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.

[Pediatric clinical experience in infectious endocarditis due to Candida spp]. / Experiencia clínica pediátrica en endocarditis infecciosa por Candida spp.

BACKGROUND: Treatment and outcome of Candida spp infectious endocarditis in children it most be based on treatment guidelines, however there are some controversies. AIM: To describe our experience on treatment of pediatric candidal infective endocarditis. METHODS: Analytic prospective study, from January 2006 to December 2017. Parametric analysis for quantitative variable. Proportions were compared by χ2 and exact Fisher Test CI 95%. Mortality rate. RESULTS: 25 episodes of Candida spp infective endocarditis were treated with standard antifungal drugs. Mortality rate was higher on patients submited to endocardic vegetation resection (66.7%) RR= 3.16, (χ2 p = 0.029), children with lymphohemophagocytic syndrome (LHFS) (50 %) RR= 1.18 (χ2 = N.S.), in multidrug resistant bacterial co infection (57.14%), RR = 2, (χ2 = NS) also thrombotic endocarditis (88.9%) RR= 4.74 (χ2 p = 0.004). CONCLUSION: Multidrug resistant bacteria co infection with Candida sp IE, LHFS, and/or surgical treatment of endocardic vegetation, might be considered as bad prognostic factors.

Experiencia clínica pediátrica en endocarditis infecciosa por Candida spp / Pediatric clinical experience in infectious endocarditis due to Candida spp

Resumen Introducción: El tratamiento y evolución de endocarditis infecciosa por Candida spp en niños debe basarse en guías de manejo; sin embargo, aún existen controversias al respecto. Objetivo: Describir nuestra experiencia en el tratamiento de EI por Candida spp en pacientes pediátricos. Métodos: Estudio prospectivo, analítico, realizado entre enero de 2006 y diciembre 2017. Análisis paramétrico de variables cuantitativas; razones, proporciones, comparación por medio de χ2 y prueba exacta de Fisher con IC al 95% para variables no paramétricas. Tasa de mortalidad. Resultados: Veinticinco episodios de endocarditis por Candida spp recibieron tratamiento anti fúngico estándar. La mortalidad fue superior en pacientes sometidos a resección de la vegetación endocárdica (66,7%) RR 3,16, χ2 p = 0,029, en niños con síndrome linfo-hemofagocítico SLHF (50%), RR= 1,18 (χ2 NS), en co infección con bacterias multi-resistentes (57,1 %) RR= 2, (χ2 NS) y en EI trombótica (88,9%) RR = 4,74 (χ2 p = 0,004). Conclusiones: Co-infección de EI por Candida sp con bacterias multi-resistentes, SLHF y/o manejo quirúrgico de la vegetación endocárdica, pueden considerarse factores de mal pronóstico.

Background: Treatment and outcome of Candida spp infectious endocarditis in children it most be based on treatment guidelines, however there are some controversies. Aim: To describe our experience on treatment of pediatric candidal infective endocarditis. Methods: Analytic prospective study, from January 2006 to December 2017. Parametric analysis for quantitative variable. Proportions were compared by χ2 and exact Fisher Test CI 95%. Mortality rate. Results: 25 episodes of Candida spp infective endocarditis were treated with standard antifungal drugs. Mortality rate was higher on patients submited to endocardic vegetation resection (66.7%) RR= 3.16, (χ2 p = 0.029), children with lymphohemophagocytic syndrome (LHFS) (50 %) RR= 1.18 (χ2 = N.S.), in multidrug resistant bacterial co infection (57.14%), RR = 2, (χ2 = NS) also thrombotic endocarditis (88.9%) RR= 4.74 (χ2 p = 0.004). Conclusion: Multidrug resistant bacteria co infection with Candida sp IE, LHFS, and/or surgical treatment of endocardic vegetation, might be considered as bad prognostic factors.