Systematic review and meta-analysis of fluid therapy protocols in acute pancreatitis: type, rate and route.

BACKGROUND: Adequate fluid resuscitation is paramount in the management of acute pancreatitis (AP). The aim of this study is to assess benefits and harms of fluid therapy protocols in patients with AP. METHODS: MEDLINE, Embase, Science Citation Index and clinical trial registries were searched for randomised clinical trials published before May 2020, assessing types of fluids, routes and rates of administration. RESULTS: A total 15 trials (1073 participants) were included. Age ranged from 38 to 73 years; follow-up period ranged from 0.5 to 6 months. Ringer lactate (RL) showed a reduced number of severe adverse events (SAE) when compared to normal saline (NS) (OR 0.48; 95%CI 0.29-0.81, p = 0.006); additionally, NS showed reduced SAE (RR 0.38; 95%IC 0.27-0.54, p < 0.001) and organ failure (RR 0.30; 95%CI 0.21-0.44, p < 0.001) in comparison with hydroxyethyl starch (HES). High fluid rate fluid infusion showed increased mortality (OR 2.88; 95%CI 1.41-5.88, p = 0.004), increased number of SAE (RR 1.42; 95%CI 1.04-1.93, p = 0.030) and higher incidence of sepsis (RR 2.80; 95%CI 1.51-5.19, p = 0.001) compared to moderate fluid rate infusion. CONCLUSIONS: In patients with AP, RL should be preferred over NS and HES should not be recommended. Based on low-certainty evidence, moderate-rate fluid infusion should be preferred over high-rate infusion.

Breast implant during orthotopic liver transplant to avoid hepatic outflow obstruction.

Donor-recipient size mismatch in liver transplantation is a recognized but uncommon situation. It can lead to a partial or complete obstruction of the inferior vena cava with subsequent hepatic outflow obstruction. Placement of a breast implant in the right upper quadrant of the abdomen during liver transplantation is a technically easy resource and can protect the liver graft from kinking or rotation.

Outcome of patients with aggressive pseudomyxoma peritonei treated by cytoreductive surgery and intraperitoneal chemotherapy.

BACKGROUND: Pseudomyxoma peritonei (PMP) is a rare disease with an incidence rate of approximately 1 per million a year. During the past few years, there has been a survival benefit for these patients treated by complete cytoreduction and perioperative chemotherapy. Better survival rates were found in the adenomucinosis group than the carcinomatosis group. The purpose of our study was to analyze the outcome and the prognosis factors of only high-grade PMP. METHODS: We selected 38 patients from a prospective database of 59 with high-grade PMP from appendiceal origin who were treated by cytoreduction surgery and HIPEC at the Hospital University Reina Sofia (Cordoba, Spain) between 1998 and July 2012. Clinical, surgical, analytical, radiological, and histological data were obtained prospectively. Survival curves were calculated using the Kaplan-Meier method, a univariate analysis was performed and the log rank-test was used to analyze the effects of several clinical and pathologic factors on overall survival (OS) and disease-free survival (DFS). RESULTS: Median follow-up time was 32 months (range, 2-170). Median age at diagnosis was 57 years (range, 32-77). In 89.5 % of patients, optimal cytoreduction CC-0 (57.9 %) and CC-1 (31.6 %) was achieved. In the remaining 10.5 %, cytoreduction was classified as CC-2. The median PCI score was 21 (range, 4-38). Morbidity complications ≥ Grade 3 in the CTCAE v 3.0 classification was 18.4 %. One patient died 45 days postsurgery. Median OS at the end of follow-up was 36 months (range, 9-83); overall 5-year survival rate was 58.7 %. In the univariate analysis for OS, significant values were obtained for lymph-node involvement and suboptimal cytoreduction. The 5-year OS was 64.5 % when an optimal cytoreduction was achieved. Median DFS was 36 months (17-54); 3-year DFS rate was 49.1 %. Neoadjuvant therapy did not affect the survival of these patients; there was no difference in the 5-year OS (43 % vs. 75 %, p = 0.068). CONCLUSIONS: In aggressive PMP, cytoreduction with peritonectomy procedure plus HIPEC is a safe procedure that suggests an improvement to the survival rates. Because optimal cytoreduction is a primary prognostic factor for survival rates, this procedure would have to be performed in an experienced center with a low morbidity. Neoadjuvant chemotherapy has not demonstrated benefits in these patients and further research will be required.

