Two stage hepatectomy (TSH) versus ALPPS for initially unresectable colorectal liver metastases: A systematic review and meta-analysis.

BACKGROUND: Although numerous comparisons between conventional Two Stage Hepatectomy (TSH) and Associating Liver Partition and Portal Vein Ligation for staged hepatectomy (ALPPS) have been reported, the heterogeneity of malignancies previously compared represents an important source of selection bias. This systematic review and meta-analysis aimed to compare perioperative and oncological outcomes between TSH and ALPPS to treat patients with initially unresectable colorectal liver metastases (CRLM). METHODS: Main electronic databases were searched using medical subject headings for CRLM surgically treated with TSH or ALPPS. Patients treated for primary or secondary liver malignancies other than CRLM were excluded. RESULTS: A total of 335 patients from 5 studies were included. Postoperative major complications were higher in the ALPPS group (relative risk [RR] 1.46, 95% confidence interval [CI] 1.04-2.06, I2 = 0%), while no differences were observed in terms of perioperative mortality (RR 1.53, 95% CI 0.64-3.62, I2 = 0%). ALPPS was associated with higher completion of hepatectomy rates (RR 1.32, 95% CI 1.09-1.61, I2 = 85%), as well as R0 resection rates (RR 1.61, 95% CI 1.13-2.30, I2 = 40%). Nevertheless, no significant differences were achieved between groups in terms of overall survival (OS) (RR 0.93, 95% CI 0.68-1.27, I2 = 52%) and disease-free survival (DFS) (RR 1.08, 95% CI 0.47-2.49, I2 = 54%), respectively. CONCLUSION: ALPPS and TSH to treat CRLM seem to have comparable operative risks in terms of mortality rates. No definitive conclusions regarding OS and DFS can be drawn from the results.

From conventional two-stage hepatectomy to ALPPS: Fifteen years of experience in a hepatobiliary surgery unit.

BACKGROUND: Hepatectomy in patients with large tumor load may result in postoperative liver failure and associated complications due to excessive liver parenchyma removal. Conventional two-stage hepatectomy (TSH) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique are possible solutions to this problem. Colorectal liver metastases (CRLM) is the most frequent indication, and there is a need to assess outcomes for both techniques to improve surgical and long-term oncological outcomes in these patients. METHODS: A single-center retrospective study was designed to compare TSH with ALPPS in patients with initially unresectable bilateral liver tumors between January 2005 and January 2020. ALPPS was performed from January 2012 onwards as the technique of choice. Long-term overall survival (OS) and disease-free survival (DFS) were evaluated as primary outcome in CRLM patients. Postoperative morbidity, mortality and liver growth in all patients were also evaluated. RESULTS: A total of 38 staged hepatectomies were performed: 17 TSH and 21 ALPPS. Complete resection rate was 76.5% (n = 13) in the TSH group and 85.7% (n = 18) in the ALPPS group (P = 0.426). Overall major morbidity (Clavien-Dindo ≥ 3a) (stage 1 + stage 2) was 41.2% (n = 7) in TSH and 33.3% (n = 7) in ALPPS patients (P = 0.389), and perioperative 90-day mortalities were 11.8% (n = 2) vs. 19.0% (n = 4) in each group, respectively (P = 0.654). Intention-to-treat OS rates at 1 and 5 years in CRLM patients for TSH (n = 15) were 80% and 33%, and for ALPPS (n = 17) 76% and 35%, respectively. DFS rates at 1 and 5 years were 36% and 27% in the TSH group vs. 33% and 27% in the ALPPS group, respectively. CONCLUSIONS: ALPPS is an effective alternative to TSH in bilateral affecting liver tumors, allowing higher resection rate, but patients must be carefully selected. In CRLM patients similar long-term OS and DFS can be achieved with both techniques.

