Resultados: Se presenta el caso de un paciente de 54 años con una tumoración sólida en porción infrarrenal y yuxtarrenal de vena cava inferior de 71 × 76 × 117 mm compatible con leiomiosarcoma de vena cava, con infiltración de uréter derecho que ocasiona uropatía obstructiva derecha grado I-II sin alteración de la función renal, que fue resecada y reconstruida mediante prótesis sin complicaciones. Discusión: Se discute la fisiopatología, el diagnóstico y manejo en relación con el caso presentado. Conclusión: la baja incidencia de estos tumores dificulta tanto la estandarización del diagnóstico como del tratamiento, aunque la cirugía sigue siendo el tratamiento de elección.

Introduction: The low incidence of leiomyosarcoma of the inferior vena cava hinders both the standardization of diagnosis and treatment. Objective: To present the management carried out in our center of a patient who developed an inferior vena cava leiomyosarcoma, a low incidence pathology with uncertain surgical rescue. Results: 54-year-old patient with a solid tumor in the infrarenal and juxtarenal portions of the inferior vena cava of 71 × 76 × 117 mm compatible with leiomyosarcoma of the vena cava, with infiltration of the right ureter that causes right obstructive uropathy grade I-II without kidney function changes; tumour was resected and continuity reconstructed with a prosthesis without complications. Discussion: The pathophysiology, diagnosis and management are commented. Conclusion: the low incidence of these lesions makes it difficult to standardize both diagnosis and treatment, although surgery remains the treatment of choice.

Duodenal stenosis surgical treatment in Crohn's disease.

We present the case of a 34-year-old man with daily vomiting and 20% weight loss in a year. A gastroduodenoscopy was performed, noticing 2nd and 3rd duodenal portion dilatation and inflammatory involvement of the 3rd and 4th portion, causing luminal stenosis. These findings are the same than in the magnetic resonance . The biopsy proves the histological diagnosis of Crohn's disease. At the beginning the patient was treated with Prednisone, Adalimumab and Ustekinumab. After 9 months, surgery was decided because the disease was refractory to treatment and there was corticosteroid dependence. A partial resection of 3rd and 4th portion of the duodenum and the first loop of jejunum was performed, with duodenojejunal anastomosis. The patient presents good postoperative evolution and after 1 year he remained asymptomatic under treatment with Ustekinumab.

Aorto-esophageal fistula secondary after thoracic endovascular aortic repair.

Aortoesophageal fistula (AEF) secondary to thoracic endovascular aortic repair (TEVAR) is a rare clinical entity that poses a threat to life as it causes massive digestive bleeding, and it is estimated that 60% of patients who suffer from it could die within within 6 months of the onset of their symptoms. It requires a high clinical suspicion to establish an early multidisciplinary surgical treatment. We present the cases of two patients diagnosed with aortoesophageal fistulas after TEVAR in the last 5 years (January 2018-December 2022) while reviewing the existing scientific literature on the matter.

Intestinal obstruction secondary to Brunner's glands hyperplasia.

Brunner's gland hyperplasia constitutes 10.6% of benign tumors of the duodenum, with an incidence of 0.008%. It is usually an incidental finding during endoscopy or imaging tests as they are small and asymptomatic. In the case of symptomatic tumors, resection of the lesion is indicated. In lesions ≤2 cm, endoscopic resection can be chosen, reserving surgery for larger lesions or endoscopically inaccessible ones. We present the case of a patient with a history of vomiting and hyporexia of months of evolution who presented peptic ulcer perforation and underwent surgery. During follow-up, she presented intestinal obstruction due to pyloric stenosis. Given the impossibility of ruling out a neoplastic process with certainty in diagnostic tests, surgical resection (antrectomy) was decided with an anatomopathological finding of Brunner's gland hyperplasia.

Splenic rupture after colonoscopy for colorectal cancer screening.

Colonoscopy is a frequently used procedure in our environment for the diagnosis, treatment and even prevention of colorectal cancer. Despite being a routine procedure, it is not exempt from possible complications. Bleeding and perforation are the main ones, with splenic rupture being extremely infrequent as well as one of the most serious complications derived from performing a colonoscopy. We present a patient with splenic rupture secondary to colorectal cancer screening colonoscopy who required urgent surgery for acute hemorrhagic shock.

Intracholecystic papillary neoplasm: potential differential diagnosis before a gallbladder polyp.

Intracholecystic papillary neoplasia (IPN) is a rare entity rarely described in the literature, of incidental anatomopathological diagnosis in a cholecystectomy specimen that presents a premalignant behavior, with progression to carcinoma in more than 50% of cases. In the absence of an invasive component, clinical follow-up is recommended, without associating another surgical gesture, with a 5-year prognosis (90% survival). We present a case of a patient with an incidental diagnosis of NPIC after laparoscopic cholecystectomy due to presenting a gallbladder polyp.

Mucinous cystic liver neoplasm with invasive component and sarcomatous differentiation.

BACKGROUND: Hepatobiliary mucinous cystic neoplasms (MCN) harbor an invasive carcinoma in 16% of the cases, mainly tubular type, but occasionally sarcomatoid or undifferentiated, these entities being frankly rare. METHODS: We present the case of a liver MCN with an invasive component and sarcomatous degeneration. RESULTS: The patient was treated surgically with subsequent adjuvant chemotherapy (capecitabine), presenting tumor progression after three months with peritoneal carcinomatosis and liver recurrence. The patient died due to liver failure 4 months after surgery. CONCLUSION: MCN with an invasive component and sarcomatous degeneration are very rare, present advanced stages, show aggressive behavior, and have a poor prognosis.

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.

Tratamiento quirúrgico de la fibromatosis agresiva en relación con cesárea previa / Surgical treatment of aggressive fibromatosis in relation to previous cesarean section

Introducción. Los tumores desmoides son lesiones de los tejidos blandos, histológicamente benignas, poco frecuentes y con gran agresividad local y carencia de potencial metastásico. Se relacionan estrechamente con antecedentes traumáticos o quirúrgicos, como la cesárea, y su tratamiento generalmente es quirúrgico. Métodos. Presentamos una serie de tres pacientes intervenidas en nuestro centro durante el año 2020. Se revisan sus antecedentes y se describe su tratamiento. Resultados. En todas nuestras pacientes se encontró algún antecedente quirúrgico, dos cesáreas y una resección de un disgerminoma. El tratamiento empleado fue la resección quirúrgica con márgenes libres y reparación del defecto mediante malla. Conclusiones. El tumor desmoide es una patología poco frecuente, su diagnóstico se realiza mediante exámenes imagenológicos y se confirma con el estudio histológico; es importante hacer el diagnóstico diferencial con el sarcoma. La cirugía radical sigue siendo el tratamiento de elección, aunque algunos autores proponen el tratamiento conservador.

Introduction. Desmoid tumors are soft tissue lesions, histologically benign, rare and with great local aggressiveness and lack of metastatic potential. They are closely related to traumatic or surgical history such as caesarean section. Their treatment is generally surgical. Methods. We present a case series of three patients operated on in our center during the year 2020. Their history is reviewed and their type of treatment is presented. Results. In all our patients, surgical history was found (two caesarean sections and one resection of a dysgerminoma). The treatment used was surgical resection with free margins and mesh repair of the defect. Conclusions. Desmoid tumor is a rare pathology; its diagnosis is made by imaging studies, and confirmed by histology. It is important to make a differential diagnosis with sarcoma. Radical surgery remains the treatment of choice, although some authors propose conservative treatment.