Does the Artery-first Approach Improve the Rate of R0 Resection in Pancreatoduodenectomy?: A Multicenter, Randomized, Controlled Trial.

OBJECTIVE: To compare the rates of R0 resection in pancreatoduodenectomy (PD) for pancreatic and periampullary malignant tumors by means of standard (ST-PD) versus artery-first approach (AFA-PD). BACKGROUND: Standardized histological examination of PD specimens has shown that most pancreatic resections thought to be R0 resections are R1. "Artery-first approach" is a surgical technique characterized by meticulous dissection of arterial planes and clearing of retropancreatic tissue in an attempt to achieve a higher rate of R0. To date, studies comparing AFA-PD versus ST-PD are retrospective cohort or case-control studies. METHODS: A multicenter, randomized, controlled trial was conducted in 10 University Hospitals (NCT02803814, ClinicalTrials.gov). Eligible patients were those who presented with pancreatic head adenocarcinoma and periampullary tumors (ampulloma, distal cholangiocarcinoma, duodenal adenocarcinoma). Assignment to each group (ST-PD or AFA-PD) was randomized by blocks and stratified by centers. The primary end-point was the rate of tumor-free resection margins (R0); secondary end-points were postoperative complications and mortality. RESULTS: One hundred seventy-nine patients were assessed for eligibility and 176 randomized. After exclusions, the final analysis included 75 ST-PD and 78 AFA-PD. R0 resection rates were 77.3% (95% CI: 68.4-87.4) with ST-PD and 67.9% (95% CI: 58.3-79.1) with AFA-PD, P=0.194. There were no significant differences in postoperative complication rates, overall 73.3% versus 67.9%, and perioperative mortality 4% versus 6.4%. CONCLUSIONS: Despite theoretical oncological advantages associated with AFA-PD and evidence coming from low-level studies, this multicenter, randomized, controlled trial has found no difference neither in R0 resection rates nor in postoperative complications in patients undergoing ST-PD versus AFA-PD for pancreatic head adenocarcinoma and other periampullary tumors.

Minimally invasive treatment of rectovesical fistula: A case report.

Management of rectovesical fistulas poses a significant challenge where a definitive surgical treatment is necessary in the majority of the patients. The application of transanal endoscopic surgery is an useful option, adding the adventages of a minimally invasive surgery. We report our first case of transanal endoscopic surgical treatment of RVF with a successful outcome.

What to do with an intraductal papilary mucinous pancreatic neoplasm? Our experience. / ¿Qué hacer ante una neoplasia mucinosa papilar intraductal de páncreas? Nuestra experiencia.

INTRODUCTION: Cystic pancreatic neoplasms are a heterogeneous group of pathology, and intraductal papillary mucinous neoplasia is becoming more common. The aim of this study is to review our series of cystic pancreatic neoplasms that underwent surgery and to evaluate the similarities with Fukuoka recommendations. METHODS: Retrospective review of our experience analyzing clinical and radiological data, indication for surgery and pathology study of 11 patients operated on in our centre from july 2011 to july 2015, aiming to evaluate the degree of agreement with the current consensus. RESULTS: In our series the majority of cases (7/11) had symptoms at diagnosis. Preoperative diagnosis was achieved in 10 patients using radiology and/or endoscopy. Indications for surgery were the presence of symptoms, radiological data suspicious of malignancy, and secondary branch neoplasia over 30mm. Pathological findings were malignancy in 6/11 cases (2 invasive neoplasia, 4 high grade dysplasia), moderate dysplasia in 2/11, low-grade dysplasia in 2/11 and no dysplasia in one patient. CONCLUSIONS: Surgical indication of intraductal mucinous pancreatic neoplasms depends on the associated symptoms, size, location, risk and suspicion of malignancy.

National survey on patient's fears before a general surgery procedure.

OBJECTIVE: To assess the magnitude of the different causes of anxiety in patients and families, facing surgery. METHODS: Cross-sectional multicenter national survey recruiting 1,260 participants between patients and companions, analyzing the impact of 14 areas selected based on scientific publications aimed at the general public, concerning patients and/or companions, focused on concern about surgery. Patient sex, age, type of surgery (minor/major) and expected inpatient or ambulatory surgery were analyzed. For the companions sex and age, and relationship to patient were analyzed. In both cases it was assessed based on a unidimensional scale of 0 to 10, with 0 being be minimal cause for concern and 10, maximum. RESULTS: The most prominent have been the fear of the unknown, possible complications, the impact on quality of life, the accuracy of diagnosis and possible malignancy of the disease, as well as anesthesia and pain control. There are significant differences in the involvement of patients and companions; and are also differences by sex and age of the patient; type of surgery (minor/major) and expected hospital admission or not. CONCLUSIONS: The patient faces surgery with a number of fears that can be reduced with increased information.

[Analysis of the results [corrected] of survey on trauma systems: The neglected disease of the modern society]. / Análisis de los resultados de una encuesta sobre los sistemas de trauma en España: la enfermedad abandonada de la sociedad moderna.

