RESUMO
BACKGROUND: There is still debate regarding the principal role and ideal timing of perioperative chemotherapy (CTx) for patients with upfront resectable colorectal liver metastases (CRLM). This study assesses long-term oncological outcomes in patients receiving neoadjuvant CTx only versus those receiving neoadjuvant combined with adjuvant therapy (perioperative CTx). METHODS: International multicentre retrospective analysis of patients with CRLM undergoing liver resection between 2010 and 2015. Characteristics and outcomes were compared before and after propensity score matching (PSM). Primary endpoints were long-term oncological outcomes, such as recurrence-free survival (RFS) and overall survival (OS). Furthermore, stratification by the tumour burden score (TBS) was applied. RESULTS: Of 967 patients undergoing hepatectomy, 252 were analysed, with a median follow-up of 45 months. The unmatched comparison revealed a bias towards patients with neoadjuvant CTx presenting with more high-risk patients (p = 0.045) and experiencing increased postoperative complications ≥Clavien-Dindo III (20.9% vs. 8%, p = 0.003). Multivariable analysis showed that perioperative CTx was associated with significantly improved RFS (hazard ratio [HR] 0.579, 95% confidence interval [CI] 0.420-0.800, p = 0.001) and OS (HR 0.579, 95% CI 0.403-0.834, p = 0.003). After PSM (n = 180 patients), the two groups were comparable regarding baseline characteristics. The perioperative CTx group presented with a significantly prolonged RFS (HR 0.53, 95% CI 0.37-0.76, p = 0.007) and OS (HR 0.58, 95% CI 0.38-0.87, p = 0.010) in both low and high TBS patients. CONCLUSIONS: When patients after resection of CRLM are able to tolerate additional postoperative CTx, a perioperative strategy demonstrates increased RFS and OS in comparison with neoadjuvant CTx only in both low and high-risk situations.
Assuntos
Neoplasias Colorretais , Neoplasias Hepáticas , Neoplasias Colorretais/patologia , Neoplasias Colorretais/terapia , Humanos , Neoplasias Hepáticas/tratamento farmacológico , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Terapia Neoadjuvante , Pontuação de Propensão , Estudos RetrospectivosRESUMO
INTRODUCTION: To assess the impact of fatigue due to incorrect night rest in the performance of a laparoscopic manual anastomosis. METHODS: A prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups were established; the FATIGUE group (F): anastomosis performed by residents coming off shift who slept less than seven hours and the REST group(R), being those who slept at home for more than 7 h. The time taken, length of the anastomosis and quality of such were compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches. RESULTS: 402 anastomoses were studied (211 rest group, 191 fatigue group). In the fatigue group leaks were detected in 33.5% anastomoses, as opposed to 19.4% in the rest group (P < .01). El rest group performed the anastomosis in 56.75 min and the fatigue group in 61,49 min (P = .006). There were no significant differences in the others parameters. CONCLUSIONS: Fatigue increases the risk of leakage and the time to do the exercise.
Assuntos
Internato e Residência , Laparoscopia , Anastomose Cirúrgica , Fadiga/etiologia , Humanos , Laparoscopia/efeitos adversos , Estudos Prospectivos , Privação do SonoRESUMO
INTRODUCTION: Learning surgical techniques is a dynamic process. In the 1980s David Kolb described developed a learning model that enabled teaching styles to adapt for better learner outcomes. The aim of this study was to identify the Kolb learning styles of the participants in a laparoscopic technical skills course and to check see if there was any relationship with performance. METHODS: An observational descriptive study was conducted with 64 participants in an intensive course in which they performed laparoscopic manual intestinal anastomoses. All completed Kolb's inventory of learning styles. For each anastomosis, join quality was assessed and the performing time recorded. After that, they were analyzed through statistical studies. RESULTS: The most frequent learning style was assimilating type (39.1%). No significant differences were observed between different learning styles and gender, professional category, the time taken or the quality of the anastomoses. CONCLUSIONS: Assimilating type was the most frequent Kolb learning style, with no differences observed between categories, age or gender. There is no relationship between the learning style of the participants and the results obtained in the course.
