The Cost of Postoperative Complications and Economic Validation of the Comprehensive Complication Index: Prospective Study.

OBJECTIVE: To validate the Comprehensive Complication Index (CCI) via an assessment of its relation to postoperative costs. BACKGROUND: The CCI summarizes all the postoperative complications graded by the Clavien-Dindo classification (CDC) on a numerical scale. Its relation to hospital costs has not been validated to date. METHODS: Prospective observational cohort study, including all patients undergoing surgery at a general surgery service during the 1-year study period. All complications graded with the CDC and CCI and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. The surgeries were classified according to their Operative Severity Score (OSS) and in 4 groups of homogeneous surgeries. All postoperative costs were recorded. RESULTS: In all, 1850 patients were included, of whom 513 presented complications (27.7%). The CDC and the CCI were moderately to strongly correlated with overall postoperative costs (OPCs) in all OSS groups (rs = 0.444-0.810 vs 0.445-0.820; P < 0.001), homogeneous surgeries (rs = 0.364-0.802 vs 0.364-0.813; P < 0.001), prolongation of postoperative stay (rs = 0.802 vs 0.830; P < 0.001), and initial operating room costs (rs = 0.448 vs 0.451; P < 0.001). This correlation was higher in emergency surgery. With higher CDC grades, the OPC tended to increase an upward trend. In the multivariate analysis, CDC, CCI, age, and duration of surgery were all associated with OPC (P < 0.001). CONCLUSIONS: In our environment, the CCI presented associations with OPC. This demonstration of its economic validity enhances its clinical validity.

Radical surgery in hepatic hydatidosis: analysis of results in an endemic area.

INTRODUCTION: radical surgery in hepatic hydatidosis is associated with less morbidity and recurrence than conservative surgery. MATERIAL AND METHODS: a retrospective observational study of patients with liver hydatid cyst surgery was performed. Seventy-one patients with 90 cysts were included between 2007 and 2017, and radical surgery was performed in 69.01 %. RESULTS: there was no difference in morbidity, mortality, biliary leakage or recurrence according to surgery. Complicated cysts were associated with a longer hospital stay and morbidity. CONCLUSION: decision-making should consider age, comorbidity, cyst characteristics and available resources. Radical surgery should be applied whenever feasible as it achieves better results with an adequate selection of patients.

Inguinal abscess as presentation of a right colon cancer. A systematic review.

Perforation in colorectal cancer is an uncommon condition, and neoplastic invasion of the abdominal wall with local infection is even rarer. Our objective is to present the case of an 84-year-old male with right colon cancer that manifested as an inguinal abscess, and also to perform a systematic review of the literature in PubMed, EMBASE, and Web of Science. A total of 59 cases in retrospective studies were found. Median age was 64 years, thirty cases were men and twenty-nine were women (51% and 49%, respectively). The most common location was the right colon with 27 cases (46%), followed by the left colon with 18 cases (31%), 12 cases in the transverse colon (20%), and 2 cases with colonic synchronous neoplasm (3%). Surgery was performed in two or more occasions for 33 cases (60%), and on one occasion for 21 cases (38%); medical treatment alone was administered in one case (2%). The most common histological type was adenocarcinoma (64%), followed by its mucinous variant (22%). There was recurrence in 33% of cases. Mortality at follow-up was 47%. As a limitation of our study, follow-up was heterogeneous, making it impossible to interpret long-term results regarding the influence of treatment on patient survival, also difficulted by the urgent nature of the condition and its exceptional incidence. Further studies are needed with prospective data collection on the management of colorectal cancer in the emergency setting, standardizing follow-up in order to facilitate an adequate analysis of the prognosis of the disease.

Influence of sarcopenia in major pancreatic surgery. A systematic review of the literature.