Post-surgical chemotherapy versus surgery alone for resectable gastric cancer.

BACKGROUND: For gastric cancer surgery is the mainstay treatment. Chemotherapy seems to improve the survival results. But chemotherapy is not a complication-free therapy and its role has been questioned by some trials. OBJECTIVES: To determine whether post-surgical chemotherapy should be used routinely in resectable gastric cancer. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (July 2013). SELECTION CRITERIA: Randomised controlled trials (RCT) comparing post-surgical chemotherapy versus surgery alone for resectable gastric cancer. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trials for inclusion and independently extracted the data. We analysed the data with both the fixed-effect and the random-effects models using the RevMan analysis software. We calculated the hazard ratio (HR) with 95% confidence interval (CI) based on intention-to-treat or available case analysis. MAIN RESULTS: The authors identified 34 studies (7824 patients) reporting overall survival (OS) and only 15 reporting disease free survival (DFS) as well. Post-surgical chemotherapy showed an improvement in OS (HR 0.85; 95% CI 0.80 to 0.90) and an improvement in DFS (HR 0.79; 95% CI 0.72 to 0.87), although all the trials had a high risk of bias.The planned analysis of quality of life, return to work, and number of hospital admissions was impossible to complete as the outcome data for the analysis were not available from any trials. AUTHORS' CONCLUSIONS: Post-surgical chemotherapy should be used routinely for resectable gastric cancer where possible. Further RCTs are needed to determine the role at each stage of disease.

Cervical ultrasound for the evaluation of the vocal cords: A pilot study in an endocrine surgery unit.

INTRODUCTION: Cervical ultrasound (CE) has emerged as a promising tool in recent years for vocal cord (VC) assessment in patients undergoing thyroid surgery. Our aim is to assess the reliability of CE once implemented in an endocrine surgery unit and performed by the surgeons themselves. MATERIAL AND METHOD: 86 participants with no history of laryngeal pathology or cervical surgery underwent CE by three independent endocrine surgeons. Laryngeal structures and specifically the VCs were analysed. To consider the examination as diagnostic, the VCs had to be visualised statically and during phonation. The time taken to perform the technique and the interobserver variability were also analysed. RESULTS: Of the 86 participants, 51.2% were male with a mean age of 43 years. The range of diagnostic examinations between surgeons was 60-68%, with substantial agreement between the 3 explorers (Fleiss's K-value = .714). Male sex and advanced age were factors associated with non-assessability of the technique. The mean procedure time was 72 s. CONCLUSIONS: CE is a fast, non-invasive, feasible bedside tool useful for the assessment of VCs prior to thyroid surgery, mainly in young women.

Atraumatic splenic rupture secondary to appendicular perforation by cecal volvulus.

Atraumatic splenic rupture, an infrequent surgical emergency, constitutes a life-threatening situation. The lack of a traumatic background makes it difficult to suspect. We present a case of a 45-year-old woman, with history of bariatric surgery, referred to our emergency due to 3 weeks long abdominal and lumbar pain, in shock. Imaging diagnosis of splenic rupture, emergent surgery was performed with atypical findings and good evolution. The bibliographic review, background and surgical findings allowed to postulate causality in this unusual presentation. Despite its low frequency, this pathology involves significant mortality and must be present in the patient in shock in the emergency room.

La rotura esplénica atraumática, una emergencia quirúrgica infrecuente, constituye una situación de riesgo vital. La falta de antecedente traumático dificulta su sospecha. Presentamos el caso de una mujer de 45 años, con antecedente de cirugía bariátrica, remitida a nuestro servicio de urgencias por dolor abdominal y lumbar de 3 semanas, en shock. Con el diagnóstico imagenológico de rotura esplénica, se realizó cirugía emergente, con hallazgos atípicos, y la paciente tuvo una buena evolución. La revisión bibliográfica, los antecedentes y los hallazgos quirúrgicos permitieron postular la causalidad en esta inusual presentación. Pese a su poca frecuencia, esta patología comporta una mortalidad importante y debe tenerse presente ante un paciente en shock en la sala de urgencias.

