Early Return to Intended Oncologic Therapy after implementation of an Enhanced Recovery After Surgery pathway for gastric cancer surgery.

PURPOSE: Time to initiation and completion of adjuvant therapy are critical to improve postoperative oncologic outcomes. This study aims to determine whether an Enhanced Recovery After Surgery (ERAS) pathway for gastric cancer surgery promotes early Return to Intended Oncologic Therapy (RIOT). METHODS: This is a before-after intervention study including patients with gastric adenocarcinoma who underwent surgery from January 2016 to January 2021. Two periods were denoted based upon the implementation date of our institutional ERAS pathway (June 2018). Our primary outcome was time to RIOT after surgery. Hodges-Lehmann analysis was used to estimate median differences of non-parametric outcomes. RESULTS: Seventy patients with gastric adenocarcinoma were included (35 in pre-ERAS period and 35 in post-ERAS period). Fourteen of the pre-ERAS and twenty-two patients of the post-ERAS period received adjuvant therapy. Time to RIOT was reduced in the post-ERAS period (median 39 days, IQR 31-49) by 12 days (95% CI 3-14 days, p = 0.01) compared to the pre-ERAS period (median 51 days, IQR 42-62). Length of hospital stay (LOS) was lower in the ERAS group (6 days, IQR 5-11 vs 10 days, IQR 8-13, p < 0.01). CONCLUSION: Our institutional ERAS pathway for gastric cancer surgery was associated with earlier RIOT and shorter LOS.

Cystic duct cyst lesions (type VI).

Todani proposed the most accepted classification for cystic lesions of the bile duct, including 5 types. Serena described another one, type VI, which includes cystic lesions of the isolated cystic duct, of which there are less than twenty reported cases. They differ from type II in terms of the distal cystic caliber, which is normal in type VI, and in the diagnosis which is performed intra-operatively in most of the cases. Neoplastic degeneration has an incidence of 10 to 30% in all these lesions, which is the reason why the most widely accepted treatment is cholecystectomy with resection of the cystic duct cyst dilatation and preservation of the main bile duct by a laparoscopic approach.

Association between use of enhanced recovery after surgery protocols and postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study.

INTRODUCTION: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. METHODS: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). RESULTS: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. CONCLUSIONS: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03865810.

Teleconsultation in General Surgery during COVID-19 pandemic, satisfaction survey and feasibility for future.

BACKGROUND: The COVID-19 pandemic has made us to respond to the needs of the community. Telemedicine has gained worldwide acceptance. We describe our experience with teleconsultation in surgical patients during the first wave of the COVID-19 pandemic and evaluate patient satisfaction and the feasibility of maintaining it as a future strategy in selected patients. METHODS: An observational, retrospective, single-site cohort study was carried out by reviewing electronic medical records and conducting a telephone survey. RESULTS: During this time, 1706 teleconsultations have been carried out: 59.5% of patients were rescheduled, 26.1% have been solved and of these 57.3% (255 patients) have been discharged; 12.19% were not contacted. The 73.6% considered that teleconsultation was able to fully or partially resolve the reason for their medical appointment; 61.6% were willing to continue with teleconsultation; 15.2% of the patients needed some kind of help or required a second call to speak with a family member, and 37.2% would prefer a face-to-face visit because of difficulties with the teleconsultation. The overall satisfaction was 8.7 out of 10. CONCLUSIONS: Telemedicine has demonstrated to be a useful tool even for surgical patients during COVID-19 pandemic. A high proportion of patients can be managed by telephone call. Patients reported a high degree of satisfaction. Teleconsultation is a feasible strategy not also during the current COVID-19 pandemic but also for future.

Primary Pure Pancreatic -Type Acinar Cell Carcinoma of the Stomach: A Rare Entity with a Difficult Diagnosis and Review of the Literature.

Acinar cell carcinoma is an uncommon tumour, representing only 1% to 2% of all exocrine pancreatic tumours. Pancreatic-type acinar cell carcinoma can occur in other organs, including the stomach, but it is extraordinarily rare. We report a case of a 51-year-old woman with a pancreatic-type pure acinar carcinoma of the stomach coexisting with a large cell B lymphoma synchronously, and a literature review of gastric carcinomas with pancreatic cell differentiation. At present there is a preoperative underdiagnosis of these tumours that could be minimized by including this entity in the differential diagnosis of gastric cancer and by performing immunohistochemical analysis with neuroendocrine markers and exocrine pancreatic enzymes.

Laparoscopic Diagnosis of Peritoneal Tuberculosis.