Assuntos
Laparoscopia , Aprendizagem , Cognição , HumanosRESUMO
BACKGROUND: There is still uncertainty regarding the role of perioperative chemotherapy (CTx) in patients with resectable colorectal liver metastases (CRLM), especially in those with a low-risk of recurrence. METHODS: Multicentre retrospective analysis of patients with CRLM undergoing liver resection between 2010-2015. Patients were divided into two groups according to whether they received perioperative CTx or not and were compared using propensity score matching (PSM) analysis. Then, they were stratified according to prognostic risk scores, including: Clinical Risk Score (CRS), Tumour Burden Score (TBS) and Genetic And Morphological Evaluation (GAME) score. RESULTS: The study included 967 patients with a median follow-up of 68 months. After PSM analysis, patients with perioperative CTx presented prolonged overall survival (OS) in comparison with the surgery alone group (82.8 vs 52.5 months, p = 0.017). On multivariable analysis perioperative CTx was an independent predictor of increased OS (HR 0.705, 95%CI 0.705-0.516, p = 0.029). The benefits of perioperative CTx on survival were confirmed in patients with CRS and TBS scores ≤2 (p = 0.022 and p = 0.020, respectively) and in patients with a GAME score ≤1 (p = 0.006). CONCLUSION: Perioperative CTx demonstrated an increase in OS in patients with CRLM. Patients with a low-risk of recurrence seem to benefit from systemic treatment.
Assuntos
Neoplasias Colorretais , Neoplasias Hepáticas , Neoplasias Colorretais/cirurgia , Hepatectomia/efeitos adversos , Humanos , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia/cirurgia , Prognóstico , Pontuação de Propensão , Estudos Retrospectivos , Fatores de RiscoRESUMO
INTRODUCTION: Learning surgical techniques is a dynamic process. In the 1980s David Kolb described developed a learning model that enabled teaching styles to adapt for better learner outcomes. The aim of this study was to identify the Kolb learning styles of the participants in a laparoscopic technical skills course and to check see if there was any relationship with performance. METHODS: An observational descriptive study was conducted with 64 participants in an intensive course in which they performed laparoscopic manual intestinal anastomoses. All completed Kolb's inventory of learning styles. For each anastomosis, join quality was assessed and the performing time recorded. After that, they were analyzed through statistical studies. RESULTS: The most frequent learning style was assimilating type (39.1%). No significant differences were observed between different learning styles and gender, professional category, the time taken or the quality of the anastomoses. CONCLUSIONS: Assimilating type was the most frequent Kolb learning style, with no differences observed between categories, age or gender. There is no relationship between the learning style of the participants and the results obtained in the course.
RESUMO
BACKGROUND: Liver transplant (LT) is a complex procedure with frequent postoperative complications. In other surgical procedures such as gastrectomy, esophagectomy or resection of liver metastases, these complications are associated with poorer long-term survival. It is possible this happens in LT but there are not enough data to establish this relationship. AIM: To analyze the possible influence of postoperative complications on long-term survival and the ability of the comprehensive complication index (CCI) to predict this. METHODS: Retrospective study in a tertiary-level university hospital. The 164 participants were all patients who received a LT from January 2012 to July 2019. The follow-up was done in the hospital until the end of the study or death. Comorbidity and risk after transplantation were calculated using the Charlson and balance of risk (BAR) scores, respectively. Postoperative complications were graded according to the Clavien-Dindo classification and the CCI. To assess the CCI cut-off value with greater prognostic accuracy a receiver operating characteristic (ROC) curve was built, with calculation of the area under the curve (AUC). Overall survival was estimated according to the Kaplan-Meier test and log-rank test. Groups were compared by the Mann-Whitney test. For the multivariable analysis the Cox regression was used. RESULTS: The mean follow-up time of the cohort was 37.76 (SD = 24.5) mo. A ROC curve of CCI with 5-year survival was built. The AUC was 0.826 (0.730-0.922), P < 0.001. The cut-off was calculated by means of the Youden index with a result of 35.95. The sensitivity was 84.6% and the specificity 61.3%. Survival curves for comparison of patients with CCI score < 36 vs ≥ 36 were calculated. The estimated 5-year survival was 57.65 and 43.95 months, respectively (log-rank < 0.001). This suggests that patients with more severe complications exhibit worse long-term survival. Other cut-off values were analysed. Comparison between patients with CCI < 33.5 vs > 33.5 (33.5 = median CCI value) showed estimated 5-year survival was 57.4 and 45.71 months, respectively (log-rank < 0.0001). Dividing patients according to the mode CCI value (20.9) showed an estimated 5-year survival of 60 mo for a CCI below 20.9 vs 57 mo for a CCI above 20.9 (log-rank = 0.147). The univariate analysis did not show any association between individual complications and long-term survival. A multivariate analysis was carried out to analyse the possible influence of CCI, Charlson comorbidity index, BAR and hepatocellular carcinoma on survival. Only the CCI score showed significant influence on long-term survival. CONCLUSION: A complicated postoperative period - well-defined by means of the CCI score - can influence not only short-term survival, but also long-term survival.
