Safety, Efficacy, and Cost-effectiveness of Outpatient Surgery for Uncomplicated Acute Appendicitis: The PENDI-CSI Randomized Clinical Trial.

OBJECTIVE: To evaluate the safety, efficacy, and cost-effectiveness of outpatient appendectomy in patients with uncomplicated acute appendicitis. BACKGROUND: Given that acute appendicitis is the most common cause of acute abdomen, the introduction of outpatient appendectomy protocols could significantly improve the effectiveness and sustainability of health care systems. METHODS: A total of 300 patients were enrolled from October 2018 to June 2021 in the PENDI-CSI randomized clinical trial: 149 were assigned to the outpatient surgery (OPS) group and 151 to the inpatient surgery (IPS) group, followed by 1 month postoperatively. All patients were aged older than 14 years and had uncomplicated acute appendicitis. Exclusion criteria were pregnancy, neoplasms, inflammatory bowel disease, and high anesthetic risk (ASA IV). The OPS group was discharged from the postanesthesia care unit while the IPS group was admitted. RESULTS: In total, 128 patients in the OPS group (85.9%) were discharged without admission. Predictors whether patients in the OPS group had to be admitted were aged over 31 years [relative risk (RR): 2.42 (1.04-5.65)], hypertension [RR: 6.21 (3.22-11.97)], anesthetic risk II-III [RR: 2.63 (1.17-5.94)], previous abdominal surgery [RR: 3.34 (1.55-7.20)], postoperative pain with visual analog scale >6 [RR: 4.28 (2.67-6.86)], and postoperative fear [RR: 2.2 (1.04-4.67)]. There were no differences in terms of complications, readmissions, and reinterventions, and the perceived quality was similar in both groups. The outpatient modality produced savings of €1 034.97 per patient ( P < 0.001). CONCLUSIONS: Outpatient appendectomy is safe and effective for uncomplicated acute appendicitis. Patient-perceived quality is similar to that of IPS, although it successfully reduces hospital costs compared with inpatient appendectomy.

Is the use of endoloops safe and efficient for the closure of the appendicular stump in complicated and uncomplicated acute appendicitis?

INTRODUCTION: There is still controversy regarding the ideal technique to close the appendicular stump in laparoscopic appendectomy (LA). The objective of this study was to determine the safety and efficiency of the use of an endoloop (EL) and endostapler (ES) in complicated and uncomplicated acute appendicitis. METHODS: Retrospective cohort study of patients undergoing LA from February 2013 to December 2019. Acute uncomplicated and complicated appendicitis were analysed separately, establishing two groups according to the stump closure technique: EL or ES. Seven hundred-nine patients were included (535 uncomplicated and 174 complicated). In uncomplicated appendicitis, an EL was used in 447 of the patients (83.55%) and an ES was used in 88 patients (16.45%). In complicated appendicitis, an EL was used in 85 patients (48.85%) and an ES was used in 89 patients (51.15%). An analysis of effectiveness and a cost analysis of each technique were performed. RESULTS: In uncomplicated appendicitis, we found no differences with respect to global complications, although there were significant differences in the total mean hospital stay (EL group 1.55 (SD 1.48) days; ES group 2.21 (SD 1.69) days; p = 0.046). This meant a savings of 514.12€ per patient using the EL p < 0.001). In complicated appendicitis, the reoperations classified as Clavien-Dindo IIIB in the EL group (6.4%) were greater than in the ES group (0%) (p = 0.012), although the rate of postoperative abscesses (p = 0.788) and the mean volume of abscesses (p = 0.891) were similar. CONCLUSION: The systematic use of an EL could reduce costs in uncomplicated appendicitis, while in complicated cases, both options are valid. Prospective studies with a greater number of patients are needed to observe differences in postoperative complications.

Implication of the presence of a variant hepatic artery during the Whipple procedure.