Peritoneal tuberculosis is a rare form of tuberculosis, which involves parietal and visceral peritoneum, omentum, and intestinal mesentery. Its incidence is increasing in developed countries due to HIV infection and immigration. We present a case of peritoneal tuberculosis in a twenty two-year-old patient misdiagnosed with appendicitis. A laparoscopic surgery was performed showing multiple implants on serosal surfaces and adhesions. Laparoscopic appendectomy and peritoneal biopsies were performed. As peritoneal tuberculosis was suspected, an early antituberculous treatment was initiated. A pathological examination of the samples revealed epithelioid granulomas with a centrale caseous necrosis and acid-fast bacilli. Peritoneal tuberculosis is a challenging diagnosis that can mimic other pathologies and should be kept in mind to establish an early antituberculosis treatment avoiding the high morbidity and mortality associated with a late treatment initiation. In case of suspicion of peritoneal tuberculosis, laparoscopy with guided biopsies is useful for the establishment of a correct diagnosis.

Primary thyroid tuberculosis: a case report.

Involvement of the thyroid gland by tuberculosis is very rare and is usually secondary to disseminated infection. Very few cases of primary thyroid tuberculosis have been described even in countries with a high incidence of this disease. We present the case of a Spanish patient operated for a suspicious thyroid nodule that was finally diagnosed as primary thyroid tuberculosis.

La afectación de la glándula tiroidea por tuberculosis es muy rara y generalmente es secundaria a una enfermedad ­diseminada. Se han descrito muy pocos casos de tuberculosis tiroidea primaria incluso en paises con alta incidencia de esta enfermedad. Presentamos el caso de una paciente española operada por un nódulo tiroideo sospechoso que fue finalmente diagnosticado como tuberculosis tiroidea primaria.

Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain.

INTRODUCTION: Introduction: a survey on peri-operative nutritional support in pancreatic and biliary surgery among Spanish hospitals in 2007 showed that few surgical groups followed the 2006 ESPEN guidelines. Ten years later we sent a questionnaire to check the current situation. Methods: a questionnaire with 21 items sent to 38 centers, related to fasting time before and after surgery, nutritional screening use and type, time and type of peri-operative nutritional support, and number of procedures. Results: thirty-four institutions responded. The median number of pancreatic resections (head/total) was 29.5 (95% CI: 23.0-35; range, 5-68) (total, 1002); of surgeries for biliary malignancies (non-pancreatic), 9.8 (95% CI: 7.3-12.4; range, 2-30); and of main biliary resections for benign conditions, 10.4 (95% CI: 7.6-13.3; range, 2-33). Before surgery, only 41.2% of the sites used nutritional support (< 50% used any nutritional screening procedure). The mean duration of preoperative fasting for solid foods was 9.3 h (range, 6-24 h); it was 6.6 h for liquids (range, 2-12). Following pancreatic surgery, 29.4% tried to use early oral feeding, but 88.2% of the surveyed teams used some nutritional support; 26.5% of respondents used TPN in 100% of cases. Different percentages of TPN and EN were used in the other centers. In malignant biliary surgery, 22.6% used TPN always, and EN in 19.3% of cases. Conclusions: TPN is the commonest nutrition approach after pancreatic head surgery. Only 29.4% of the units used early oral feeding, and 32.3% used EN; 22.6% used TPN regularly after surgery for malignant biliary tumours. The 2006 ESPEN guideline recommendations are not regularly followed 12 years after their publication in our country.

INTRODUCCIÓN: Introducción: realizamos una encuesta sobre soporte nutricional perioperatorio en cirugía pancreática y biliar en hospitales españoles en 2007, que mostró que pocos grupos quirúrgicos seguían las guías de ESPEN 2006. Diez años después enviamos un cuestionario para comprobar la situación actual. Métodos: treinta y ocho centros recibieron un cuestionario con 21 preguntas sobre tiempo de ayunas antes y después de la cirugía, cribado nutricional, duración y tipo de soporte nutricional perioperatorio, y número de procedimientos. Resultados: respondieron 34 grupos. La mediana de pancreatectomías (cabeza/total) fue de 29,5 (IC 95%: 23,0-35; rango, 5-68) (total, 1002), la de cirugías biliares malignas de 9,8 (IC 95%: 7,3-12,4; rango, 2-30) y la de resecciones biliares por patología benigna de 10,4 (IC 95%: 7,6-13,3; rango, 2-33). Solo el 41,2% de los grupos utilizaban soporte nutricional antes de la cirugía (< 50% habian efectuado un cribado nutricional). El tiempo medio de ayuno preoperatorio para sólidos fue de 9,3 h (rango, 6-24 h), y de 6,6 h para líquidos (rango, 2-12). Tras la pancreatectomía, el 29,4% habían intentado administrar una dieta oral precoz, pero el 88,2% de los grupos usaron algún tipo de soporte nutricional y el 26,5% usaron NP en el 100% de los casos. Los demás grupos usaron diferentes porcentajes de NP y NE en sus casos. En la cirugía biliar maligna, el 22,6% utilizaron NP siempre y NE en el 19,3% de los casos. Conclusiones: la NP es el soporte nutricional más utilizado tras la cirugía de cabeza pancreática. Solo el 29,4% de las unidades usan nutrición oral precoz y el 32,3% emplean la NE tras este tipo de cirugía. El 22,6% de las instituciones usan NP habitualmente tras la cirugía de tumores biliares malignos. Las guías ESPEN 2006 no se siguen de forma habitual en nuestro país tras más de 10 años desde su publicación.

