Resultados de una encuesta nacional sobre el manejo de los pacientes diagnosticados de diverticulitis aguda no complicada / Results of a national survey about the management of patients with acute uncomplicated diverticulitis

Introducción: El manejo de los pacientes diagnosticados de diverticulitis aguda no complicada ha evolucionado en los últimos años, y según diversas guías clínicas internacionales actuales, el tratamiento ambulatorio y sin antibioterapia puede ser utilizado en pacientes seleccionados. El objetivo de este estudio es evaluar la adhesión de los distintos centros nacionales a estas y otras recomendaciones en esta enfermedad. Métodos: Se realizó una encuesta online a nivel nacional que se dio a conocer a través de diversas aplicaciones informáticas y se analizaron estadísticamente los resultados obtenidos. Resultados: Participaron 104 cirujanos, representando 69 centros hospitalarios nacionales. En el 82,6% de los centros, se realiza manejo ambulatorio de los pacientes diagnosticados de diverticulitis aguda no complicada. El 23,2% de los centros tiene implantado un protocolo de tratamiento sin antibioterapia en pacientes seleccionados, mientras que en los centros que no siguen estas recomendaciones, las razones principales son las dificultades logísticas para su desarrollo (49,3%) y la ausencia de evidencia actual para ello (44,8%). Se han encontrado diferencias estadísticamente significativas al comparar la implantación de dichos protocolos entre centros con unidades acreditadas avanzadas y aquellas que no, con mayores tasas de manejo ambulatorio y sin antibioterapia en los centros acreditados avanzados (p≤0,05). Conclusiones: A pesar de ser una enfermedad muy frecuente, existe mucha heterogeneidad en su tratamiento a nivel nacional, por lo que sería recomendable la unificación de criterios diagnósticos y de tratamiento mediante la colaboración de las sociedades científicas y la simplificación de la puesta en marcha de protocolos hospitalarios.(AU)

Introduction: Management of patients diagnosed of acute uncomplicated diverticulitis has evolved lately and according to the latest guidelines, outpatient treatment and management without antibiotherapy may be used in selected patients. The aim of this study is to evaluate the adhesion among national centres to these and others recommendations related to this pathology. Methods: An online national survey, that has been broadcast by several applications, was performed. The results obtained were statistically analysed. Results: A total of 104 surgeons participated, representing 69 national hospitals. Of those, in 82.6% of the centers, outpatient management is performed for acute uncomplicated diverticulitis. 23.2% of the hospitals have a protocol stablished for treatment without antibiotherapy in selected patients. Centers that do not follow these protocols allege that the mean reasons are the logistic difficulties to set them up (49.3%) and the lack of current evidence for it (44.8%). Significative statistical differences have been found when comparing the establishment of such protocols between centers with advanced accredited units and those who are not, with higher rates of outpatient management and treatment without antibiotics in accredited units (P≤.05). Conclusions: In spite that this a very common disease, there is a huge national heterogeneity in its treatment. This is why it would adviseable to unify diagnostic and treatment criteria by the collaboration of scientific societies and the simplification of the development of hospitalary protocols.(AU)

Critical appraisal of surgical margins according to KRAS status in liver resection for colorectal liver metastases: Should surgical strategy be influenced by tumor biology?

BACKGROUND: KRAS mutation is a negative prognostic factor for colorectal liver metastases. Several studies have investigated the resection margins according to KRAS status, with conflicting results. The aim of the study was to assess the oncologic outcomes of R0 and R1 resections for colorectal liver metastases according to KRAS status. METHODS: All patients who underwent resection for colorectal liver metastases between 2010 and 2015 with available KRAS status were enrolled in this multicentric international cohort study. Logistic regression models were used to investigate the outcomes of R0 and R1 colorectal liver metastases resections according to KRAS status: wild type versus mutated. The primary outcomes were overall survival and disease-free survival. RESULTS: The analysis included 593 patients. KRAS mutation was associated with shorter overall survival (40 vs 60 months; P = .0012) and disease-free survival (15 vs 21 months; P = .003). In KRAS-mutated tumors, the resection margin did not influence oncologic outcomes. In multivariable analysis, the only predictor of disease-free survival and overall survival was primary tumor location (P = .03 and P = .03, respectively). In KRAS wild-type tumors, R0 resection was associated with prolonged overall survival (74 vs 45 months, P < .001) and disease-free survival (30 vs 17 months, P < .001). The multivariable model confirmed that R0 resection margin was associated with prolonged overall survival (hazard ratio = 1.43, 95% confidence interval: 1.01-2.03) and disease-free survival (hazard ratio = 1.42; 95% confidence interval: 1.06-1.91). CONCLUSIONS: KRAS-mutated colorectal liver metastases showed more aggressive tumor biology with inferior overall survival and disease-free survival after liver resection. Although R0 resection was not associated with improved oncologic outcomes in the KRAS-mutated tumors group, it seems to be of paramount importance for achieving prolonged long-term survival in KRAS wild-type tumors.