INTRODUCTION: The anatomical variants of the hepatic artery may have important implications for pancreatic cancer surgery. The aim of our study is to compare the outcome following a pancreatoduodenectomy (PD) in patients with or without a variant hepatic artery arising from superior mesenteric artery. MATERIAL AND METHODS: We reviewed 151 patients with periampullary tumoral pathology. All patients underwent oncological PD between January 2005 and February 2012. Our series was divided into two groups: Group A: Patients with a hepatic artery arising from superior mesenteric artery; and Group B: Patients without a hepatic artery arising from superior mesenteric artery. We expressed the results as mean +/- standard deviation for continuous variables and percentages for qualitative variables. Statistical tests were considered significant if p < 0.05. RESULTS: We identified 11 patients with a hepatic artery arising from superior mesenteric artery (7.3%). The most frequent variant was an aberrant right hepatic artery (n = 7), following by the accessory right hepatic artery (n = 2) and the common hepatic artery trunk arising from the superior mesenteric artery (n = 2). In 73% of cases the diagnosis of the variant was intraoperative. R0 resection was performed in all patients with a hepatic artery arising from superior mesenteric artery. There were no significant differences in the tumor resection margins and the incidence of postoperative complications. CONCLUSION: Oncological PD is feasible by the presence of a hepatic artery arising from superior mesenteric artery. The complexity of having it does not seem to influence in tumor resection margins, complications and survival.

Results of the Spanish National Polytrauma Registry. Where are we and where are we heading?

INTRODUCTION: In 2017, the Spanish National Polytrauma Registry (SNPR) was initiated in Spain with the goal to improve the quality of severe trauma management and evaluate the use of resources and treatment strategies. The objective of this study is to present the data obtained with the SNPR since its inception. METHODS: We conducted an observational study with prospective data collection from the SNPR. The trauma patients included were over 14 years of age, with ISS ≥ 15 or penetrating mechanism of injury, from a total of 17 tertiary hospitals in Spain. RESULTS: From 1/1/17 to 1/1/22, 2069 trauma patients were registered. The majority were men (76.4%), with a mean age of 45 years, mean ISS 22.8, and mortality 10.2%. The most common mechanism of injury was blunt trauma (80%), the most frequent being motorcycle accident (23%). Penetrating trauma was presented in 12% of patients, stab wounds being the most common (84%). On hospital arrival, 16% of patients were hemodynamically unstable. The massive transfusion protocol was activated in 14% of patients, and 53% underwent surgery. Median hospital stay was 11 days, while 73.4% of patients required intensive care unit (ICU) admission, with a median ICU stay of 5 days. CONCLUSIONS: Trauma patients registered in the SNPR are predominantly middle-aged males who experience blunt trauma with a high incidence of thoracic injuries. Early addressed detection and treatment of these kind of injuries would probably improve the quality of trauma care in our environment.

Early laparoscopic cholecystectomy in oldest-old patients: a propensity score matched analysis of a nationwide registry.

The role of early laparoscopic cholecystectomy (ELC) in "oldest-old" patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study is to assess the safety of ELC for ACC in ≥ 85-year-old patients. Multicentric retrospective study that analysed data of patients who underwent ELC for ACC between 2013 and 2018. Patients ≥ 85-year-old (oldest-old patients) were compared with younger patients, before and after propensity score matching (PSM). The main outcomes were mortality, post-operative complications, length of stay (LOS), and readmissions. The study included 1670 patients. The unmatched comparison revealed a selection bias towards the oldest-old group, which was associated with higher Charlson Comorbidity Index (5 vs 1, p < 0.001), more ASA III/IV subjects (54.2% vs 19.3%, p < 0.001), class II/III ACC (80.1% vs 69.1%, p = 0.016) and higher Chole-Risk Score (p > 0.001). The oldest-old also required more conversion to open surgery (20% vs 10.3%, p = 0.005). Postoperatively, they had a higher 90-day mortality rate (7.6% vs 1%, p < 0.001), more total complications (40.6% vs 17.7%, p < 0.001), complications ≥ IIIa Clavien-Dindo (14.4% vs 5.8%, p = 0.002), longer LOS (6 vs 5 days, p < 0.001), and more readmissions (6.6% vs 2.6%, p < 0.001). After PSM (n = 206), the two groups were comparable in terms of baseline characteristics and intraoperative outcomes. No differences were observed in post-operative complications; bile leak; incisional, intrabdominal, urinary or respiratory tract infections; LOS or readmissions. In the oldest-old, ELC for ACC is still associated with significant morbidity and mortality. However, it seems to be safe in selected patients. Therefore, age itself should not be regarded as a contraindication to ELC for ACC.

How to Predict Postoperative Complications After Early Laparoscopic Cholecystectomy for Acute Cholecystitis: the Chole-Risk Score.