RESUMO
INTRODUCTION: Surgical training based on simulation seeks the acquisition of skills in novice participants and ongoing sill development in experts. The aim of this study is to assess the evolution of students in an intensive laparoscopic anastomosis course and to analyse their results depending on their level and previous experience. METHODS: The students of all the anastomosis courses conducted during 30 months in the Valdecilla virtual hospital (Santander) were analysed. Manual side-to-side intestinal anastomoses with porcine 'ex vivo' viscera were performed in a laparoscopic endotrainer. The technical and quality differences between the first and the last anastomoses were analyzed and the progression between residents and specialists was compared. RESULTS: We analyzed 45 participants, 22 of them residents and 23 specialists. A statistically significant improvement of 80.5% was observed in all procedural parameters (94.8% residents vs. 67.3% specialists). The time was reduced by 48.1% in the residents and 43.2% in the specialists (p<.001). In terms of quality, significant improvements were obtained in the group of residents: an increase of 90% in adequate tension, and a reduction of 75% of everted edges and 60% of leaks. In addition, they obtained results comparable to the specialists (27.3% leak in the last anastomosis vs. 34.8% by the specialists, p=.59), which presented improvement without statistical significance. CONCLUSIONS: The group of residents presented a major and significant improvement in procedural skills and in the quality of the technique, reaching the level of the specialists after completion of the course.
Assuntos
Anastomose Cirúrgica/educação , Internato e Residência , Laparoscopia/educação , Aprendizagem Baseada em Problemas/métodos , Treinamento por Simulação/métodos , Adulto , Animais , Competência Clínica , Escolaridade , Feminino , Humanos , Internato e Residência/métodos , Masculino , Modelos Anatômicos , SuínosRESUMO
OBJECTIVE: The objective of the study was to analyze surgical site infection (SSI) frequency with different duration antibiotic courses to establish the minimum necessary duration. METHODS: This is an observational study of prospective surveillance of 287 consecutive patients (mean age 67.8 years) operated on for acute cholecystitis of grade II severity in the first 72 h. Postoperative antibiotics had been withdrawn before diagnosis of any infection as an inclusion criterion. Patients were classified into three groups, according to therapy duration: group 1 (0-4 days, n = 45, 15.7 %); group 2 (5-7 days, n = 75, 26.1 %); and group 3 (>7 days, n = 167, 58.2 %). A multivariable analysis of risk infection was performed. RESULTS: Overall SSI frequency in groups 1, 2, and 3 was 2.2, 10.7, and 9 %, respectively. Risk analysis showed an increase in both crude and adjusted relative risks of overall infection in group 2 (crude relative risk (RR): 4.80 (0.62-37.13); adjusted RR, 2.03 (0.20-20.91)) and in group 3 (crude RR, 4.04 (0.55-29.79); adjusted RR, 2.35 (0.28-20.05)) by comparison with group 1, although without statistical significance. As a result, treatment lasting 4 days or less was not associated with overall surgical site infection incidence higher than longer treatment. CONCLUSION: Antibiotic treatment over 4 days after early cholecystectomy provides no advantage in decreasing surgical site infection incidence.
Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Colecistectomia/efeitos adversos , Colecistite Aguda/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Idoso , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ácido Penicilânico/análogos & derivados , Ácido Penicilânico/uso terapêutico , Piperacilina/uso terapêutico , Combinação Piperacilina e Tazobactam , Cuidados Pós-Operatórios , Estudos Prospectivos , Medição de Risco , Infecção da Ferida Cirúrgica/microbiologia , Fatores de TempoRESUMO
Simple closure followed by Helicobacter pylori (Hp) eradication has become the most used procedure in perforated ulcer treatment. However, its efficacy and safety are still to be determined. To assess recurrence and re-perforation rates, and as a secondary objective, to analyze Hp infection rates in perforated ulcer patients and controls, we conducted a prospective study. Ninety-two consecutive patients (ages: 19-96 years) were operated on between 1996 and 2002, and treated by simple closure followed by Hp eradication and NSAID avoidance. The data were prospectively collected in a database. Hp infection was diagnosed in 68 patients (73.9%). Thirty-four patients (37%) consumed nonsteroidal anti-inflammatory drugs (NSAIDs), and 23 (25%) had both Hp infection and NSAID antecedents. The perforation was gastric in 4 cases and pre-pyloric, pyloric or duodenal in 88. There were postoperative complications in 24 patients (26%) and 4 patients died (4.3%). Hp eradication was shown in 46 patients. There was clinical ulcer recurrence in 4 (4.3%); in 3 of them recurrence manifested as re-perforation, all in gastric locations. Overall relapse and re-perforation 1-year crude rates were 6.1% and 4.1%, respectively. Crude rates for non-gastric ulcer recurrence were 0 at 1 year and 2.6% at 2 years and for non-gastric ulcer re-perforation rates were 0 at 1 and 2 years. This therapeutic strategy is associated with a low rate of recurrence and no re-perforations in case of duodenal, pyloric, or pre-pyloric perforated ulcers, but it is not acceptable for perforated gastric ulcers.