Evaluación de la seguridad y satisfacción de los pacientes en un programa de colecistectomía laparoscópica ambulatoria con criterios expandidos / Evaluation of patient safety and satisfaction in a program of ambulatory laparoscopic cholecystectomy program with expanded criteria

Introducción: Los buenos resultados obtenidos con la implementación de los programas de colecistectomía laparoscópica ambulatoria han llevado a la ampliación de los criterios iniciales de inclusión. Como objetivo principal planteamos evaluar los resultados y el grado de satisfacción de los pacientes incluidos en un programa de colecistectomía laparoscópica sin ingreso, con criterios expandidos. Métodos: Estudio observacional de una cohorte de 260 pacientes intervenidos de colecistectomía laparoscópica ambulatoria entre abril del 2013 y marzo del 2016 en un hospital de tercer nivel. Clasificamos a los pacientes en 2 grupos en función del cumplimiento de los criterios iniciales de inclusión del programa ambulatorio. El grupo I (criterios restrictivos) incluye a 164 pacientes, mientras que, en el grupo II, se incluyen 96 pacientes (criterios expandidos: no cumplían alguno de los criterios de selección). Comparamos el tiempo quirúrgico, la tasa de ingresos no deseados, tasa de conversión, reintervenciones, mortalidad y el índice de satisfacción. Resultados: El porcentaje global de éxito de la colecistectomía laparoscópica ambulatoria fue del 92,8%. La causa más frecuente de ingresos no esperados fue por causas médicas. No se objetivaron diferencias estadísticamente significativas entre los 2 grupos en la duración del procedimiento quirúrgico, en la tasa de conversión a cirugía abierta, ni en el número de complicaciones mayores posquirúrgicas. Cumplimentaron la encuesta el 88,5% de los pacientes, no encontrando diferencias entre los 2 grupos en el índice de satisfacción de los pacientes. La calificación global del proceso fue significativamente mejor en el grupo ii (p = 0,023). Conclusiones: La colecistectomía laparoscópica ambulatoria es un procedimiento seguro y con una buena aceptación por parte del grupo de pacientes con criterios expandidos que fueron incluidos en el programa de cirugía sin ingreso

Introduction: The good results obtained with the implementation of ambulatory laparoscopic cholecystectomy programs have led to the expansion of the initial inclusion criteria. The main objective was to evaluate the results and the degree of satisfaction of the patients included in a program of laparoscopic cholecystectomy without admission, with expanded criteria. Methods: Observational study of a cohort of 260 patients undergoing ambulatory laparoscopic cholecystectomy between April 2013 and March 2016 in a third level hospital. We classified the patients into 2 groups based on compliance with the initial inclusion criteria of the outpatient program. Group I (restrictive criteria) includes 164 patients, while in group II (expanded criteria) we counted 96 patients. We compared the surgical time, the rate of failures in ambulatory surgery, rate of conversion, reinterventions and mortality and the satisfaction index. Results: The overall success rate of ambulatory laparoscopic cholecystectomy was 92.8%. The most frequent cause of unexpected income was for medical reasons. There was no statistically significant difference between the 2 groups for total surgery time, the rate of conversion to open surgery and the number of major postoperative complications Do not demostrate differences in surgical time, nor in the number of perioperative complications (major complications 1,2%), or the number of failures in ambulatory surgery, nor the number of readmissions between both groups. There was no death. 88.5% of patients completed the survey, finding no differences between both groups in the patient satisfaction index. The overall score of the process was significantly better in group ii(P=.023). Conclusions: Ambulatory laparoscopic cholecystectomy is a safe procedure with a good acceptance by patients with expanded criteria who were included in the surgery without admission program

Evaluation of patient safety and satisfaction in a program of ambulatory laparoscopic cholecystectomy program with expanded criteria. / Evaluación de la seguridad y satisfacción de los pacientes en un programa de colecistectomía laparoscópica ambulatoria con criterios expandidos.

INTRODUCTION: The good results obtained with the implementation of ambulatory laparoscopic cholecystectomy programs have led to the expansion of the initial inclusion criteria. The main objective was to evaluate the results and the degree of satisfaction of the patients included in a program of laparoscopic cholecystectomy without admission, with expanded criteria. METHODS: Observational study of a cohort of 260 patients undergoing ambulatory laparoscopic cholecystectomy between April 2013 and March 2016 in a third level hospital. We classified the patients into 2groups based on compliance with the initial inclusion criteria of the outpatient program. Group I (restrictive criteria) includes 164 patients, while in group ii (expanded criteria) we counted 96 patients. We compared the surgical time, the rate of failures in ambulatory surgery, rate of conversion, reinterventions and mortality and the satisfaction index. RESULTS: The overall success rate of ambulatory laparoscopic cholecystectomy was 92.8%. The most frequent cause of unexpected income was for medical reasons. There was no statistically significant difference between the 2groups for total surgery time, the rate of conversion to open surgery and the number of major postoperative complications Do not demostrate differences in surgical time, nor in the number of perioperative complications (major complications 1,2%), or the number of failures in ambulatory surgery, nor the number of readmissions between both groups. There was no death. 88.5% of patients completed the survey, finding no differences between both groups in the patient satisfaction index. The overall score of the process was significantly better in group ii(P=.023). CONCLUSIONS: Ambulatory laparoscopic cholecystectomy is a safe procedure with a good acceptance by patients with expanded criteria who were included in the surgery without admission program.