BACKGROUND: Early laparoscopic cholecystectomy (ELC) is the gold standard treatment for patients with acute calculous cholecystitis (ACC); however, it is still related to significant postoperative complications. The aim of this study is to identify factors associated with an increased risk of postoperative complications and develop a preoperative score able to predict them. METHODS: Multicentric retrospective analysis of 1868 patients with ACC submitted to ELC. Included patients were divided into two groups according to the presentation of increased postoperative complications defined as postoperative complications ≥ Clavien-Dindo IIIa, length of stay greater than 10 days and readmissions within 30 days of discharge. Variables that were independently predictive of increased postoperative complications were combined determining the Chole-Risk Score, which was validated through a correlation analysis. RESULTS: We included 282 (15.1%) patients with postoperative complications. The multivariate analysis predictors of increased morbidity were previous percutaneous cholecystostomy (OR 2.95, p=0.001), previous abdominal surgery (OR 1.57, p=0.031) and diabetes (OR 1.62, p=0.005); Charlson Comorbidity Index >6 (OR 2.48, p=0.003), increased total bilirubin > 2 mg/dL (OR 1.88, p=0.002), dilated bile duct (OR 1.79, p=0.027), perforated gallbladder (OR 2.62, p<0.001) and severity grade (OR 1.93, p=0.001). The Chole-Risk Score was generated by grouping these variables into four categories, with scores ranging from 0 to 4. It presented a progressive increase in postoperative complications ranging from 5.8% of patients scoring 0 to 47.8% of patients scoring 4 (p<0.001). CONCLUSION: The Chole-Risk Score represents an intuitive tool capable of predicting postoperative complications in patients with ACC.

Laparoscopic cholecystectomy for acute cholecystitis: is the surgery still safe beyond the 7-day barrier? A multicentric observational study.

Timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. This study assesses ELC for ACC with delayed presentation, according to hospital volume. Multicentric retrospective analysis of 1868 ELC. Patients were classified into two groups according to the timing of surgery from clinical onset and centre volume. Group 1 (G1) within the first 7 days, group 2 (G2) beyond that. Then centres were classified in low volume centres (LVC) and higher volume centres (HVC) according to the number of ELC performed per year. Overall, G2 showed increased conversion rate (17.7% vs 10.7%; p = 0.004), intraoperative complications (7.3% vs 2.9%; p = 0.001); postoperative haemorrhage (3.6% vs 0.8%; p < 0.001), infections (16.6% vs 9.3%; p = 0.003) and global complications (27.6% vs 19.8%; p = 0.011). HVC in comparison with LVC presented decreased conversion rate (17.1% vs 7.6%; p < 0.001), intraoperative bleeding (2.1% vs 1%; p = 0.047), postoperative bile leakage (4.1% vs 2.1%; p = 0.011), infectious (13.7% vs 7.5%; p < 0.001) and global complications (25.7% vs 17.1%; p < 0.001). HVC did not show an increase in any of the above-mentioned outcomes when G1 and G2 were compared. ELC must be indicated cautiously in patients with ACC and more than 1 week of symptom duration. It should be performed in centres with sufficient experience in the management of this disease.

Association of Negative Pressure Wound Therapy and Dermatotraction for Management of Necrotizing Soft Tissue Infections: A Case Series.

INTRODUCTION: Soft tissue infections (STIs), which include infections of the skin, subcutaneous tissue, fascia, and muscle, encompass a wide variety of heterogeneous pathologies. Treatment of STIs is based on surgical debridement of the affected area. One such treatment, negative pressure wound therapy (NPWT), has improved the management of STIs. OBJECTIVE: The purpose of this study is to assess the safety and utility of NPWT in conjunction with dermatotraction in the early stage management of necrotizing STIs. MATERIALS AND METHODS: The authors report a retrospective series of 3 cases in which NPWT and dermatotraction (NPWT-D) were used in an attempt to manage necrotizing STI. The NPWT-D device combination was employed to approximate the edges of the wounds. The NPWT device was changed every 2 or 3 days, and dermatotraction tension was adjusted concurrently. RESULTS: The NPWT-D device changes ranged from 3 to 4 times for 2 of the 3 patients, as 1 patient passed away secondary to STIs and therefore did not receive complete treatment. The total treatment ranged from 8 to 10 days in the remaining 2 patients. In both cases, complete wound closure was achieved while avoiding skin grafts. After 5 days of therapy in the incomplete treatment case, the wound area was reduced by about half. CONCLUSIONS: Based on the experiences herein, NPWT-D may be a safe and useful alternative surgical treatment for the management of necrotizing STIs. In the present cases, NPWT-D improved and shortened the wound healing process, and it achieved a tertiary wound closure, thereby avoiding the need for skin grafts.

