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.

Laparoscopic Versus Open Incisional Hernia Repair: Long-Term Follow-up Results of a Randomized Clinical Trial.

PURPOSE: Long-term extension of a previous randomized controlled clinical trial comparing open (OVHR) vs. laparoscopic (LVHR) ventral hernia repair, assessing recurrence, reoperation, mesh-related complications and self-reported quality of life with 10 years of follow-up. METHODS: Eighty-five patients were followed up to assess recurrence (main endpoint), reoperation, mesh complications and death, from the date of index until recurrence, death or study completion, whichever was first. Recurrence, reoperation rates and death were estimated by intention to treat. Mesh-related complications were only assessed in the LVHR group, excluding conversions (intraperitoneal onlay; n = 40). Quality of life, using the European Hernia Society Quality of Life score, was assessed in surviving non-reoperated patients (n = 47). RESULTS: The incidence rates with 10 person-years of follow-up were 21.01% (CI 13.24-33.36) for recurrence, 11.92% (CI: 6.60-21.53) for reoperation and 24.88% (CI 16.81-36.82) for death. Sixty-two percent of recurrences occurred within the first 2 years of follow-up. No significant differences between arms were found in any of the outcomes analyzed. Incidence rate of intraperitoneal mesh complications with 10 person-years of follow-up was 6.15% (CI 1.99-19.09). The mean EuraHS-QoL score with 13.8 years of mean follow-up for living non-reoperated patients was 6.63 (CI 4.50-8.78) over 90 possible points with no significant differences between arms. CONCLUSION: In incisional ventral hernias with wall defects up to 15 cm wide, laparoscopic repair seems to be as safe and effective as open techniques, with no long-term differences in recurrence and reoperation rates or global quality of life, although lack of statistical power does not allow definitive conclusions on equivalence between alternatives. TRIAL REGISTRATION NUMBER: ClinicalTrial.gov (NCT04192838).

Initial results of the oesophageal and gastric cancer registry from the Comunidad Valenciana. / Resultados iniciales del registro de carcinomas esófago-gástricos de la Comunidad Valenciana.

AIMS: To evaluate the initial results of the oesophagogastric cancer registry developed for the Sociedad Valenciana de Cirugía and the Health Department of the Comunidad Valenciana (Spain). METHODS: Fourteen of the 24 public hospitals belonging to the Comunidad Valenciana participated. All patients with diagnosis of oesophageal or gastric carcinomas operated from January 2013 to December 2014 were evaluated. Demographic, clinical and pathological data were analysed. RESULTS: Four hundred and thirty-four patients (120 oesophageal carcinomas and 314 gastric carcinomas) were included. Only two hospitals operated more than 10 patients with oesophageal cancer per year. Transthoracic oesophaguectomy was the most frequent approach (84.2%) in tumours localized within the oesophagus. A total gastrectomy was performed in 50.9% patients with gastroesophageal junction (GOJ) carcinomas. Postoperative 30-day and 90-day mortality were 8% and 11.6% in oesophageal carcinoma and 5.9 and 8.6% in gastric carcinoma. Before surgery, middle oesophagus carcinomas were treated mostly (76,5%) with chemoradiotherapy. On the contrary, lower oesophagus and GOJ carcinomas were treated preferably with chemotherapy alone (45.5 and 53.4%). Any neoadjuvant treatment was administered to 73.6% of gastric cancer patients. Half patients with oesophageal carcinoma or gastric carcinoma received no adjuvant treatment. CONCLUSIONS: This registry revealed that half patients with oesophageal cancer were operated in hospitals with less than 10 cases per year at the Comunidad Valenciana. Also, it detected capacity improvement for some clinical outcomes of oesophageal and gastric carcinomas.

Surgical treatment of acute diverticulitis. A retrospective multicentre study. / Tratamiento quirúrgico de la diverticulitis aguda. Estudio retrospectivo multicéntrico.

INTRODUCTION: To analyze short and medium-term results of different surgical techniques in the treatment of complicated acute diverticulitis (CAD). METHODS: Multicentre retrospective study including patients operated on as surgical emergency or deferred-urgency with the diagnosis of CAD. RESULTS: A series of 385 patients: 218 men and 167 women, mean age 64.4±15.6 years, operated on in 10 hospitals were included. The median (25th-75th percentile) time from symptoms to surgery was 48 (24-72) h, being peritonitis the main surgical indication in a 66% of cases. Surgical approach was usually open (95.1%), and the commonest findings, a purulent peritonitis (34.8%) or pericolonic abscess (28.6%). Hartmann procedure (HP) was the most used technique in 278 (72.2%) patients, followed by resection and primary anastomosis (RPA) in 69 (17.9%). The overall postoperative morbidity and mortality was 53.2% and 13% respectively. Age, immunosupression, presence of general risk factors and faecal peritonitis were associated with increased mortality. Laparoscopic peritoneal lavage (LPL) was associated with an increased reoperation rate frequently involving a stoma, and anastomotic leaks presented in 13.7 patients after RPA, without differences in morbimortality when compared with HP. Median postoperative length of stay was 12 days, and was correlated with age, surgical risk, ASA score, hospital and postoperative complications. CONCLUSIONS: Surgery for CAD has important morbidity and mortality and is frequently associated with an end-stoma. Moreover LPL presented high reoperation rates. It seems better to resect and anastomose in most cases, even with an associated protective stoma.

Ovarian involvement in Crohn´s disease: A rare complication.