Hartmann's procedure for obstructive carcinoma of the left colon and rectum: a comparative study with one-stage surgery.

INTRODUCTION AND OBJECTIVES: Despite the criticisms from prestigious expert committees, a high percentage of surgeons continue to use, as the technique-of-choice, Hartmann's procedure for acute malignant intestinal obstruction of the distal colon and rectum, without faecal peritonitis. We have reviewed our results with this technique and compared them with other series of patients in the literature undergoing one-stage surgery (resection with primary anastomosis or sub-total colectomy). MATERIAL AND METHODS: A retrospective and descriptive study using clinical histories and, from which, the variables studied were: median hospitalisation stay, morbido-mortality and reconstruction index. RESULTS: Included in the analysis were 44 patients (24 male; 20 female) with an age range between 37 and 87 years (median age: 67.04 years). The median hospitalisation stay was 15.59 days (range: 8-39). In the 10 patients undergoing reconstruction this was 12.8 days (range: 10-17). The overall stay, therefore, was 28.39 days. The median stay in the series of patients having one-stage surgery was 13.9 days. The morbidity using Hartmann's procedure was 43.18% (19/44) and, in the patients with reconstruction, 40% (4/10). The morbidity in the literature series with one-stage surgery was 22.53%. Mortality in our study was 0%. The mortality in the 16 cases from the literature was close to 5%, although in 3 of the studies this was also 0%. The percentage undergoing reconstruction was 22.72% (10 cases). The median age in the non-reconstructed patients was 71.42 years (range: 46-87) compared to a median age of 52.6 (range 37-67) in the group with reconstruction (p < 0.001). The percentages undergoing reconstruction, according to tumour stage, were Dukes B: 36.84%; Dukes C: 23.07%; Dukes D: 0% (p < 0.001). The median waiting-time for a reconstruction was 15.73 months (range: 8-33). CONCLUSIONS: Comparisons of our results with the outcomes in the series of patients in the literature with one-stage surgery indicate that "one-stage surgery" is the more suitable but, however, with two conditions: a sufficient command of the technique so as to minimise complications and a strict patient selection, with the Hartmann's procedure being retained for patients with high anaesthesia risk.

Carcinoma verrucoso esofágico: una rara entidad de difícil diagnóstico / Verrucous carcinoma of the esophagus: A rare entity with a difficult diagnosis

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Association between use of enhanced recovery after surgery protocols and postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study / Asociación entre el uso de protocolos de recuperación intensificada y complicaciones postoperatorias tras cirugía gástrica por cáncer (POWER 4): estudio nacional, prospective multicéntrico

Introduction: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. Methods: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). Results: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. Conclusions: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. (AU)

Introducción: La efectividad de los protocolos de recuperación intensificada o ERAS en la cirugía del cáncer gástrico sigue siendo controvertida. Métodos: Estudio de cohortes prospectivo multicéntrico de pacientes intervenidos de cáncer gástrico. Se evaluó la adherencia a 22 elementos ERAS en todos los pacientes, independientemente de la existencia de un protocolo ERAS. Cada centro tuvo un período de reclutamiento de tres meses, con un seguimiento de 30 días. La medida de resultado primario fue el numero de complicaciones posoperatorias moderadas a graves. Las medidas de resultado secundarias fueron el número total de complicaciones, la adherencia a los elementos ERAS, la mortalidad y la estancia. Resultados: Se incluyeron 743 pacientes en 72 hospitales, 211 (28,4 %) en centros ERAS. 245 pacientes (33 %) experimentaron complicaciones posoperatorias, moderadas o graves en 172 (23,1 %). No hubo diferencias en la incidencia de complicaciones moderadas a graves (22,3 % vs. 23,5 %; OR, 0,92 (IC 95 %, 0,59 a 1,41); P = 0,068), o complicaciones posoperatorias totales entre los centros ERAS y no ERAS (33,6 % vs. 32,7 %; OR, 1,05 (IC 95 %, 0,70 a 1,56); P = 0,825). La adherencia a los elementos ERAS fue del 52% [IQR 45 a 60]. No hubo diferencias entre los cuartiles de cumplimiento ERAS más alto (Q1, > 60 %) y más bajo (Q4, ≤ 45 %). Conclusiones: Ni la aplicación parcial de medidas ERAS ni el tratamiento en centros ERAS mejoraron los resultados en pacientes sometidos a cirugía gástrica por cáncer. (AU)

