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INTRODUCTION: Laparoscopic cholecystectomy is one of the most frequently performed procedures by general surgeons. Strategies for minimizing bile duct injuries including use of the critical view of safety method, as outlined by the SAGES Safe Cholecystectomy Program, are not always possible. Subtotal cholecystectomy has emerged as a safe "bail-out" maneuver to avoid iatrogenic bile duct injury in these difficult cases. Strasberg and colleagues defined two main types of subtotal cholecystectomies: reconstituting and fenestrating. As there is a paucity of studies comparing the two subtypes of laparoscopic subtotal cholecystectomy (LSC), we performed a systematic review and meta-analysis comparing the reconstituting and fenestrating techniques for managing the difficult gallbladder. METHODS: A search of PubMed, Embase, and Cochrane databases was conducted to identify prospective and retrospective studies comparing fenestrating and reconstituting LSC. The outcomes of interest were bile leak, reoperation, readmissions, completion cholecystectomy, postoperative ERCP, and retained CBD stones. RESULTS: We screened 2855 studies and included 13 studies with a total population of 985 patients. Among them, 330 patients (33.5%) underwent reconstituting LSC and 655 patients (55.5%) underwent fenestrating LSC. Twelve studies were retrospective, and one was prospective. Notably, reconstituting STC was associated with decreased incidence of bile leak (OR 0.29; CI 95% 0.16-0.55; p = 0.0002; I2 = 36%). We also noted increased rates of postoperative ERCP with fenestrating STC in sensitivity analysis (OR 0.32; CI 95% 0.16-0.64; p = 0.001; I2 = 31%). In addition, there was no difference between the two techniques regarding the rates of completion of cholecystectomy, reoperation, readmission, and retained CBD stones. CONCLUSIONS: Fenestrating LSC leads to a higher incidence of postoperative bile leakage. In addition, our sensitivity analysis revealed that the fenestrating technique is associated with a higher incidence of postoperative ERCP. Further randomized trials and studies with longer-term follow-up are still necessary to better understand these techniques in the difficult gallbladder cases.
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Introduction: In Brazil, approximately 5% are born with a congenital disorder, potentially fatal without surgery. This study aims to evaluate the relationship between gastrointestinal congenital malformation (GICM) mortality, health indicators, and socioeconomic factors in Brazil. Methods: GICM admissions (Q39-Q45) between 2012 and 2019 were collected using national databases. Patient demographics, socioeconomic factors, clinical management, outcomes, and the healthcare workforce density were also accounted for. Pediatric Surgical Workforce density and the number of neonatal intensive care units in a region were extracted from national datasets and combined to create a clinical index termed 'NeoSurg'. Socioeconomic variables were combined to create a socioeconomic index termed 'SocEcon'. Simple linear regression was used to investigate if the temporal changes of both indexes were significant. The correlation between mortality and the different indicators in Brazil was evaluated using Pearson's correlation coefficient. Results: Over 8 years, Brazil recorded 12804 GICM admissions. The Southeast led with 6147 cases, followed by the Northeast (2660), South (1727), North (1427), and Midwest (843). The North and Northeast reported the highest mortality, lowest NeoSurg, and SocEcon Index rates. Nevertheless, mortality rates declined across regions from 7.7% (2012) to 3.9% (2019), a 51.7% drop. The North and Midwest experienced the most substantial reductions, at 63% and 75%, respectively. Mortality significantly correlated with the indexes in nearly all regions (p<0.05). Conclusion: Our study highlights the correlation between social determinants of health and GICM mortality in Brazil, using two novel indexes in the pediatric population. These findings provide an opportunity to rethink and discuss new indicators that could enhance our understanding of our country and could lead to the development of necessary solutions to tackle existing challenges in Brazil and globally.
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BACKGROUND: Colorectal liver metastasis has a high incidence, and RAS oncogene mutation status carries significant prognostic information. We aimed to assess whether RAS-mutated patients present more or less frequently with positive margins in their hepatic metastasectomy. METHODS: We performed a systematic review and meta-analysis of studies from PubMed, Embase, and Lilacs databases. We analyzed liver metastatic colorectal cancer studies, which included information on RAS status and had surgical margin analysis of the liver metastasis. Odds ratios were computed using a random-effect model due to anticipated heterogeneity. We further performed a subanalysis limited to studies that included only patients with KRAS instead of all-RAS mutations. RESULTS: From the 2,705 studies screened, 19 articles were included in the meta-analysis. There were 7,391 patients. The prevalence of positive resection margin was not significantly different between patients carrier vs non-carrier for the all-RAS mutations (OR .99; 95% CI 0.83-1.18; P = .87), and for only KRAS mutation (OR .93; 95% CI 0.73-1.19; P = .57). CONCLUSIONS: Despite the strong correlation between colorectal liver metastasis prognosis and RAS mutation status, our meta-analysis's results suggest no correlation between the RAS status and the prevalence of positive resection margins. The findings contribute to a better understanding of the RAS mutation's role in the surgical resections of colorectal liver metastasis.