Veinticinco años de colecistectomía laparoscópica en régimen ambulatorio / Twenty-five years of ambulatory laparoscopic cholecystectomy

Es bien aceptado por la comunidad quirúrgica que la colecistectomía laparoscópica (CL) es la técnica de elección en el tratamiento de la colelitiasis sintomática. Sin embargo, más controvertida es la estandarización de su realización en régimen de cirugía mayor ambulatoria (CMA) por las diversas connotaciones que presenta. Este artículo tiene por objeto actualizar los factores influyentes en la realización de la CL en régimen de cirugía sin ingreso, analizando estos 25 años desde su implantación, incidiendo en la calidad y aceptación del proceso por parte del paciente. Es fundamental la individualización del proceso: un estricto criterio de selección de pacientes y la realización por equipos con experiencia en CL, son factores que aseguran una alta garantía de éxito

It is accepted by the surgical community that laparoscopic cholecystectomy (LC) is the technique of choice in the treatment of symptomatic cholelithiasis. However, more controversial is the standardization of system implementation in Ambulatory Surgery because of its different different connotations. This article aims to update the factors that influence the performance of LC in day surgery, analyzing the 25 years since its implementation, focusing on the quality and acceptance by the patient. Individualization is essential: patient selection criteria and the implementation by experienced teams in LC, are factors that ensure high guarantee of success

Actualización en el manejo del abdomen agudo no obstétrico en la paciente gestante / Update on the management of non-obstetric acute abdomen in pregnant patients

En la paciente embarazada, el abdomen agudo es una entidad infrecuente, cuya incidencia es de una por cada 500-635 gestantes. Pero su aparición requiere una respuesta rápida y un diagnóstico temprano para tratar la enfermedad de base y evitar la morbimortalidad maternofetal. Las pruebas de imagen son fundamentales para ello, dado el enmascaramiento clínico y analítico en estas pacientes. La apendicitis y la enfermedad biliar complicada son las causas más frecuentes de abdomen agudo no obstétrico. La decisión de intervenir, la elección del momento y la vía de abordaje son esenciales para un correcto manejo de esta dolencia. El objetivo de esta publicación es realizar una revisión y puesta al día sobre el diagnóstico y tratamiento del abdomen agudo de origen no obstétrico en la paciente gestante

Acute abdomen is a rare entity in the pregnant patient, with an incidence of one in 500-635 patients. Its appearance requires a quick response and an early diagnosis to treat the underlying disease and prevent maternal and fetal morbidity. Imaging tests are essential, due to clinical and laboratory masking in this subgroup. Appendicitis and complicated biliary pathology are the most frequent causes of non-obstetric acute abdomen in the pregnant patient. The decision to operate, the timing, and the surgical approach are essential for a correct management of this pathology. The aim of this paper is to perform a review and update on the diagnosis and treatment of non-obstetric acute abdomen in pregnancy

Update on the management of non-obstetric acute abdomen in pregnant patients. / Actualización en el manejo del abdomen agudo no obstétrico en la paciente gestante.

Acute abdomen is a rare entity in the pregnant patient, with an incidence of one in 500-635 patients. Its appearance requires a quick response and an early diagnosis to treat the underlying disease and prevent maternal and fetal morbidity. Imaging tests are essential, due to clinical and laboratory masking in this subgroup. Appendicitis and complicated biliary pathology are the most frequent causes of non-obstetric acute abdomen in the pregnant patient. The decision to operate, the timing, and the surgical approach are essential for a correct management of this pathology. The aim of this paper is to perform a review and update on the diagnosis and treatment of non-obstetric acute abdomen in pregnancy.

Twenty-five years of ambulatory laparoscopic cholecystectomy. / Veinticinco años de colecistectomía laparoscópica en régimen ambulatorio.