Successful Outflow Reconstruction to Salvage Traumatic Hepatic Vein-Caval Avulsion of a Normothermic Machine Ex-Situ Perfused Liver Graft: Case Report and Management of Organ Pool Challenges.

Donor organ shortage continues to limit the availability of liver transplantation, a successful and established therapy of end-stage liver diseases. Strategies to mitigate graft shortage include the utilization of marginal livers and recently ex-situ normothermic machine perfusion devices. A 59-year-old woman with cirrhosis due to primary sclerosing cholangitis was offered an ex-situ machine perfused graft with unnoticed severe injury of the suprahepatic vasculature due to road traffic accident. Following a complex avulsion, repair and reconstruction of all donor hepatic veins as well as the suprahepatic inferior vena cava, the patient underwent a face-to-face piggy-back orthotopic liver transplantation and was discharged on the 11th postoperative day after an uncomplicated recovery. This report illustrates the operative technique to utilize an otherwise unusable organ, in the current environment of donor shortage and declining graft quality. Normothermic machine perfusion can definitely play a role in increasing the graft pool, without compromising the quality of livers who had vascular or other damage before being ex-situ perfused. Furthermore, it emphasizes the importance of promptly and thoroughly communicating organ injuries, as well as considering all reconstructive options within the level of expertise at the recipient center.

Pancreaticojejunostomy Versus Pancreaticogastrostomy After Pancreaticoduodenectomy: An Up-to-date Meta-Analysis.

BACKGROUND: The reconstruction of the pancreas after pancreaticoduodenectomy (PD) is a crucial factor in preventing postoperative complications as pancreatic anastomosis failure is associated with a high morbidity rate and contributes to prolonged hospitalization and mortality. Several techniques have been described for the reconstruction of pancreatic digestive continuity in the attempt to minimize the risk of a pancreatic fistula. The aim of this study was to compare the results of pancreaticogastrostomy and pancreaticojejunostomy after PD. METHODS: A systematic review and meta-analysis were conducted of randomized controlled trials (RCTs) published up to January 2015 comparing patients with pancreaticogastrostomy (PG group) versus pancreaticojejunostomy (PJ group). Two reviewers independently assessed the eligibility and quality of the studies. The meta-analysis was conducted using either the fixed-effect or the random-effect model. RESULTS: Eight RCTs describing 1,211 patients were identified for inclusion in the study. The meta-analysis shows that the PG group had a significantly lower incidence rate of postoperative pancreatic fistulas [OR 0.64 (95% confidence interval 0.46-0.86), p = .003], intra-abdominal abscesses [OR 0.53 (95% CI, 0.33-0.85), p = .009] and length of hospital stay [MD -1.62; (95% CI 2.63-0.61), p = .002] than the PJ group, while biliary fistula, mortality, morbidity, rate of delayed gastric emptying, reoperation, and bleeding did not differ between the two groups. CONCLUSION: This meta-analysis suggests that the most effective treatment for reconstruction of pancreatic continuity after pancreatoduodenectomy is pancreaticogastrostomy. However, the advantage of the latter could potentially be demonstrated through further RCTs, including only patients at high risk of developing pancreatic fistulas.

A comparative review between laparoscopic and robotic pancreaticoduodenectomies.

In pancreatic surgery, there is an increasing interest in the feasibility of minimal access techniques. Robotic surgery has improved some limitations of standard laparoscopy and it is expected as a promising access. We provide a comparative review between laparoscopic and robotic pancreaticoduodenectomies. Between 1996 and 2013, we found 284 patients in the laparoscopic group and 147 in the robotic. Operative time, morbidity, and mortality were similar for both the groups (425.94 min, 30.28%, 2.19% in the laparoscopic group and 415.88 min, 36.78%, and 2.72% for the robotic arm, respectively). The mean hospital stay, mean estimated blood loss, fistula, and conversion rates were 11.09 days, 172,93 mL, 13.02%, and 5.63% and 13.84 days, 346.44 mL, 27.69%, and 11.56% for the laparoscopic and robotic group, respectively (P<0.05). Laparoscopic pancreaticoduodenectomy may confer benefits over robotic pancreaticoduodenectomies, although it is expected that outcomes of both modalities are likely to improve with greater experience and better patient selection.