Results of a national survey about the management of patients with acute uncomplicated diverticulitis.

INTRODUCTION: Management of patients diagnosed of acute uncomplicated diverticulitis has evolved lately and according to the latest guidelines, outpatient treatment and management without antibiotherapy may be used in selected patients. The aim of this study is to evaluate the adhesión among national centres to these and others recommendations related to this pathology. METHODS: An online national survey, that has been broadcast by several applications, was performed. The results obtained were statistically analysed. RESULTS: A total of 104 surgeons participated, representing 69 national hospitals. Of those, in 82.6% of the centres, outpatient management is performed for acute uncomplicated diverticulitis. 23.2% of the hospitals have a protocol stablished for treatment without antibiotherapy in selected patients. Centres that do not follow these protocols allege that the mean reasons are the logistic difficulties to set them up (49.3%) and the lack of current evidence for it (44.8%). Significative statistical differences have been found when comparing the establishment of such protocols between centres with advanced accredited units and those who are not, with higher rates of outpatient management and treatment without antibiotics in accredited units (p ≤ .05). CONCLUSIONS: In spite that this a very common disease, there is a huge national heterogeneity in its treatment. This is why it would adviseable to unify diagnostic and treatment criteria by the collaboration of scientific societies and the simplification of the development of hospitalary protocols.

Repeated pancreatic resection for pancreatic metastases from renal cell Carcinoma: A Spanish multicenter study (PANMEKID).

BACKGROUND AND OBJECTIVES: Recurrent isolated pancreatic metastasis from Renal Cell Carcinoma (RCC) after pancreatic resection is rare. The purpose of our study is to describe a series of cases of relapse of pancreatic metastasis from renal cancer in the pancreatic remnant and its surgical treatment with a repeated pancreatic resection, and to analyse the results of both overall and disease-free survival. METHODS: Multicenter retrospective study of patients undergoing pancreatic resection for RCC pancreatic metastases, from January 2010 to May 2020. Patients were grouped into two groups depending on whether they received a single pancreatic resection (SPS) or iterative pancreatic resection. Data on short and long-term outcome after pancreatic resection were collected. RESULTS: The study included 131 pancreatic resections performed in 116 patients. Thus, iterative pancreatic surgery (IPS) was performed in 15 patients. The mean length of time between the first pancreatic surgery and the second was 48.9 months (95 % CI: 22.2-56.9). There were no differences in the rate of postoperative complications. The DFS rates at 1, 3 and 5 years were 86 %, 78 % and 78 % vs 75 %, 50 % and 37 % in the IPS and SPS group respectively (p = 0.179). OS rates at 1, 3, 5 and 7 years were 100 %, 100 %, 100 % and 75 % in the IPS group vs 95 %, 85 %, 80 % and 68 % in the SPS group (p = 0.895). CONCLUSION: Repeated pancreatic resection in case of relapse of pancreatic metastasis of RCC in the pancreatic remnant is justified, since it achieves OS results similar to those obtained after the first resection.

FiLaC procedure for highly selected anal fistula patients: indications,safety and efficacy from an observational study at a tertiary referral center / Procedimiento FiLaC para pacientes con fístula anal altamente seleccionados: indicaciones, seguridad y eficacia de un estudio observacional en un centro de referencia terciario

