Laparoscopic vs open approach for acute cholecystitis in octogenarians. A prospective multicenter observational nationwide study.

BACKGROUND: The world population is aging, with octogenarians expected to reach over 400 million by 2050. Acute cholecystitis is a serious complication in the elderly. Age is not a contraindication for emergency cholecystectomy, an option that can both save lives and preserve quality of life. METHODS: The present study aimed to compare open and laparoscopic surgical approaches. Over six months, 38 emergency surgery units enrolled all consecutive octogenarians with acute cholecystitis undergoing cholecystectomy. Postoperative outcomes were compared after propensity score matching analysis. RESULTS: The study included 212 patients (84 years [81-86], 47.2% women). The open approach was used in 32.1% of patients, and the laparoscopic approach in 67.9%. After propensity score matching, a decrease in hospital stays (open, 8 days [6-13]; laparoscopic, 5 days [4-8]; P < .001), 30-day morbidity (open, 48.5%; laparoscopic, 26.5%; P = .01), and 30-day mortality (open, 13.2%, laparoscopic, 1.5%; P = .02) was found. Among the specific postoperative complications, a decrease in septicemia (open, 14.7%; laparoscopic, 0%; P = .001) was observed. CONCLUSIONS: Laparoscopic approach was used in two out of three octogenarians. After propensity score matching, octogenarians undergoing laparoscopic approach had shorter length of hospital stay, fewer 30-day postoperative complications, fewer episodes of septicemia, and less 30-day mortality than octogenarians undergoing open approach. These findings suggest that the laparoscopic approach may be the preferred choice for octogenarians with acute cholecystitis undergoing cholecystectomy.

Prediction of peritoneal soiling in acute appendicitis with simple clinical and laboratory data. Prospective, multicenter, cohort study of 2,645 adult patients nationwide.

BACKGROUND AND AIMS: In order to facilitate the preoperative prediction of complicated appendicitis, we propose a complementary approach by selecting an endpoint defined by the intraoperative finding of peritoneal soiling (PS). METHODS: Over a 6-month period, 38 centers (5% of all public hospitals) attending emergency general surgery patients on a 24-h, 7-days a week basis, enrolled consecutive adult patients requiring appendectomy. Patients were stratified according to the absence or the finding of PS during the surgical procedure. RESULTS: A total of 2645 patients were included; median age (IQR) was 35 (22-51) years, 44.3% were female. The laparoscopic approach was used in 70.8% of appendectomies. In a third of patients (31.7%), there was PS with pus around the appendix, or bowel contents, free pus, or blood in the peritoneal cavity. To develop the prediction model, 1764 patients were randomly selected for the derivation cohort and the remaining 881 patients were assigned to the validation cohort. On multivariable logistic regression analysis of all patients, two clinical variables (age, and pulse) and three laboratory variables (serum urea, serum sodium, and white blood cell count) were individually associated (P < .05) with a greater probability of having PS (Hosmer-Lemeshow chi, 1.63; P = .99; C-statistic, 0.7). Based on the multivariable regression model, both static and dynamic nomograms were developed for the prediction of PS in patients with acute appendicitis. CONCLUSIONS: The entry of simple clinical and laboratory variables in the dynamic nomogram may be useful in guiding the initial management of patients with acute appendicitis in resource-limited settings.

Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study.

BACKGROUND AND AIMS: Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures. METHODS: Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator. RESULTS: A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity. CONCLUSIONS: This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

[Optical coherence tomography study in tamoxifen maculopathy]. / Maculopatía por tamoxifeno. Estudio mediante la tomografía de coherencia óptica.

CASE REPORT: We describe the case of a patient who presented with progressive and bilateral loss of vision. She had been treated with tamoxifen for 13 years. We performed fluorescein angiography and optical coherence tomography in order to study the macula. DISCUSSION: Loss of visual acuity related to tamoxifen maculopathy may be caused either by retinal nerve fibre atrophy or macular oedema. Macular findings obtained by fluorescein angiography and optical coherence tomography are complementary.

Maculopatía por tamoxifeno. Estudio mediante la tomografía de coherencia óptica / Optical coherence tomography study in tamoxifen maculopathy

Caso clínico: Se describe el caso de una paciente que acudió por pérdida bilateral y progresiva de la visión después de haber recibido tratamiento con tamoxifeno durante 13 años. Para el estudio detallado de las alteraciones maculares se realizaron la angiografía fluoresceínica y la tomografía de coherencia óptica. Discusión: La pérdida de visión debido a la maculopatía por tamoxifeno puede ser debida tanto a la atrofia de las capas de fibras nerviosas de la retina como a la presencia de edema macular. Los hallazgos maculares obtenidos mediante la angiografía fluoresceínica y la tomografía de coherencia óptica son complementarios

Case report: We describe the case of a patient who presented with progressive and bilateral loss of vision. She had been treated with tamoxifen for 13 years. We performed fluoresce in angiography and optical coherence tomography in order to study the macula. Discussion: Loss of visual acuity related to tamoxifen maculopathy may be caused either by retinal nerve fibre atrophy or macular o edema. Macular findings obtained by fluorescein angiography and optical coherence tomography are complementary

[Amniotic membrane transplantation after surgical resection in conjunctival Kaposi's sarcoma]. / Trasplante de membrana amniótica tras resección quirúrgica en sarcoma de Kaposi conjuntival.

OBJECTIVES/METHODS: To describe a case of isolated conjunctival Kaposi's sarcoma treated with surgical resection and amniotic membrane graft. After surgical resection of the lesion an amniotic membrane graft was used to reconstruct the conjunctival surface. Histological studies were performed. RESULTS/CONCLUSIONS: Rapid regeneration of the conjunctiva, with minimal scarring, occurred after the surgical procedure and no recurrence of the lesion was observed at 18 months of follow-up. Surgical resection with amniotic membrane grafting appears to be a useful therapeutic option in isolated conjunctival Kaposi's sarcoma.

Trasplante de membrana amniótica tras resección quirúrgica en sarcoma de Kaposi conjuntival / Amniotic membrane transplantation after surgical resection in conjunctival Kaposi's sarcoma

Objetivo/Métodos: Presentar un caso de sarcoma de Kaposi conjuntival tratado con resección quirúrgica e injerto de membrana amniótica. Después de la resección quirúrgica de la lesión, un injerto de membrana amniótica se utilizó para reconstruir la superficie ocular. Se realizó estudio histológico de la lesión.Resultados/Conclusiones: Una rápida regeneración de la superficie ocular con una mínima cicatrización ocurrió después de la resección quirúrgica y no se observaron recurrencias de la lesión en un periodo de seguimiento de 18 meses. La resección conjuntival con trasplante de membrana amniótica puede ser una opción terapéutica útil en casos de sarcoma de Kaposi conjuntival aislado (AU)

Objectives/Methods: To describe a case of isolated conjunctival Kaposi’s sarcoma treated with surgical resection and amniotic membrane graft. After surgical resection of the lesion an amniotic membrane graft was used to reconstruct the conjunctival surface. Histological studies were performed. Results/Conclusions: Rapid regeneration of the conjunctiva, with minimal scarring, occurred after the surgical procedure and no recurrence of the lesion was observed at 18 months of follow-up. Surgical resection with amniotic membrane grafting appears to be a useful therapeutic option in isolated conjunctival Kaposi´s sarcoma (AU)