Textbook outcome in patients with biliary duct injury during cholecystectomy.

BACKGROUND: Iatrogenic bile duct injury (BDI) during cholecystectomy is associated with a complex and heterogeneous management owing to the burden of morbidity until their definitive treatment. This study aimed to define the textbook outcomes (TOs) after BDI with the purpose to indicate the ideal treatment and to improve it management. METHODS: We collected data from patients with an BDI between 1990 and 2022 from 27 hospitals. TO was defined as a successful conservative treatment of the iatrogenic BDI or only minor complications after BDI or patients in whom the first repair resolves the iatrogenic BDI without complications or with minor complications. RESULTS: We included 808 patients and a total of 394 patients (46.9%) achieved TO. Overall complications in TO and non-TO groups were 11.9% and 86%, respectively (P < .001). Major complications and mortality in the non-TO group were 57.4% and 9.2%, respectively. The use of end-to-end bile duct anastomosis repair was higher in the non-TO group (23.1 vs 7.8, P < .001). Factors associated with achieving a TO were injury in a specialized center (adjusted odds ratio [aOR], 4.01; 95% CI, 2.68-5.99; P < .001), transfer for a first repair (aOR, 5.72; 95% CI, 3.51-9.34; P < .001), conservative management (aOR, 5.00; 95% CI, 1.63-15.36; P = .005), or surgical management (aOR, 2.45; 95% CI, 1.50-4.00; P < .001). CONCLUSION: TO largely depends on where the BDI is managed and the type of injury. It allows hepatobiliary centers to identify domains of improvement of perioperative management of patients with BDI.

Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama.

BACKGROUND: The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery. METHODS: This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes. RESULTS: A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P = .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ˂ .001). The need for vascular reconstruction was associated with higher mortality (P = .04). Two of the 4 patients transplanted died. CONCLUSION: Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results.

Machine Learning-Based Analysis in the Management of Iatrogenic Bile Duct Injury During Cholecystectomy: a Nationwide Multicenter Study.

BACKGROUND: Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels. METHODS: This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index. RESULTS: We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p < 0.01), treatment in specialized centers (p < 0.01), and surgical repair (p < 0.001) were associated with better prognosis. The risk-scoring model was 82.3% (79.0-85.3%, 95% confidence interval [CI]) and 71.7% (63.8-78.7%, 95% CI) accurate in predicting success in the development and validation cohorts, respectively. Surgical repair, successful initial repair, and repair between 2 and 6 weeks were associated with better outcomes. DISCUSSION: Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.

Malignant prediction in paragangliomas: analysis for clinical risk factors.

INTRODUCTION: Paragangliomas are infrequent neuroendocrine tumours whose only criterion for malignancy is presence of metastases; thus, all paragangliomas show malignant potential. Actually, different risk factors have been analyzed to predict metastases but they remain unclear. PURPOSE: To analyze clinical, histological, and genetic factors to predict the occurrence of metastasis. PATIENTS AND METHOD: A multicentre retrospective observational analysis was performed between January 1990 and July 2019. Patients diagnosed with paraganglioma were selected. Clinical, histological, and genetic features were analyzed for the prediction of malignancy. RESULTS: A total of 83 patients diagnosed with paraganglioma were included, of which nine (10.8%) had malignant paraganglioma. Tumour size was greater in malignant tumours than in benign (6 cm vs. 4 cm, respectively; p = 0.027). The most frequent location of malignancy was the thorax-abdomen-pelvis area observed in six cases (p = 0.024). No differences were observed in histological differentiation, age, symptoms, and catecholaminergic production. The most frequent genetic mutation was SDHD followed by SDHB but no differences were observed between benign and malignant tumours. In the univariate analysis for predictive factors for malignancy, location, tumour size, and histological differentiation showed statistical significance (p = 0.025, p = 0.014, and p = 0.046, respectively); however, they were not confirmed as predictive factors for malignancy in the multivariate analysis. CONCLUSION: In this study, no risk factors for malignancy have been established; therefore, we recommend follow-up of all patients diagnosed with paraganglioma.

Gastric perforation during removal of an intragastric balloon.

The intragastric balloon system is licensed for temporary use in moderately obese patients who have significant health risks related to their obesity and have failed to achieve and maintain significant weight loss with a supervised weight control program alone. Although intragastric balloons are advocated as safe devices, major complications have been described. We report a case of a gastric perforation during the removal of an intragastric balloon. This is the first case reported in the literature.

[Adrenal incidentalomas. A disease on the increase]. / Incidentalomas suprarrenales. Una enfermedad en auge.

INTRODUCTION: Adrenal incidentalomas are unsuspected, clinically silent adrenal lesions discovered incidentally by imaging tests performed a priori for problems unrelated to the adrenal glands. The aim of this study was to present a series of incidentalomas and review the diagnostic process and treatment techniques. PATIENTS AND METHOD: Of a series of 63 patients studied and/or treated for adrenal disease, there were 34 patients with adrenal incidentalomas. The mean age of the patients with incidentaloma was 50.6 years. There were 23 women (67.6%) and 11 men (32.3%). All patients underwent hormonal investigations to rule out hyperfunction. Imaging techniques consisted of ultrasonography, computed tomography (CT) and/or magnetic resonance imaging (MRI) to determine the size and characteristics of the lesion. In patients with an indication for surgery, the lateral transabdominal approach was used in laparoscopic surgery and the anterior approach was used in open surgery. RESULTS: Of the 34 patients, 23 patients (67.6%) (18 women and 5 men) with a mean age of 50.9 years underwent surgery. The mean tumoral diameter was 10.18 cm. Incidentalomas were located in the right adrenal gland in 16 patients and in the left adrenal gland in 7 patients. Laparoscopic surgery was performed in 9 patients (39.1%) and open surgery was performed in the remaining 14 (60.8%). The mean length of hospital stay was 8.6 days in open surgery and 4 days in laparoscopic surgery. Complications consisted of pneumonia in 2 patients (8.6%). There was no intraoperative mortality in the series. Surgery was not performed in 11 patients (32.3%) (5 women and 6 men) with a mean age of 56.3 years. The mean size of the tumor in these patients, identified by CT, was 2.5 cm. These patients underwent subsequent monitoring with a mean follow-up of 32 months. CONCLUSIONS: Due to the high resolution of ultrasonography, CT and MRI, as well as the greater number of radiological investigations performed, identification of adrenal incidentalomas has increased. In our series these tumors represented 53.9% of adrenal disease.