Lesiones quísticas del conducto cístico (lesiones tipo VI) / Cystic duct cyst lesions (type VI)

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Quiste de duplicación gástrica de epitelio respiratorio: una lesión infrecuente de difícil diagnóstico diferencial / Gastric duplication cyst with respiratory epithelium: An uncommon injury that has a difficult diferential diagnosis

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Hartmann's procedure for obstructive carcinoma of the left colon and rectum: a comparative study with one-stage surgery

Introducción y objetivos. Un número elevado de cirujanos continúa empleando como técnica de elección la intervención de Hartmann en la obstrucción intestinal aguda maligna de colon distal al ángulo esplénico, sin peritonitis fecaloidea, a pesar de las críticas desde las unidades coloproctológicas de prestigio. Nos proponemos revisar nuestros resultados con esta técnica y compararlos con los de otras series con cirugía en un tiempo (resección y anastomosis primaria y colectomía subtotal). Material y métodos. Estudio retrospectivo y descriptivo sobre historias clínicas. Las variables estudiadas son: estancia media, morbimortalidad e índice de reconstrucción. Resultados. Cuarenta y cuatro pacientes (24 hombres y 20 mujeres) forman parte del estudio, con edades comprendidas entre 37 y 87 años (media 67,04). La estancia media hospitalaria fue de 15,59 días (rango: 8-39). En los 10 pacientes reconstruidos la estancia fue 12,8 (rango: 10-17). La estancia acumulada, por tanto, fue 28,39 días. La estancia media de las series consultadas con cirugía en un tiempo es de 13,9 días. El porcentaje de complicaciones en la operación de Hartmann fue del 43,18% (19/44) y en la reconstrucción siguiente del tránsito fue del 40% (4/10). La morbilidad media de las series consultadas en un tiempo es del 22,53% La mortalidad global de nuestra serie fue del 0%. La mortalidad media de las 16 series consultadas es ligeramente superior al 4%, aunque en 3 de ellas fue también del 0%. El porcentaje de reconstrucción fue del 22,72% (10 casos). La media de edad en los pacientes no reconstruidos fue 71,42 años (rango: 46-87), frente a 52,6 (rango: 37-67) en el grupo de los reconstruidos (p < 0,001). El porcentaje de reconstrucción según el estadio tumoral fue: estadio B el 36,84%, C el 23,07% y D el 0% (p < 0,001). El tiempo medio de espera antes de la reconstrucción fue 15,73 meses (rango: 8-33). Conclusiones. El análisis comparativo de nuestros resultados con los propios de las series de cirugía en un tiempo nos invita a aconsejar esta última como la más idónea, aunque siempre bajo dos condiciones: un dominio de su técnica, para minimizar complicaciones, y una rígida selección de los pacientes, procurando la técnica de Hartmann para los más deteriorados

Introduction and objectives. Despite the criticisms from prestigious expert committees, a high percentage of surgeons continue to use, as the technique-of-choice, Hartmann's procedure for acute malignant intestinal obstruction of the distal colon and rectum, without faecal peritonitis. We have reviewed our results with this technique and compared them with other series of patients in the literature undergoing one-stage surgery (resection with primary anastomosis or sub-total colectomy). Material and methods. A retrospective and descriptive study using clinical histories and, from which, the variables studied were: median hospitalisation stay, morbido-mortality and reconstruction index. Results. Included in the analysis were 44 patients (24 male; 20 female) with an age range between 37 and 87 years (median age: 67.04 years). The median hospitalisation stay was 15.59 days (range: 8-39). In the 10 patients undergoing reconstruction this was 12.8 days (range: 10-17). The overall stay, therefore, was 28.39 days. The median stay in the series of patients having one-stage surgery was 13.9 days. The morbidity using Hartmann's procedure was 43.18% (19/44) and, in the patients with reconstruction, 40% (4/10). The morbidity in the literature series with one-stage surgery was 22.53%. Mortality in our study was 0%. The mortality in the 16 cases from the literature was close to 5%, although in 3 of the studies this was also 0%. The percentage undergoing reconstruction was 22.72% (10 cases). The median age in the non-reconstructed patients was 71.42 years (range: 46-87) compared to a median age of 52.6 (range 37-67) in the group with reconstruction (p < 0.001). The percentages undergoing reconstruction, according to tumour stage, were Dukes B: 36.84%; Dukes C: 23.07%; Dukes D: 0% (p < 0.001). The median waiting-time for a reconstruction was 15.73 months (range: 8-33). Conclusions. Comparisons of our results with the outcomes in the series of patients in the literature with one-stage surgery indicate that "one-stage surgery" is the more suitable but, however, with two conditions: a sufficient command of the technique so as to minimise complications and a strict patient selection, with the Hartmann's procedure being retained for patients with high anaesthesia risk