It is accepted by the surgical community that laparoscopic cholecystectomy (LC) is the technique of choice in the treatment of symptomatic cholelithiasis. However, more controversial is the standardization of system implementation in Ambulatory Surgery because of its different different connotations. This article aims to update the factors that influence the performance of LC in day surgery, analyzing the 25 years since its implementation, focusing on the quality and acceptance by the patient. Individualization is essential: patient selection criteria and the implementation by experienced teams in LC, are factors that ensure high guarantee of success.

Risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer: results from a prospective, multicentric study of 1102 patients.

BACKGROUND: Studies focused on postoperative outcome after oncologic right colectomy are lacking. The main objective was to determine pre-/intraoperative risk factors for anastomotic leak after elective right colon resection for cancer. Secondary objectives were to determine risk factors for postoperative morbidity and mortality. METHODS: Fifty-two hospitals participated in this prospective, observational study (September 2011-September 2012), including 1102 patients that underwent elective right colectomy. Forty-two pre-/intraoperative variables, related to patient, tumor, surgical procedure, and hospital, were analyzed as potential independent risk factors for anastomotic leak and postoperative morbidity and mortality. RESULTS: Anastomotic leak was diagnosed in 93 patients (8.4 %), and 72 (6.5 %) of them needed radiological or surgical intervention. Morbidity, mortality, and wound infection rates were 29.0, 2.6, and 13.4 %, respectively. Preoperative serum protein concentration was the only independent risk factor for anastomotic leak (p < 0.0001, OR 0.6 per g/dL). When considering only clinically relevant anastomotic leaks, stapled technique (p = 0.03, OR 2.1) and preoperative serum protein concentration (p = 0.004, OR 0.6 g/dL) were identified as the only two independent risk factors. Age and preoperative serum albumin concentration resulted to be risk factors for postoperative mortality. Male gender, pulmonary or hepatic disease, and open surgical approach were identified as risk factors for postoperative morbidity, while male gender, obesity, intraoperative complication, and end-to-end anastomosis were risk factors for wound infection. CONCLUSIONS: Preoperative nutritional status and the stapled anastomotic technique were the only independent risk factors for clinically relevant anastomotic leak after elective right colectomy for cancer. Age and preoperative nutritional status determined the mortality risk, while laparoscopic approach reduced postoperative morbidity.

Risk Factors for Anastomotic Leak After Colon Resection for Cancer: Multivariate Analysis and Nomogram From a Multicentric, Prospective, National Study With 3193 Patients.

OBJECTIVE: To determine pre-/intraoperative risk factors for anastomotic leak after colon resection for cancer and to create a practical instrument for predicting anastomotic leak risk. BACKGROUND: Anastomotic leak is still the most dreaded complication in colorectal surgery. Many risk factors have been identified to date, but multicentric prospective studies on anastomotic leak after colon resection are lacking. METHODS: Fifty-two hospitals participated in this prospective, observational study. Data of 3193 patients, operated for colon cancer with primary anastomosis without stoma, were included in a prospective online database (September 2011-September 2012). Forty-two pre-/intraoperative variables, related to patient, tumor, surgical procedure, and hospital, were analyzed as potential independent risk factors for anastomotic leak (60-day follow-up). A nomogram was created to easily predict the risk of anastomotic leak for a given patient. RESULTS: The anastomotic leak rate was 8.7%, and widely varied between hospitals (variance of 0.24 on the logit scale). Anastomotic leak significantly increased mortality (15.2% vs 1.9% in patients without anastomotic leak, P < 0.0001) and length of hospitalization (median 23 vs 7 days in uncomplicated patients, P < 0.0001). In the multivariate analysis, the following variables were independent risk factors for anastomotic leak: obesity [P = 0.003, odds ratio (OR) = 2.7], preoperative serum total proteins (P = 0.03, OR = 0.7 per g/dL), male sex (P = 0.03, OR = 1.6), ongoing anticoagulant treatment (P = 0.05, OR = 1.8), intraoperative complication (P = 0.03, OR = 2.2), and number of hospital beds (P = 0.04, OR = 0.95 per 100 beds). CONCLUSIONS: Anastomotic leak after colon resection for cancer is a frequent, relevant complication. Patients, surgical technique, and hospital are all important determining factors of anastomotic leak risk.