Background: the ideal clinical profile of patients or fistula features for fistula laser closure (FiLaC®) technique remain to be established. The aim of this study was to analyze clinical outcomes and the safety profile of FiLaC® in search for an ideal setting for this technique. Methods: a retrospective observational study was performed from a prospective database including all consecutive patients who underwent surgery for anal fistula (AF) with FiLaC® in the coloproctology unit of a tertiary referral center, between October 2015 and December 2021. The FiLaC® procedure was offered to AF patients who were considered to be at risk of fecal incontinence. Fistulas were described according to Parks’ classification and categorized as complex or simple according to the American Gastroenterological Association (AGA) guidelines. Healing was defined by the closure of the internal and external openings for at least six months. Predictive factors of AF healing were investigated. Results: a total of 36 patients were included, with a mean age of 48 ± 13.9 years. Twenty patients (55.6 %) were male and 13 patients (36 %) had Crohn’s disease (CD). Fourteen patients (38.8 %) had a complex fistula. The primary and secondary healing rates were 55.6 % and 91.7 %, respectively, during a median follow-up time of 12 months (IQR 7-29). No fecal continence impairment was registered in any case. The proportion of patients with primary healing was significantly higher in CD patients (76.9 % vs 43.5 %, p = 0.048). Conclusions: FiLaC® is a sphincter-preserving procedure with an excellent safety profile and reasonable success rate despite of the strict patient selection. This technique may be attractive for patients with CD due to its higher primary healing rate.(AU)

Evaluation of the validated intraoperative bleeding scale in liver surgery: study protocol for a multicenter prospective study.

Background: Surgical hemostasis has become one of the key principles in the advancement of surgery. Hemostatic agents are commonly administered in many surgical specialties, although the lack of consensus on the definition of intraoperative bleeding or of a standardized system for its classification means that often the most suitable agent is not selected. The recommendations of international organizations highlight the need for a bleeding severity scale, validated in clinical studies, that would allow the selection of the best hemostatic agent in each case. The primary objective of this study is to evaluate the VIBe scale (Validated Intraoperative Bleeding Scale) in humans. Secondary objectives are to evaluate the scale's usefulness in liver surgery; to determine the relationship between the extent of bleeding and the hemostatic agent used; and to assess the relationship between the grade of bleeding and postoperative complications. Methods: Prospective multicenter observational study including 259 liver resections that meet the inclusion criteria: patients scheduled for liver surgery at one of 10 medium-high volume Spanish HPB centers using an open or minimally invasive approach (robotic/laparoscopic/hybrid), regardless of diagnosis, ASA score <4, age ≥18, and who provide signed informed consent during the study period (September 2023 until the required sample size has been recruited). The participating researchers will be responsible for collecting the data and for reporting them to the study coordinators. Discussion: This study will allow us to evaluate the VIBe scale for intraoperative bleeding in humans, with a view to its subsequent incorporation in daily clinical practice. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT05369988?term = serradilla&draw = 2&rank = 3, [NCT0536998].

Gender inequity in the medical profession: the women doctors in Spain (WOMEDS) study.

BACKGROUND: The long-standing underrepresentation of women in leadership positions in medicine is well-known, but poorly documented globally. There is some evidence of the gender gap in academia, medical society leadership, or specific problems in some specialties. However, there are no investigations analyzing all medical specialties together and reporting the glass ceiling from a 360º perspective that includes positions in academia, research, professional organizations, and clinical activity. Additionally, the majority of studies have a US perspective, and we wonder if the perspective of a European country might be different. The WOmen in MEDicine in Spain (WOMEDS) project ( https://womeds.es ) aims to describe and characterize, in a systematic and detailed way, the gender bias in the medical profession in Spain in order to monitor its evolution over time and contribute to prioritizing gender policies. METHODS: We retrieved data for the calendar years 2019-2021 from several sources and selected surveys. We built four groups of indicators to describe leadership positions in the medical profession: (i) leadership in healthcare according to specialty and region; (ii) leadership in scientific and professional bodies; (iii) academic career; and (iv) leadership in clinical research activity. As a summary measure, we reported the women ratios, calculated as the percentage of women in specific top positions divided by the percentage of women in the relevant population. RESULTS: We found gender inequity in leadership positions in all four settings. During the observed period, only 27.6% of the heads of departments in hospitals were women compared to 61.1% of women in medical staff. Ten of the 46 medical societies grouped in the Spanish Federation of Medical Societies (FACME) (21.7%) had a women president at some point during the study period, and only 4 annual congresses had ratios of women speakers higher than 1. Women were over-represented in the lower positions and underrepresented in the top academic ones. Only 26% and 27%, respectively, of the heads of departments and deans were women. The applications for public funding for research projects are led by women only in 45% of the cases, and the budget granted to women in public calls was 24.3% lower than that of men. CONCLUSION: In all the areas analyzed, the leadership positions are still mostly occupied by men despite the feminization of medicine in Spain. The severe gender inequity found calls for urgent interventions within a defined time horizon. Such measures must concern all levels, from national or regional regulation to changes in organizational culture or incentives in specific organizations.

