RESUMEN
The role of early laparoscopic cholecystectomy (ELC) in "oldest-old" patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study is to assess the safety of ELC for ACC in ≥ 85-year-old patients. Multicentric retrospective study that analysed data of patients who underwent ELC for ACC between 2013 and 2018. Patients ≥ 85-year-old (oldest-old patients) were compared with younger patients, before and after propensity score matching (PSM). The main outcomes were mortality, post-operative complications, length of stay (LOS), and readmissions. The study included 1670 patients. The unmatched comparison revealed a selection bias towards the oldest-old group, which was associated with higher Charlson Comorbidity Index (5 vs 1, p < 0.001), more ASA III/IV subjects (54.2% vs 19.3%, p < 0.001), class II/III ACC (80.1% vs 69.1%, p = 0.016) and higher Chole-Risk Score (p > 0.001). The oldest-old also required more conversion to open surgery (20% vs 10.3%, p = 0.005). Postoperatively, they had a higher 90-day mortality rate (7.6% vs 1%, p < 0.001), more total complications (40.6% vs 17.7%, p < 0.001), complications ≥ IIIa Clavien-Dindo (14.4% vs 5.8%, p = 0.002), longer LOS (6 vs 5 days, p < 0.001), and more readmissions (6.6% vs 2.6%, p < 0.001). After PSM (n = 206), the two groups were comparable in terms of baseline characteristics and intraoperative outcomes. No differences were observed in post-operative complications; bile leak; incisional, intrabdominal, urinary or respiratory tract infections; LOS or readmissions. In the oldest-old, ELC for ACC is still associated with significant morbidity and mortality. However, it seems to be safe in selected patients. Therefore, age itself should not be regarded as a contraindication to ELC for ACC.
Asunto(s)
Colecistectomía Laparoscópica , Colecistitis Aguda , Anciano de 80 o más Años , Colecistectomía Laparoscópica/efectos adversos , Colecistitis Aguda/cirugía , Humanos , Tiempo de Internación , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/cirugía , Puntaje de Propensión , Sistema de Registros , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. This study assesses ELC for ACC with delayed presentation, according to hospital volume. Multicentric retrospective analysis of 1868 ELC. Patients were classified into two groups according to the timing of surgery from clinical onset and centre volume. Group 1 (G1) within the first 7 days, group 2 (G2) beyond that. Then centres were classified in low volume centres (LVC) and higher volume centres (HVC) according to the number of ELC performed per year. Overall, G2 showed increased conversion rate (17.7% vs 10.7%; p = 0.004), intraoperative complications (7.3% vs 2.9%; p = 0.001); postoperative haemorrhage (3.6% vs 0.8%; p < 0.001), infections (16.6% vs 9.3%; p = 0.003) and global complications (27.6% vs 19.8%; p = 0.011). HVC in comparison with LVC presented decreased conversion rate (17.1% vs 7.6%; p < 0.001), intraoperative bleeding (2.1% vs 1%; p = 0.047), postoperative bile leakage (4.1% vs 2.1%; p = 0.011), infectious (13.7% vs 7.5%; p < 0.001) and global complications (25.7% vs 17.1%; p < 0.001). HVC did not show an increase in any of the above-mentioned outcomes when G1 and G2 were compared. ELC must be indicated cautiously in patients with ACC and more than 1 week of symptom duration. It should be performed in centres with sufficient experience in the management of this disease.
Asunto(s)
Colecistectomía Laparoscópica , Colecistitis Aguda/cirugía , Colecistectomía Laparoscópica/efectos adversos , Colecistectomía Laparoscópica/estadística & datos numéricos , Colecistitis Aguda/etiología , Conversión a Cirugía Abierta/estadística & datos numéricos , Cálculos Biliares/complicaciones , Cálculos Biliares/cirugía , Hospitales/estadística & datos numéricos , Complicaciones Intraoperatorias/epidemiología , Complicaciones Intraoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Pronóstico , Estudios Retrospectivos , Seguridad , Factores de TiempoRESUMEN
INTRODUCTION: Soft tissue infections (STIs), which include infections of the skin, subcutaneous tissue, fascia, and muscle, encompass a wide variety of heterogeneous pathologies. Treatment of STIs is based on surgical debridement of the affected area. One such treatment, negative pressure wound therapy (NPWT), has improved the management of STIs. OBJECTIVE: The purpose of this study is to assess the safety and utility of NPWT in conjunction with dermatotraction in the early stage management of necrotizing STIs. MATERIALS AND METHODS: The authors report a retrospective series of 3 cases in which NPWT and dermatotraction (NPWT-D) were used in an attempt to manage necrotizing STI. The NPWT-D device combination was employed to approximate the edges of the wounds. The NPWT device was changed every 2 or 3 days, and dermatotraction tension was adjusted concurrently. RESULTS: The NPWT-D device changes ranged from 3 to 4 times for 2 of the 3 patients, as 1 patient passed away secondary to STIs and therefore did not receive complete treatment. The total treatment ranged from 8 to 10 days in the remaining 2 patients. In both cases, complete wound closure was achieved while avoiding skin grafts. After 5 days of therapy in the incomplete treatment case, the wound area was reduced by about half. CONCLUSIONS: Based on the experiences herein, NPWT-D may be a safe and useful alternative surgical treatment for the management of necrotizing STIs. In the present cases, NPWT-D improved and shortened the wound healing process, and it achieved a tertiary wound closure, thereby avoiding the need for skin grafts.