BACKGROUND: Trauma injuries are the main cause of death in the world. The aim of this study is to determine how trauma patients are treated in Spain at an organizational level. MATERIAL AND METHODS: A questionnaire was prepared consisting of 14 questions regarding aspects of the trauma care organization and trauma education. It was posted on the web site of the Spanish College of Surgeons and all members were encouraged to participate. RESULTS: One hundred and ninety questionnaires from 110 different hospitals were received. More than two-thirds (67.3%) of the centers had protocols for treating trauma patients, with 81% of them based on ATLS guidelines. Almost three-quarters (72.6%) of the doctors had completed the ATLS course, and 38.9% the DSTC course. There was a specific education program in trauma in 24.5% of the centers, and 35.5% had a Trauma Committee. There was a rehabilitation program in 24.5% of the centers. CONCLUSION: Very few of the participating centers would fulfill the requirements of the American College of Surgeons accreditation for trauma centers. Trauma care in Spain has improved a lot in the recent years, but there is still a lot to do to reach the level of that in the United States of America.

[Spleen injuries in Spain: at what point are we?]. / Traumatismo esplénico en España: ¿en qué punto estamos?

INTRODUCTION: Management of spleen trauma has changed over last decades, although there is no data on its treatment in Spain. The aim of this study is to determine the characteristics of spleen injuries in adults with severe abdominal injuries and how we manage them. METHODS: A prospective study using the databases of six Spanish hospitals: Gregorio Marañón Hospital, Virgen de la Vega Hospital, Torrevieja Hospital, Getafe Hospital, Doce de Octubre Hospital and Corporació Sanitària Parc Taulí. RESULTS: A total of 566 patients who had sustained spleen injuries were analyzed (448 males and 118 females), most of them were due to blunt trauma (94%), and the most frequent mechanism of injury was motor vehicle accident. The mean Injury Severity Score (ISS) was 25.2. The initial treatment was surgical in 56.6% of the patients (85.3% total splenectomy and 14.7% other conservative surgical procedures, of which 4.6% finally failed and required total splenectomy). The remaining 43.4% were initially managed conservatively, but 6.5% of them finally required surgical splenectomy, and in 8.8% angio-embolization was performed. CONCLUSION: In Spain, management of spleen trauma is mainly surgical (particularly splenectomy). Angio-embolization and conservative surgical procedures are now hardly used.

Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis.

OBJECTIVE: To determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing two guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. METHODS: Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg/day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg/day for BMI of 35-40 and 60mg/day for BMI 40-60. RESULTS: 675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g/dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. CONCLUSIONS: The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis. / Riesgo trombótico y hemorrágico en cirugía bariátrica con programas de rehabilitación multimodal comparando 2 pautas reducidas de profilaxis farmacológica.

OBJECTIVE: to determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing 2guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. METHODS: Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg / day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg / day for BMI of 35-40 and 60mg/day for BMI 40-60. RESULTS: 675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g / dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. CONCLUSIONS: The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons]. / Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos.

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients.

Burnout in General Surgery Residents. Survey From the Spanish Association of Surgeons. / Desgaste profesional o burnout en los residentes de Cirugía General. Encuesta de la Asociación Española de Cirujanos.

INTRODUCTION: Physicians, especially surgeons, are significatively affected by burnout. Duty-hour violation, as well as discrimination, abuse and sexual harassment may contribute to burnout. A study about this topic has been published in residents from United States, demonstrating a high incidence of burnout. Our objective is to know which is the situation in Spain and to compare it with United States. METHODS: Cross-sectional observational study carried out in January-February 2020, based on the responses to a validated survey administered to General Surgery residents in Spain. RESULTS: There are 931 General Surgery Residents. 739 have entered in the survey and 452 (61.2%) eventually responded to it. In any occasion during the training period, 55.1% reported discrimination based on their gender, 8.8% reported racial discrimination, 73.9% reported verbal/psychological abuse, 7.1% reported physical abuse and 16.4% reported sexual harassment. Attending surgeons are the most frequent source of sexual harassment and physical and verbal abuse, whereas patients are the most frequent cause of gender discrimination. Burnout symptoms were reported by 47.6% of residents and 4.6% reported suicidal thoughts. 98% of residents reported duty-hour violations and 47% of them do not have the day off after to be on call. Both of these issues are burnout predictive factors. CONCLUSIONS: Mistreatment (discrimination, abuse and harassment) occurs among General Surgery residents during their training period in our country. Every kind of mistreatment is more frequent in Spain than in the United States, with the exception of racial discrimination. It is associated with exceeding weekly duty-hour. It is necessary to know these problems and to avoid them in order to improve work environment of General Surgery training period.

Upper gastrointestinal bleeding due to hepatic artery aneurysm: Case report and literature review.