Post-operative morbidity of pancreatectomies occurs in up to 40-50% of patients, even in modern series. There is a need to find a simple scale in order to identify patients with increased risk of developing major post-operative complications after pancreatic resections. Many studies have been published on sarcopenia and surgical outcomes. Aspects of sarcopenia are presented, along with a systematic review using PRISMA guidelines, in order to search for articles about sarcopenia and pancreatic surgery. The impact of sarcopenia on morbidity and mortality in pancreatic resections is still unclear. The studies presented have been carried out over long periods of time, and many of them compare patients with different diseases. There are also different definitions of sarcopenia, and this can influence the results, as some of the reviewed articles have already shown. It is necessary to unify criteria, both in the definition and in the cut-off values. Prospective studies and consensus on sarcopenia diagnosis should be achieved.

Readmission rates after laparoscopic cholecystectomy: are they affected by ERCP prior to surgery?

AIM: the aim of this study was to assess the reasons for and the time of hospital readmissions after cholecystectomy, according to whether an endoscopic retrograde cholangiopancreatography (ERCP) was performed. METHOD: all patients that underwent cholecystectomy at the Service of Digestive Diseases and General Surgery of the Hospital Universitario de Guadalajara between January 2011 and December 2016 were retrospectively reviewed. Patients who underwent cholecystectomy and were readmitted to any hospital service within 90 days of surgery were included. The following cases were excluded: patients that underwent cholecystectomy in combination with other procedures, an active oncological pathology at the time of cholecystectomy, admissions previously scheduled for another unrelated pathology and those with tumor histology in the cholecystectomy specimen. RESULTS: of a total of 1,714 patients, 80 were readmitted within 90 days of discharge after cholecystectomy, which equates to a readmission rate of 4.6%. The performance of an ERCP prior to surgery was associated with an increase in postoperative morbidity (40% vs 21.54%). A prior ERCP reduced the rate of biliary complications during the 90 days after cholecystectomy. Furthermore, there was an increase in the number of days prior to readmission in these cases, with a mean period of 22 days with ERCP vs seven days without ERCP. CONCLUSION: patients in our series who required an ERCP prior to cholecystectomy had a greater postoperative morbidity. However, those that did not require ERCP had more biliary complications and were readmitted earlier.

Clinical Validation of the Comprehensive Complication Index as a Measure of Postoperative Morbidity at a Surgical Department: A Prospective Study.

OBJECTIVE: Using clinical outcomes, to validate the comprehensive complication index (CCI) as a measure of postoperative morbidity in all patients undergoing surgery at a general surgery department. BACKGROUND: The Clavien-Dindo classification (CDC) is the most widely used system to assess postoperative morbidity. The CCI is a numerical scale based on the CDC. Once validated, it could be used universally to establish and compare the real postoperative complications of each surgical procedure. METHODS: Observational prospective cohort study. All patients who underwent surgery during the 1-year study period were included. All the complications graded with the CDC and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. Surgical procedures were classified according to the operative severity score (OSS) as minor, moderate, major, or major+. The clinical validation of the CCI was performed by assessing its correlation with 4 different clinical outcomes. RESULTS: A total of 1850 patients were included: 513 (27.7%) presented complications and 101 (5.46%) were readmitted. In the multivariate analysis, the CCI and CDC were associated with postoperative stay, prolongation of postoperative stay, readmission, and disability in all OSS groups (P < 0.001). The CCI was superior to the CDC in all models except for prolongation of stay for OSS moderate and major+. CONCLUSIONS: The CCI can be applied in all the procedures carried out at general surgery departments. It is able to determine the morbidity and allows the comparison of the outcomes at different services.

Elevated parathyroid hormone levels after successful parathyroidectomy for primary hyperparathyroidism: a clinical review.

