Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters.

INTRODUCTION AND AIMS: The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes. MATERIALS AND METHODS: A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion. RESULTS: The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%. CONCLUSIONS: Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

Usefulness of inflammatory markers in detecting esophagojejunostomy leakage.

INTRODUCTION AND AIM: Total gastrectomy is utilized in different pathologies. Esophagojejunostomy leakage is a frequent complication. Our aim was to determine the association of the neutrophil-lymphocyte ratio (NLR) with esophagojejunostomy leakage that subsequently required invasive treatment. MATERIALS AND METHODS: A retrospective study included patients that underwent esophagojejunostomy within the time frame of 2002-2017. Patients were grouped into those with or without anastomotic leakage that had conservative treatment (group A) and those with anastomotic leakage that had invasive treatment (group B). ROC curves and the Youden index were used for the optimum cutoff values of the NLR. RESULTS: Fifty-seven patients were included. Thirty-two (56.14%) were men, and mean patient age was 61.8 ± 13.4 years. Forty-five patients were assigned to group A and 12 to group B. Mean NLR was higher for group B on postoperative day 3 (group A 9.5 ± 7.5 vs. group B 13.9 ± 4.9) (p = 0.05). Mean total leukocytes was higher in group B on postoperative day 5 (group A 7.8 ± 3.4 × 103/mcl vs. group B 10.3 ± 4.4 × 103/mcl) (p = 0.03). NLR and total leukocyte accuracy on postoperative day 3 was calculated with ROC curves, at 0.78 and 0.63, respectively. For the NLR and leukocyte count, sensitivity was 91.7% and 58%, specificity was 64.4% and 60%, positive predictive value was 40% and 28%, and negative predictive value was 96% and 84%, respectively. CONCLUSIONS: Postoperatively, the NLR identified the total gastrectomy with esophagojejunostomy patients that subsequently required an invasive procedure secondary to esophagojejunostomy leakage.

Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters. / Conversión de colecistectomía laparoscópica a abierta: análisis de factores de riesgo con base en parámetros clínicos, de laboratorio y de ultrasonido.

INTRODUCTION AND AIMS: The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes. MATERIALS AND METHODS: A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion. RESULTS: The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%. CONCLUSIONS: Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

Percutaneous cholecystostomy as treatment for acute cholecystitis: What has happened over the last five years? A literature review. / Colecistostomía percutánea como tratamiento de colecistitis aguda: ¿qué ha pasado en los últimos 5 años? Revisión de la literatura.

Acute cholecystitis is one of the most frequent diseases faced by the general surgeon. In recent decades, different prognostic factors have been observed, and effective treatments described, to improve the results in patients with said pathology (lower morbidity and mortality, shorter hospital stay, and minimum conversion of laparoscopic to open procedures). In general, laparoscopic cholecystectomy is the standard treatment for acute cholecystitis, but it is not exempt from complications, especially in patients with numerous comorbidities or those that are critically ill. Percutaneous cholecystostomy emerged as a less invasive alternative for the treatment of acute cholecystitis in patients with organ failure or a prohibitive surgical risk. Even though it is an effective procedure, its usefulness and precise indications are subjects of debate. In addition, there is little evidence on cholecystostomy catheter management. We carried out a review of the literature covering the main aspects physicians involved in the management of acute cholecystitis should be familiar with.

Myths and realities in the management of the open abdomen with negative pressure systems. A case report and literature review.

INTRODUCTION: The open abdomen is a useful resource for treating patients with abdominal hypertension and abdominal compartment syndrome. Currently, early closure assisted with negative pressure devices is considered standard of treatment, and its use has demonstrated favorable outcomes and a decreased rate of complications. PRESENTATION OF A CASE: We present a case of a 32-year-old male patient with diagnosis of non-seminomatous germinal testicular tumor (Stage IIIB (T3-N3-M1), which was summited to surgery, as a complication he presented massive bleeding, that culminated in acute compartment syndrome. With the aforementioned findings the patient re entered the operating room and was managed with open abdomen combined with a medial retraction technique of the abdominal fascia. Currently, the patient has not presented recurrence or late complications after a year. DISCUSSION: The use of negative pressure techniques for open abdomen management began to be generalized in 1995. Subsequently, this technique evolved to V.A.C therapy (Vacuum-assisted closure therapy). Currently, these negative pressure techniques have become the most used method for the temporary closure and management of open abdomen. Controversies continue to limit its widespread use and effectiveness. CONCLUSION: Adequate application of negative pressure therapy in combination with techniques of medial retraction of the abdominal fascia, have proved to be useful in management for patients with open abdomen.

Recurrent giant Brunner's gland adenoma.

Benign duodenal tumours are extremely rare, with an incidence of 0.008% among general population; those originating from Brunner's Gland represent 11% of this neoplasms. Most cases remain asymptomatic and are often diagnosed during routine endoscopic procedures, however their clinical presentation may be variable making resection treatment of choice in order to prevent complications. Recurrence has not been reported previously on literature. 59-year-old male presented to the emergency department nine months following endoscopic resection of a 2x1.5cm Brunner's gland adenoma complaining of bloating, weight loss and gastro intestinal bleeding, diagnostic approach revealed a 10x4cm mass occupying the duodenum. Tumour size did not allow for endoscopic resection and surgical removal was performed with excellent outcome and no further recurrence at 30 months.

Clinical usefulness of extending the proximal margin in total gastrectomies for gastric adenocarcinoma. / Utilidad clínica de la ampliación del margen proximal en gastrectomías totales por adenocarcinoma gástrico.

INTRODUCTION AND AIMS: Surgical resection with negative margins is part of the curative treatment of gastric adenocarcinoma. Positive surgical margins are associated with worse outcome. The aim of the present study was to determine the clinical usefulness of extending the proximal surgical margin in patients undergoing total gastrectomy for gastric adenocarcinoma. MATERIALS AND METHODS: A retrospective analysis of patients that underwent total gastrectomy within the time frame of 2002 and 2017 was conducted. Patients diagnosed with adenocarcinoma that underwent curative surgery were included. Patients were divided into three groups, depending on proximal surgical margin status: negative margin (R0), positive margin with additional resection to achieve negative margin (R1-R0), and positive margin (R1). Demographic and clinical variables were analyzed. The outcome measures to evaluate were recurrence, disease-free survival, and overall survival. RESULTS: Forty-eight patients were included in the study. Thirty-seven were classified as R0, 9 as R1-R0, and 2 as R1. Fifty-two percent of the patients had clinical stage III disease. The overall surgical mortality rate was 2% and the morbidity rate was higher than 29%. The local recurrence rate was 0% in the R1-R0 group vs. 50% in the R1 group (p = 0.02). Disease-free survival was 49 months in the R1-R0 group vs. 32 months in the R1 group (p = 0.6). Overall survival was 51 months for the R1-R0 group vs. 35 months for the R1 group (p = 0.5). CONCLUSIONS: Intraoperative extension of the positive surgical margin improved the local recurrence rate but was not associated with improvement in overall survival or disease-free survival and could possibly increase postoperative morbidity.