Translational pancreatic cancer research: A comparative study on patient-derived xenograft models.

AIM: To assess the viability of orthotopic and heterotopic patient-derived pancreatic cancer xenografts implanted into nude mice. METHODS: This study presents a prospective experimental analytical follow-up of the development of tumours in mice upon implantation of human pancreatic adenocarcinoma samples. Specimens were obtained surgically from patients with a pathological diagnosis of pancreatic adenocarcinoma. Tumour samples from pancreatic cancer patients were transplanted into nude mice in three different locations (intraperitoneal, subcutaneous and pancreatic). Histological analysis (haematoxylin-eosin and Masson's trichrome staining) and immunohistochemical assessment of apoptosis (TUNEL), proliferation (Ki-67), angiogenesis (CD31) and fibrogenesis (α-SMA) were performed. When a tumour xenograft reached the target size, it was re-implanted in a new nude mouse. Three sequential tumour xenograft generations were generated (F1, F2 and F3). RESULTS: The overall tumour engraftment rate was 61.1%. The subcutaneous model was most effective in terms of tissue growth (69.9%), followed by intraperitoneal (57.6%) and pancreatic (55%) models. Tumour development was faster in the subcutaneous model (17.7 ± 2.6 wk) compared with the pancreatic (23.1 ± 2.3 wk) and intraperitoneal (25.0 ± 2.7 wk) models (P = 0.064). There was a progressive increase in the tumour engraftment rate over successive generations for all three models (F1 28.1% vs F2 71.4% vs F3 80.9%, P < 0.001). There were no significant differences in tumour xenograft differentiation and cell proliferation between human samples and the three experimental models among the sequential generations of tumour xenografts. However, a progressive decrease in fibrosis, fibrogenesis, tumour vascularisation and apoptosis was observed in the three experimental models compared with the human samples. All three pancreatic patient-derived xenograft models presented similar histological and immunohistochemical characteristics. CONCLUSION: In our experience, the faster development and greatest number of viable xenografts could make the subcutaneous model the best option for experimentation in pancreatic cancer.

Resultados del Registro Nacional de Politraumatismos español ¿Dónde estamos y a dónde nos dirigimos? / Results of the Spanish National Polytrauma Registry. Where are we and where are we heading?

Introducción: En 2017 se emprendió el Registro Nacional de Politraumatismos (RNP) a nivel estatal español, cuya finalidad residía en mejorar la calidad de la atención al paciente politraumatizado grave y evaluar el uso de recursos y estrategias de tratamiento. El objetivo de este trabajo es presentar los datos recogidos en el RNP hasta la actualidad. Métodos: Estudio observacional retrospectivo a partir de los datos recogidos prospectivamente en el RNP. Se incluyen pacientes mayores de 14 años, con ISS≥15 o mecanismo de trauma penetrante, atendidos en 17 hospitales de tercer nivel de España. Resultados: Del 1/1/17 al 1/1/22 se han registrado un total de 2.069 pacientes politraumatizados. El 76,4% son varones; edad media: 45 años; ISS medio: 22,8 y mortalidad: 10,2%. El mecanismo de lesión más frecuente es el cerrado (80%) con mayor incidencia de accidentes de moto (23%). Un 12% de los pacientes sufren un traumatismo penetrante, por arma blanca en el 84%. Un 16% de los pacientes ingresa hemodinámicamente inestable en el hospital. Activando el protocolo de transfusión masiva en el 14% de los pacientes e interviniendo quirúrgicamente a un 53%. La estancia hospitalaria mediana es de 11 días. Precisando ingreso en la UCI un 73,4% (estancia media: 5 días). Conclusiones: Los pacientes politraumatizados registrados en el RNP son mayoritariamente varones de mediana edad, que sufren traumatismos cerrados y presentan una elevada incidencia de lesiones torácicas. La detección y el tratamiento dirigido de este tipo de lesiones probablemente permitirá mejorar la calidad asistencial del politraumatizado en nuestro medio. (AU)