Clinical pathway for the treatment of primary spontaneous pneumothorax in a general surgery department.

Primary spontaneous pneumothorax is a common abnormality for which there is a variety of treatments. This study presents the results of a year's evaluation of a clinical pathway (CP). A series of 34 patients treated during 1 year before CP development was analyzed to identify the weak points. To address these weak points, the CP includes associated protocols. In the CP, 31 patients were evaluated during 1 year; the results were compared with those of the pre-CP series. The mean length of stay of the pre-CP patients and the CP patients was 7.3 days and 5.0 days, respectively. The number of radiographs fell from 4.3 to 3.2. The rate of complications and readmissions is similar in both groups. The mean cost per process dropped from 1863 [UNKNOWN] to 1168 [UNKNOWN]. The CP for pneumothorax successfully manages to reduce both the variability in care patterns and hospital costs, justifying the work involved in its development and implementation.

Evaluation of the clinical pathway for laparoscopic cholecystectomy.

Clinical pathways are comprehensive systematized patient care plans for specific procedures. The clinical pathway for laparoscopic cholecystectomy was implemented in our department in March 2002. The aim of this study is to evaluate the clinical pathway for this procedure 1 year after implementation. A study was conducted on all the patients included in the clinical pathway since its implementation. The assessment criteria include degree of compliance, indicators of clinical care effectiveness, financial impact, and survey-based indicators of satisfaction. The results are compared to a series of patients undergoing surgery the year prior to implementation of the clinical pathway. As our hospital has a system of cost management, we analyzed the mean cost per procedure before and after clinical pathway implementation. Evaluation was made of a series of 160 consecutive patients who underwent surgery during the period 1 year prior to development of the clinical pathway and met the accepted inclusion criteria. The mean length of hospital stay was 3.27 days, and the mean cost per procedure before pathway implementation was 2149 (+/-768) euros. One year after implementation of the pathway, 140 patients were included (i.e., an inclusion rate of 100%). The mean length of hospital stay of the patients included in the clinical pathway was 2.2 days. The degree of compliance with stays was 66.7 per cent. The most frequent reasons for noncompliance were staff-dependent, followed by patient-dependent causes (oral intolerance, pain, etc.). The mean cost in the series of patients included in the clinical pathway was 1845 (+/-618) euros. Laparoscopic cholecystectomy is an ideal procedure for commencing the systemization of clinical pathways. Results show that it has significantly reduced the length of hospital stay and mean cost per procedure with no increased morbidity and with a high degree of patient satisfaction.

[Clinical pathway for the treatment of primary spontaneous pneumothorax in a general surgery department]. / Vía clínica para el tratamiento del neumotórax espontáneo primario en un servicio de cirugía general.

INTRODUCTION: Primary spontaneous pneumothorax (PSP) is a common entity. Treatment varies widely across different health systems and even among doctors in the same department. In our general surgery department 30 to 40 patients with PSP are treated each year and there is significant variability in care delivery. This prompted the development of a clinical pathway (CP) based on analysis of the process, a search for studies with the greatest scientific evidence and professional consensus. The aim of this study was to present the results after 1 year's evaluation of the CP. PATIENTS AND METHOD: A series of 34 patients treated in the year prior to the design of the pathway was analyzed to identify weak points and areas for improvement. To address these weak points the CP included associated protocols and principal documents. Thirty-one patients included in the CP were treated over 1 year and the results were compared with those of the pre-pathway series. RESULTS: The mean length of stay in the pre-pathway patients was 7.3 days compared with 5.0 days in the pathway patients. The number of radiographs also fell from 4.3 to 3.2. The rate of complications and re-admissions was similar in both groups. The mean cost per process decreased from 1863 Euro to 1168 Euro. CONCLUSION: The CP for pneumothorax reduced both variability in professional care patterns and hospital costs, justifying the work involved in its development and implementation.

Crossing the Red Sea: phylogeography of the hamadryas baboon, Papio hamadryas hamadryas.

The hamadryas baboon (Papio hamadryas hamadryas) is found both in East Africa and western Arabia and is the only free-ranging nonhuman primate in Arabia. It has been hypothesized that hamadryas baboons colonized Arabia in the recent past and were possibly even transported there by humans. We investigated the phylogeography of hamadryas baboons by sequencing a portion of the control region of mtDNA in 107 baboons from four Saudi Arabian populations and combing these data with published data from Eritrean (African) P. h. hamadryas. Analysis grouped sequences into three distinct clades, with clade 1 found only in Arabia, clade 3 found only in Africa, but clade 2 found in both Arabian and African P. h. hamadryas and also in the olive baboon, P. h. anubis. Patterns of variation within Arabia are neither compatible with the recent colonization of Arabia, implying that baboons were not transported there by humans, nor with a northerly route of colonization of Arabia. We propose that hamadryas baboons reached Arabia via land bridges that have formed periodically during glacial maxima at the straits of Bab el Mandab in the southern Red Sea. We suggest that the genetic differentiation of Arabian from African populations suggests that Arabian populations have a higher conservation status than recognized previously.