BACKGROUND: The transmural condition of Crohn's disease predisposes to fistulae or abscesses. The internal fistulae incidence is about 15%. Among them, enteroovarian fistula is rarely described on the literature. Herein, the authors present three cases of enteroovarian fistulas. CASE REPORTS: Two women are diagnosed with ileal Crohn's disease that presented a pelvic abscess diagnosed by ultrasound and CT. On surgery, an inflammatory mass involving the ileum and the ovary was found. The third woman was operated because of a tuboovarian abscess and was diagnosed with ileal Crohn's disease afterwards. In the three cases, the histopathological analysis of the ovary showed granulomas with abscess compatible with Crohn's disease. In one of the cases, multinucleated giant cells were found in the foreign body reaction to vegetable matter. A right ileocolectomy and an adnexectomy were performed in all three cases. No further involvement of the contralateral ovary or other gynaecological complications was observed. DISCUSSION: The treatment of Crohn's disease complications should be individualised. In the case of ovarian involvement, surgical treatment should include adnexectomy.

Results of adrenal surgery. Data of a Spanish National Survey.

PURPOSE: Given the availability of laparoscopy and the rising detection of incidentalomas, indications for adrenalectomy may be changing. The Endocrine Surgery Section of the Spanish Association of Surgeons designed a survey to assess its indications, techniques, and results in Spanish Surgical Departments. METHODS: Collected data included hospital and department type, yearly hospital volume of procedures; location studies and preoperative preparation performed, indications, surgical approach and instruments used, and results in terms of morbidity and overall hospital stay. The analysis included a comparison between results of high- or low-volume centers and surgeons, using the Student's t test for quantitative and chi-square test for qualitative variables. Level of significance was set at 0.05. RESULTS: Nineteen centers returned the questionnaire, including 155 adrenalectomies performed in 2008. Most frequent indications were pheochromocytoma (23.2%), aldosteronoma (16.7%), incidentaloma (12.2%), metastasis (10.3%), Cushing adenoma (9.6%), and carcinoma (3.8%). Laparoscopy was performed in 83.9% of cases (9.4% required conversion to laparotomy). Four patients required urgent reoperation. Average hospital stay: 4.6 days (3.3 days after laparoscopy, 7 days after laparotomy). High-volume centers had a greater proportion of laparoscopically treated cases (p = 0.008), more malignant lesions treated (p = 0.03), a shorter overall stay (p < 0.0001), and a shorter stay after laparotomic adrenalectomy (p = 0.01). High-volume surgeons had similar results, and less in-hospital morbidity (p = 0.02). CONCLUSIONS: In Spain, adrenalectomy is performed in hospitals of varying complexity. Laparoscopic approach is the rule, with good results in terms of morbidity and stay. High-volume centers and surgeons had best results in terms of use of minimally invasive surgery and hospital stay.

Open randomized clinical trial of laparoscopic versus open incisional hernia repair.

BACKGROUND: Incisional hernia is a common complication following abdominal surgery. Although the use of prosthetics has decreased recurrence rates, the standard open approach is still unsatisfactory. Laparoscopic techniques are an attempt to provide similar outcomes with the advantages of minimally invasive surgery. METHODS: Open randomized controlled clinical trial with follow-up at 1, 2, 3, 7, and 15 days, and 1, 3, and 12 months from hernia repair. The study was carried out in the surgery departments of three general hospitals of the Valencia Health Agency. OBJECTIVES: To compare laparoscopic with anterior open repair using health-related quality of life outcomes as main endpoints. RESULTS: Eighty-four patients with incisional hernia were randomly allocated to an open group (OG) (n = 39) or to a laparoscopic group (LG) (n = 45). Seventy-four patients completed 1-year follow up. Mean length of stay and time to oral intake were similar between groups. Operative time was 32 min longer in the LG (p < 0.001). Conversion rate was 11%. The local complication rate was superior in the LG (33.3% versus 5.2%) (p < 0.001). Recurrence rate at 1 year (7.9% versus 9.7%) was similar in the two groups. There were no significant differences in the pain scores or the EQ5D tariffs between the two groups during follow-up. CONCLUSIONS: Laparoscopic incisional hernia repair does not seem to be a better procedure than the open anterior technique in terms of operative time, hospitalization, complications, pain or quality of life.

[Adverse outcomes in the surgical treatment of acute appendicitis]. / Efectos adversos en la cirugía de la apendicitis aguda.

OBJECTIVES: To describe adverse outcomes after appendectomy for acute appendicitis and to analyze the association between these outcomes and specific characteristics of the patient and hospital admission. MATERIAL AND METHODS: We studied a cohort of 792 patients who underwent appendectomy for acute appendicitis. Postoperative complications, reoperations and deaths were prospectively studied and all readmissions were retrospectively identified. Logistic regression was used to evaluate the relationship between complications and patient characteristics, as well as hospital admission. RESULTS: Postsurgical complications developed in 9.8% of the patients. These complications mainly consisted of surgical wound infection (4.2%) and intra-abdominal complications (2.1%). A total of 0.7% of patients underwent reoperation during admission, 0.5% were admitted to the intensive care unit and five patients (0.6%) died in hospital. The rate of operation-related readmissions in the following year was 3.2%. Length of hospital stay was longer in patients with complications than in those without complications (9.6 and 3.5 days, respectively). Postoperative complications were associated with older age (45-65 years, OR 3.62, p < 0.001; more than 65 years OR 8.68, p < 0.001) and acute appendicitis complicated with peritonitis or perforation (OR 3.69, p < 0.005). Readmissions related to previous surgery were associated only with complications during the first admission (OR 18.79, p < 0.001). CONCLUSIONS: In appendectomy, the most frequent adverse outcomes are surgical wound infection and intra-abdominal complications, which are associated with older patients and perforations. This subgroup of patients at high risk requires closer surveillance.