Introduction: In 2017 the Spanish National Polytrauma Registry (SNPR) was initiated in Spain, its goal was to improve the quality of severe trauma management and evaluate the use of resources and treatment strategies. The objective of this study is to present the information obtained with the SNPR since it was initiated. Methods: Observational study with prospective data collection from the SNPR. Trauma patients included are older than 14 yeas, with ISS ≥ 15 or penetrating mechanism. In total 17 hospitals from Spain have participated. Results: From 1/1/17 to 1/1/22, 2069 trauma patients were registered. The majority were men (76.4%); mean age: 45 years; mean ISS: 22.8 and mortality: 10.2%. The most common mechanism of injury was blunt trauma (80%), being motorbike accident the most frequent (23%). Penetrating trauma is presented in 12% of patients, being stab wound the most common (84%). Sixteen percent of patients are hemodynamically unstable on hospital arrival. Massive transfusion protocol is activated in 14% of patients and 53% are operated. Median hospital stay is 11 days. There is a 73.4% of patients who need intensive care unit (ICU) admission, with a median ICU stay of 5 days. Conclusions: Trauma patients registered in the SNPR are predominantly middle-aged males who experience blunt trauma with a high incidence of thoracic injuries. Early and addressed detection of these kind of injuries would probably improve trauma quality of care in our environment. (AU)

Miopatía vacuolar del esfínter anal interno como causa infrecuente de proctalgia fugaz y estreñimiento / Vacuolar internal anal sphincter myophaty as a rare cause of proctalgia fugax and constipation

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Implicaciones de las variantes arteriales hepáticas durante la duodenopancreatectomía cefálica oncológica / Implication of the presence of a variant hepatic artery during the Whipple procedure

INTRODUCCIÓN: las variantes anatómicas de la arteria hepática pueden tener importantes implicaciones en la cirugía oncológica del páncreas. Nuestro objetivo es comparar los resultados tras un procedimiento de Whipple en pacientes con y sin presencia de una arteria hepática variante procedente de la arteria mesentérica superior. MATERIAL Y MÉTODOS: estudio analítico observacional retrospectivo en el que hemos analizado 151 pacientes con patología tumoral periampular sometidos a una duodenopancreatectomía desde enero de 2005 hasta febrero de 2012. Diferenciamos entre 2 grupos: grupo A (variante de la arteria hepática) y grupo B (no evidencia de variante de la arteria hepática). Hemos expresado los resultados como la media ± desviación estándar para las variables continuas y porcentajes para las cualitativas. Los test estadísticos fueron considerados significativos si la p < 0,05. RESULTADOS: hemos detectado 11 pacientes con anomalías de la arteria hepática (7,3%). La variante más frecuentemente fue la arteria hepática derecha aberrante (n = 7), seguida de la arteria hepática derecha accesoria (n = 2) y tronco de la arteria hepática común procedente de la arteria mesentérica superior (n = 2). En el 73% de los casos la detección de la variante arterial fue intraoperatoria. En todos los pacientes se realizó una resección R0. No se han apreciado diferencias significativas en los márgenes de resección tumoral, complicaciones, ni en la supervivencia. CONCLUSIÓN: la cirugía oncológica de la región céfalopancreática en presencia de una variante de la artería hepática es factible. La complejidad que supone tener una variante anatómica de la arteria hepática no parece influir en los márgenes de resección tumoral, complicaciones o supervivencia

INTRODUCTION: The anatomical variants of the hepatic artery may have important implications for pancreatic cancer surgery. The aim of our study is to compare the outcome following a pancreatoduodenectomy (PD) in patients with or without a variant hepatic artery arising from superior mesenteric artery. MATERIAL AND METHODS: We reviewed 151 patients with periampullary tumoral pathology. All patients underwent oncological PD between January 2005 and February 2012. Our series was divided into two groups: Group A: Patients with a hepatic artery arising from superior mesenteric artery; and Group B: Patients without a hepatic artery arising from superior mesenteric artery. We expressed the results as mean +/- standard deviation for continuous variables and percentages for qualitative variables. Statistical tests were considered significant if p < 0.05. RESULTS: We identified 11 patients with a hepatic artery arising from superior mesenteric artery (7.3%). The most frequent variant was an aberrant right hepatic artery (n = 7), following by the accessory right hepatic artery (n = 2) and the common hepatic artery trunk arising from the superior mesenteric artery (n = 2). In 73% of cases the diagnosis of the variant was intraoperative. R0 resection was performed in all patients with a hepatic artery arising from superior mesenteric artery. There were no significant differences in the tumor resection margins and the incidence of postoperative complications. CONCLUSION: Oncological PD is feasible by the presence of a hepatic artery arising from superior mesenteric artery. The complexity of having it does not seem to influence in tumor resection margins, complications and survival