Improving early cholecystectomy rate in acute cholecystitis with an evidence-based local multidisciplinary protocol and a surgical audit: single-center experience through an Acute Care Surgery Division.

PURPOSE: To analyze if, after implementation of an evidence-based local multidisciplinary protocol for acute cholecystitis (AC), an intermediate surgical audit could improve early cholecystectomy (EC) rate and other therapeutic indicators. METHODS: Longitudinal cohort study at a tertiary center. The local protocol, promoted, created, and periodically revised by the Acute Care Surgery Unit (ACSu) was updated and approved on March 2019. A specific registry was prospectively fulfilled with demographics, comorbidity, type of presentation, diagnostic items, therapeutic decision, and clinical course, considering both non-operative management (NOM) or cholecystectomy, early and delayed (EC and DC). Phase 1: April 2019-April 2021. A critical analysis and a surgical audit with the participation of all the involved Departments were then performed, especially focusing on improving global EC rate, considered primary outcome. Phase 2: May 2021-May 2023. Software SPSS 23.0 was used to compare data between phases. RESULTS: Initial EC rate was significantly higher on Phase 2 (39.3%vs52.5%, p < 0.004), as a significantly inferior rate of patients were initially bailed out from EC to NOM because of comorbidity (14.4%vs8%, p < 0.02) and grade II with severe inflammatory signs (7%vs3%, p < 0.04). A higher percentage of patients was recovered for EC after an initial decision of NOM on Phase 2, but without reaching statistical significance (21.8%vs29.2%, n.s.). Global EC rate significantly increased between phases (52.5%vs66.3%, p < 0.002) without increasing morbidity and mortality. A significant minor percentage of elective cholecystectomies after AC episodes had to be performed on Phase 2 (14%vs6.7%, p < 0.009). Complex EC and those indicated after readmission or NOM failure were usually performed by the ACSu staff. CONCLUSION: To adequately follow up the implementation of a local protocol for AC healthcare, registering and periodically analyzing data allow to perform intermediate surgical audits, useful to improve therapeutic indicators, especially EC rate. AC constitutes an ideal model to work with an ACSu.

Perioperative and oncologic outcomes of interval colectomy performed by acute care surgeons after stenting as a bridge to surgery for left-sided malignant colonic obstruction are non-inferior to the outcomes of colorectal surgeons in the elective setting: single center experience.

PURPOSE: To analyze if perioperative and oncologic outcomes with stenting as a bridge to surgery (SEMS-BS) and interval colectomy performed by acute care surgeons for left-sided occlusive colonic neoplasms (LSCON) are non-inferior to those obtained by colorectal surgeons for non-occlusive tumors of the same location in the full-elective context. METHODS: From January 2011 to January 2021, patients with LSCON at University Regional Hospital in Málaga (Spain) were directed to a SEMS-BS strategy with an interval colectomy performed by acute care surgeons and included in the study group (SEMS-BS). The control group was formed with patients from the Colorectal Division elective surgical activity dataset, matching by ASA, stage, location and year of surgery on a ratio 1:2. Stages IV or palliative stenting were excluded. Software SPSS 23.0 was used to analyze perioperative and oncologic (defined by overall -OS- and disease free -DFS-survival) outcomes. RESULTS: SEMS-BS and control group included 56 and 98 patients, respectively. In SEMS-BS group, rates of technical/clinical failure and perforation were 5.35% (3/56), 3.57% (2/56) and 3.57% (2/56). Surgery was performed with a median interval time of 11 days (9-16). No differences between groups were observed in perioperative outcomes (laparoscopic approach, primary anastomosis rate, morbidity or mortality). As well, no statistically significant differences were observed in OS and DFS between groups, both compared globally (OS:p < 0.94; DFS:p < 0.67, respectively) or by stages I-II (OS:p < 0.78; DFS:p < 0.17) and III (OS:p < 0.86; DFS:p < 0.70). CONCLUSION: Perioperative and oncologic outcomes of a strategy with SEMS-BS for LSCON are non-inferior to those obtained in the elective setting for non-occlusive neoplasms in the same location. Technical and oncologic safety of interval colectomy performed on a semi-scheduled situation by acute care surgeons is absolutely warranted.

Up-to-7 Criteria for Hepatocellular Carcinoma Liver Transplantation: A Retrospective Analysis of Experiences.

INTRODUCTION: The expansion of criteria for hepatocellular carcinoma (HCC) liver transplantation should produce satisfactory outcomes in terms of survival and recurrence. OBJECTIVES: To investigate if the up-to-7 criteria are applicable to liver transplantation for HCC. METHODS: A review of all liver transplantations performed at our unit between January 2002 and December 2010 was conducted (645 patients). The 91 patients of the sample who had HCC were divided into 3 groups: in Milan criteria (MC; n = 74), in up-to-7 criteria (UTSC; n = 12), and outside of up-to-7 criteria (OUTSC; n = 5). A descriptive retrospective study was carried out to analyze the characteristics of liver tumors and recipients and to estimate recurrence and survival rates for this population of patients. RESULTS: The characteristics of transplant recipients of the 3 groups were comparable. Statistically significant differences were observed in the number of tumors (1 ± 0.65 for MC, 3 ± 1.05 for UTSC, 6 ± 4.10 for OUTSC; P < .001), largest tumor size (2.47 ± 1.12 cm for MC, 3.78 ± 0.04 cm for UTSC, 4.04 ± 1.73 cm for OUTSC; P < .001), and recurrence (5.4% for MC; 33.3% for UTSC; 20% for OUTSC; P = .008). Survival rates (MC, UTSC, and OUTSC) at 3 and 5 years were 71.6%, 66.7%, and 60%, and 58.1%, 58.3%, and 40%, respectively, whereas tumor-free survival rates were 70.3%, 58.3%, and 60%, and 58.1%, 50%, and 40%, respectively. CONCLUSIONS: Survival in patients with HCC transplanted under up-to-7 criteria is acceptable. However, the expansion of criteria involves an increase in the number of patients included in the waiting list and a higher probability of relapse.

Acute Liver Failure Caused by Primary Non-Hodgkin's Lymphoma of the Liver.

INTRODUCTION: Acute liver failure (ALF) is a rare syndrome involving maximum liver dysfunction. This disease is characterized by a less than 26-week history of coagulopathy (INR ≥1.5) and hepatic encephalopathy and generally occurs in patients without any previously known disease. METHODS: We report the case of a healthy 25-year-old subject who presented with fulminant liver failure caused by a primary non-Hodgkin's lymphoma of the liver that required emergency liver transplantation. Diagnosis was based on pathologic confirmation of T-cell/histiocyte-rich large B-cell lymphoma and submassive hepatocyte necrosis. One year after surgery, the patient remains in complete remission. CONCLUSIONS: Fulminant liver failure is a sudden-onset severe disease that can be caused by a primary non-Hodgkin's lymphoma of the liver, which accounts for <1% of extranodal lymphomas. The diagnosis of this rare disease demands high diagnostic suspicion, and progression can be prevented through liver transplantation.