INTRODUCTION: Surgery for primary hyperparathyroidism (PHPT) is traditionally deemed to be successful if serum calcium levels return to normal 6 months after parathyroidectomy. Regular monitoring of serum calcium and parathyroid hormone (PTH) in the follow-up of patients after parathyroidectomy for PHPT has drawn attention to the presence of a normocalcemic group of patients with elevated PTH (NCePTH) during the post-operative period. The etiological factors and mechanisms underlying this condition, its consequences, and the possibility of treatment are the object of this study. MATERIALS AND METHODS: We conducted an unlimited PubMed search updated on March 31, 2017, which yielded 1628 results. We selected 37 articles, 33 of which included cases of NCePTH in their series and 23 performed statistical studies to assess factors associated with NCePTH. RESULTS: The maximum mean prevalence of NCePTH in the various series was 23.5%, ranging from 3 to 46%. Many factors were associated with NCePTH. The most important were higher pre-operative PTH, low pre-operative 25 (OH) D3, lower pre-operative creatinine clearance and greater adenoma weight. The origin of NCePTH may be multifactorial, since several factors were implicated in the etiology. NCePTH does not seem to be related to an increase in PHPT recurrence, although this possibility should not be dismissed. Vitamin D deficiency should be corrected. Treatment with calcium supplements seems to be clearly beneficial. CONCLUSION: The prevalence of NCePTH is high. The causes of secondary hyperparathyroidism should be investigated carefully. Patients require treatment and long-term follow-up.

An intrahepatic cavoportal collateral pathway due to a liver hydatid cyst obstructing the inferior vena cava.

Congenital or acquired obstruction of the inferior vena cava may lead to the development of collateral pathways with tributary vein to portal system. We present a patient with intrahepatic cavoportal collateral pathway due to hepatic hydatid cyst.

[Complicated jejunoileal diverticular disease: a 12 cases' serie and literature review]. / Enfermedad diverticular yeyuno-ileal complicada tratada quirúrgicamente: serie de 12 casos y revisión de literatura.

OBJECTIVE: To perform a retrospective analysis of a series of complicated JID (jejunoileal diverticulitis) cases surgically treated in our service during the period from 2002 to 2015. MATERIALS AND METHODS: We treated 12 cases of jejunoileal complicated diverticulosis. 7 women and 5 men. The mean age was 76 years. The clinical presentation in all cases was acute abdominal pain, one with gastrointestinal bleeding. All cases had leukocytosis, neutrophilia and increased acute phase reactants. All patients underwent emergency abdominal CT. RESULTS: In 11 cases, there was consistency between imaging studies and surgical findings. Diverticula were located: jejunum (9) and ileum (3). Urgent exploratory laparotomy was always done and findings were: diverticular perforation with peritonitis (7 cases), diverticular perforation with abscess (4 cases) and in one case an ischemic area with diverticular perforation after embolization. Intestinal resection and anastomosis was performed in all cases. There were no patients, in which the diagnosis of diverticulosis jejunoileal was previously known. Complications were: Clavien I (2), Clavien IIIa (1), Clavien IVb (1), Clavien V (1). CONCLUSIONS: Jejunoileal diverticulitis is a rare entity, usually the first sign of onset of diverticular disease not previously known. Abdominal CT is of great diagnostic value. Resection of the affected segment is the treatment of choice.

Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey.

BACKGROUND: The methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown. The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. METHODS: Using a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. RESULTS: The survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population. Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients' discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. CONCLUSIONS: This study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.

Comparison and combination of three data sources from patient medical records to determine optimal quantification of postoperative morbidity according to the Clavien Dindo Classification and the Comprehensive Complication Index. A prospective study.

INTRODUCTION: It is currently unknown which data sources from the clinical history, or combination thereof, should be evaluated to achieve the most complete calculation of postoperative complications (PC). The objectives of this study were: to analyze the morbidity and mortality of 200 consecutive patients undergoing major surgery, to determine which data sources or combination collect the maximum morbidity, and to determine the accuracy of the morbidity reflected in the discharge report. METHODS: Observational and prospective cohort study. The sum of all PC found in the combined review of medical notes, nursing notes, and a specific form was considered the gold standard. PC were classified according to the Clavien Dindo Classification and the Comprehensive Complication Index (CCI). RESULTS: The percentage of patients who presented PC according to the gold standard, medical notes, nursing notes and form were: 43.5%, 37.5%, 35% and 18.7% respectively. The combination of sources improved CCI agreement by 8%-40% in the overall series and 39.1-89.7 % in patients with PC. The correct recording of PC was inversely proportional to the complexity of the surgery, and the combination of sources increased the degree of agreement with the gold standard by 35 %-67.5% in operations of greater complexity. The CDC and CCI of the discharge report coincided with the gold-standard values in patients with PC by 46.8% and 18.2%, respectively. CONCLUSIONS: The combination of data sources, particularly medical and nursing notes, considerably increases the quantification of PC in general, most notably in complex interventions.