Incarcerated umbilical hernia as the debut of abdominal actinomycosis.

BACKGROUND: Abdominal actinomycosis is a rare infection with a difficult diagnosis that can simulate multiple surgical scenarios such as neoplasms or complications of inflammatory bowel disease. CLINICAL CASE: We present the case of a 69-year-old female who underwent emergency surgery due to a difficult and painful tumor, suggesting an incarcerated umbilical hernia. Whitish lesions were discovered in the abdominal wall and a stenotic colonic mass was managed similar to a neoplasm. Anatomopathological study showed abdominal actinomycosis, requiring a lengthy course with penicillin. CONCLUSION: Actinomycosis infection is a chronic disease with granulomatous lesions and areas of fibrosis. Its incidence is increasing and the location usually is cervicofacial. The great challenge of this pathology lies in the diagnosis because it simulates different diseases of diverse natures. This type of infection can be treated successfully with drugs if the etiology is identified in a timely manner. However, in the case of our patient, the manner of presentation made diagnosis more difficult prior to surgical trauma.

Ecografía cervical para la evaluación de las cuerdas vocales: estudio piloto en una unidad de cirugía endocrina / Cervical ultrasound for the evaluation of the vocal cords: A pilot study in an endocrine surgery unit

Introducción: La ecografía cervical (EC) ha surgido como una herramienta prometedora en los últimos años para la evaluación de las cuerdas vocales (CV) en pacientes sometidos a cirugía de tiroides. Nuestro objetivo es valorar la fiabilidad de la EC una vez implementada en una unidad de cirugía endocrina y realizada por los propios cirujanos. Método: Se incluyeron 86 participantes sin antecedentes de enfermedad laríngea ni cirugía cervical a los que se les realizó una EC por parte de 3 cirujanos endocrinos independientes. Se analizaron las estructuras laríngeas y específicamente las CV. Para considerar la exploración como diagnóstica debían visualizarse las CV de manera estática y durante la fonación. También se analizó el tiempo de realización de la técnica y la variabilidad interobservador. Resultados: De los 86 participantes el 51,2% fueron varones y la edad media fue de 43 años. El rango de exploraciones diagnósticas entre los cirujanos fue de 60-68%, con una concordancia sustancial entre los 3 exploradores (valor K de Fleiss's=0,714). El sexo masculino y la edad avanzada fueron factores asociados a la no evaluabilidad de la técnica. El tiempo medio del procedimiento fue de 72segundos. Conclusión: La EC es una herramienta rápida, no invasiva, viable a pie de cama y útil para la evaluar las CV antes de la cirugía tiroidea, principalmente en mujeres jóvenes. (AU)

Introduction: Cervical ultrasound (CE) has emerged as a promising tool in recent years for vocal cord (VC) assessment in patients undergoing thyroid surgery. Our aim is to assess the reliability of CE once implemented in an endocrine surgery unit and performed by the surgeons themselves. Method: 86 participants with no history of laryngeal pathology or cervical surgery underwent CE by three independent endocrine surgeons. Laryngeal structures and specifically the VCs were analysed. To consider the examination as diagnostic, the VCs had to be visualised statically and during phonation. The time taken to perform the technique and the interobserver variability were also analysed.Results: Of the 86 participants, 51.2% were male with a mean age of 43 years. The range of diagnostic examinations between surgeons was 60-68%, with substantial agreement between the 3 explorers (Fleiss's K-value=.714). Male sex and advanced age were factors associated with non-assessability of the technique. The mean procedure time was 72s. Conclusion: CE is a fast, non-invasive, feasible bedside tool useful for the assessment of VCs prior to thyroid surgery, mainly in young women. (AU)