INTRODUCTION: Aneurysm of the hepatic artery is most of the time a rare and asymptomatic pathology, but in case of complication it shows high morbidity and mortality requiring in many cases an urgent treatment. PRESENTATION OF CASE: A 92-year-old male presented at the emergency department with high gastrointestinal bleeding and abdominal pain. Gastroscopy showed a submucosal lesion with active bleeding that was controlled through this approach. The study was expanded with a CT angiogram and a complicated hepatic aneurysm with duodenal fistulization was observed. DISCUSSION: After reviewing the case, surgical treatment is proposed as the first option but it is rejected by the patient. Thus, aneurysm embolization with coils and thrombin is performed, without further complications. CONCLUSION: Selective embolization of the hepatic artery aneurysm is a therapeutic alternative in cases that implies large comorbidities, being an increasingly used technique.

The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain. / El modelo Acute Care Surgery en el mundo y la necesidad e implantación de unidades de trauma y cirugía de urgencia en España.

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

De Garengeot's hernia: Case report and literature review.

INTRODUCTION: De Garengeot's Hernia is a rare type of femoral hernia in which the appendix is located inside the herniated sac. Diagnosis of the condition is challenging and its treatment must be performed without delay. PRESENTATION OF CASE: We present the case of a 75-year-old patient with a femoral hernia in which an appendix with signs of inflammation was found. An appendectomy followed by hernia repair was performed under an open preperitoneal approach according to Nyhus technique. The patient did not present any complications and was discharged on the second postoperative day. DISCUSSION: This type of hernia is often unexpected and its preoperative diagnosis is difficult to perform. In most cases the clinical picture is indistinguishable from a common incarcerated hernia. Contrast-enhanced CT is the most useful complementary test, although it is not as accurate as desirable, so the diagnosis is frequently found intraoperatively. There is a wide variety of surgical options and there is no consensus on the most appropriate one. The preperitoneal approach enables the performance of an appendectomy and subsequent hernia reparation. The use of prosthesis should be considered if there are no signs of perforation or abscess. CONCLUSION: De Garengeot's hernia is a very rare entity. The diagnosis and subsequent surgical treatment must be early to prevent the disease progression. The preperitoneal approach should be considered as the first choice technique, as it allows the exploration of the herniated sac and the performance of surgical procedures on its content.

Lesión pancreática aislada tras traumatismo abdominal cerrado: a propósito de un caso / Isolated pancreatic injury after blunt abdominal trauma: a case report

Introducción. La incidencia de lesiones traumáticas del páncreas es baja debido a su localización retroperitoneal, y las lesiones aisladas son excepcionales debido a la proximidad del páncreas a otros órganos y estructuras vasculares. Caso clínico. Presentamos el caso de un varón de 21 años con lesión aislada del páncreas tras traumatismo abdominal cerrado, que precisó manejo quirúrgico. Discusión. Las lesiones pancreáticas aisladas secundarias a traumatismo son raras, pero debemos tenerlas en cuenta en un paciente politraumatizado. Su diagnóstico precoz y manejo adecuado son cruciales para evitar el desarrollo de complicaciones

Introduction. The incidence of traumatic injuries to the pancreas is low due to its retroperitoneal location, and isolated injuries are rare due to the proximity of the pancreas to other vascular organs and structures. Clinical case. We present the case of a 21-year-old man with an isolated lesion of the pancreas after blunt abdominal trauma, which required surgical management.Discussion. Isolated pancreatic injuries secondary to trauma are rare but must be taken into account in a multiple trauma patient. Its early diagnosis and proper management are crucial to avoid the development of complications

Laparoscopic cholecystectomy and incidental carcinoma of the extrahepatic bilary tree.

BACKGROUND AND OBJECTIVES: Gallbladder carcinoma is found in 0.2% to 5% of patients undergoing cholecystectomy, and gallstones are found in 70% to 98% of patients with gallbladder carcinoma. Early diagnosis of carcinoma is difficult because of the absence of specific symptoms and the frequent association with chronic cholecystitis and gallstones. At present, laparoscopic cholecystectomy is the gold standard for the surgical treatment of symptomatic cholelithiasis and other benign gallbladder diseases. The aims of this study were to evaluate retrospectively the incidence of occasional and occult gallbladder carcinomas to ascertain the effect of laparoscopy on diagnosis and treatment of unexpected extrahepatic biliary tree carcinomas and to assess possible guidelines that can be taken into consideration when the problem is encountered. METHODS: Clinical records of 3900 patients undergoing laparoscopic cholecystectomy were reviewed. Patients with occasional (intraoperative = Group A) or occult (postoperative = Group B) diagnosis of gallbladder or common bile duct carcinoma entered the study group. Follow-up data were obtained in June 2000. RESULTS: A total of 14 patients (0.35%), 3 men and 11 women, mean age 60.8 years (range 37 to 73) with extrahepatic biliary tree carcinoma were found. Occasional carcinomas occurred in 8 patients, occult carcinomas in 6. No deaths occurred in either group. The overall survival at mean follow-up of 30.5 months is 50%. Five patients are disease free, and 2 are alive with evidence of recurrence. DISCUSSION: In 2 large series of unselected consecutive laparoscopic cholecystectomy, only 14 unsuspected malignant tumors of the extrahepatic biliary tree were found (0.35%). The limits of the preoperative workup and the difficult diagnosis of biliary tract carcinoma during laparoscopic cholecystectomy, has led to the present retrospective study and several significant recommendations.