Quality-adjusted life years and surgical waiting list: Systematic review of the literature.

BACKGROUND: The quality-adjusted life year (QALY) is a metric that is increasingly used today in the field of health economics to evaluate the value of different medical treatments and procedures. Surgical waiting lists (SWLs) represent a pressing problem in public healthcare. The QALY measure has rarely been used in the context of surgery. It would be interesting to know how many QALYs are lost by patients on SWLs. AIM: To investigate the relationship between QALYs and SWLs in a systematic review of the scientific literature. METHODS: The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. An unlimited search was carried out in PubMed, updated on January 19, 2024. Data on the following variables were investigated and analyzed: Specialty, country of study, procedure under study, scale used to measure QALYs, the use of a theoretical or real-life model, objectives of the study and items measured, the economic value assigned to the QALY in the country in question, and the results and conclusions published. RESULTS: Forty-eight articles were selected for the study. No data were found regarding QALYs lost on SWLs. The specialties in which QALYs were studied the most in relation to the waiting list were urology and general surgery, with 15 articles each. The country in which the most studies of QALYs were carried out was the United States (n = 21), followed by the United Kingdom (n = 9) and Canada (n = 7). The most studied procedure was organ transplantation (n = 39), including 15 kidney, 14 liver, 5 heart, 4 lung, and 1 intestinal. Arthroplasty (n = 4), cataract surgery (n = 2), bariatric surgery (n = 1), mosaicplasty (n = 1), and septoplasty (n = 1) completed the surgical interventions included. Thirty-nine of the models used were theoretical (the most frequently applied being the Markov model, n = 34), and nine were real-life. The survey used to measure quality of life in 11 articles was the European Quality of Life-5 dimensions, but in 32 articles the survey was not specified. The willingness-to-pay per QALY gained ranged from $100000 in the United States to €20000 in Spain. CONCLUSION: The relationship between QALYs and SWLs has only rarely been studied in the literature. The rate of QALYs lost on SWLs has not been determined. Future research is warranted to address this issue.

Surgery of Colorectal Liver Metastases Involving the Inferior Vena Cava: A Systematic Review.

Combined hepatic and inferior vena cava (IVC) resection is the only potentially curative treatment for patients with colorectal liver metastases (CRLM) involving the IVC. Most of the existing data come from case reports or small case series. In this paper, a systematic review based on the PICO strategy was performed in accordance with the PRISMA statement. Papers from January 1980 to December 2022 were searched in Embase, PubMed, and the Cochrane Library databases. Articles considered for inclusion had to present data on simultaneous liver and IVC resection for CRLM and report surgical and/or oncological outcomes. From a total of 1175 articles retrieved, 29, including a total of 188 patients, met the inclusion criteria. The mean age was 58.3 ± 10.8 years. The most frequent techniques used were right hepatectomy ± caudate lobe for hepatic resections (37.8%), lateral clamping (44.8%) for vascular control, and primary closure (56.8%) for IVC repair. The thirty-day mortality reached 4.6%. Tumour relapse was reported in 65.8% of the cases. The median overall survival (OS) was 34 months (with a confidence interval of 30-40 months), and the 1-year, 3-year, and 5-year OS were 71.4%, 19.8%, and 7.1%, respectively. In the absence of prospective randomized studies, which are difficult to perform, IVC resection seems to be safe and feasible.