RESUMEN EN ESPAÑOL: ANTECEDENTES: La prolongada infrarrepresentación de las mujeres en los puestos de liderazgo en medicina es bien conocida, pero está poco documentada de forma global. Hay evidencia sobre la brecha de género en la universidad, en el liderazgo en sociedades médicas o en determinadas especialidades. Sin embargo, no hay investigaciones que analicen el techo de cristal de cada una de las especialidades médicas desde una perspectiva 360º que incluya el liderazgo en la universidad, en la investigación con fondos públicos, en la representación en sociedades científicas y colegios profesionales y en la actividad clínica. Además, la mayoría de los estudios tienen una perspectiva estadounidense y nos preguntamos si la perspectiva de un país europeo podría ser diferente. El proyecto Mujeres en Medicina en España (WOMEDS) ( https://womeds.es ) tiene como objetivo describir y caracterizar de forma sistemática y detallada sesgo de género en la profesión médica en España, para monitorizar su evolución en el tiempo y contribuir a priorizar las políticas de género. MéTODOS: Construimos cuatro grupos de indicadores sobre liderazgo de mujeres médicos: (i) en la asistencia sanitaria; (ii) en las organizaciones científicas y profesionales; (iii) carrera académica, y; and (iv) l en la investigación basándonos en datos públicos y resultados de encuestas propias s referidas a los años 2019­2021. Como medida de análisis, calculamos los ratios de mujeres, definidos como el porcentaje de mujeres en puestos altos específicos dividido por el porcentaje de mujeres en la población relevante. RESULTADOS: Encontramos un sesgo de género en los cuatro ámbitos. Durante el periodo observado, solo el 27.6% de los jefes de servicio de los hospitales eran mujeres, frente al 61.1% de mujeres en la plantilla. Diez de las 46 sociedades médicas agrupadas en la Federación de Asociaciones Científico Médicas Españolas (FACME) (21.7%) tuvieron una mujer como presidente en algún momento del periodo de estudio y sólo 4 congresos anuales tenían ratios de mujeres ponentes superiores a 1. Las mujeres estaban sobrerepresentadas en los cargos inferiores e infrarrepresentadas en los cargos académicos superiores. Sólo el 26% y el 27%, respectivamente, de los jefes de departamento y decanos eran mujeres. La solicitud de proyectos de investigación con financiación pública fue liderada por mujeres en un 45% de los casos y la financiación media de los proyectos concedidos a las mujeres fue un 24.3% inferior a la de los hombres. CONCLUSIóN: En todos los ámbitos analizados, las posiciones de liderazgo siguen siendo mayoritariamente ocupada por varones a pesar de la feminización de la medicina. Para cambiar esto, será necesario tomar medidas, tanto regulatorias -a nivel nacional y nacional regional como promover cambios en la cultura organizativa o en los incentivos en organizaciones concretas.

FiLaC® procedure for highly selected anal fistula patients: indications, safety and efficacy from an observational study at a tertiary referral center.

BACKGROUND: the ideal clinical profile of patients or fistula features for fistula laser closure (FiLaC®) technique remain to be established. The aim of this study was to analyze clinical outcomes and the safety profile of FiLaC® in search for an ideal setting for this technique. METHODS: a retrospective observational study was performed from a prospective database including all consecutive patients who underwent surgery for anal fistula (AF) with FiLaC® in the coloproctology unit of a tertiary referral center, between October 2015 and December 2021. The FiLaC® procedure was offered to AF patients who were considered to be at risk of fecal incontinence. Fistulas were described according to Parks' classification and categorized as complex or simple according to the American Gastroenterological Association (AGA) guidelines. Healing was defined by the closure of the internal and external openings for at least six months. Predictive factors of AF healing were investigated. RESULTS: a total of 36 patients were included, with a mean age of 48 ± 13.9 years. Twenty patients (55.6 %) were male and 13 patients (36 %) had Crohn's disease (CD). Fourteen patients (38.8 %) had a complex fistula. The primary and secondary healing rates were 55.6 % and 91.7 %, respectively, during a median follow-up time of 12 months (IQR 7-29). No fecal continence impairment was registered in any case. The proportion of patients with primary healing was significantly higher in CD patients (76.9 % vs 43.5 %, p = 0.048). CONCLUSIONS: FiLaC® is a sphincter-preserving procedure with an excellent safety profile and reasonable success rate despite of the strict patient selection. This technique may be attractive for patients with CD due to its higher primary healing rate.

Treatment for acute uncomplicated diverticulitis without antibiotherapy: systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Use of antibiotics in selected cases of acute uncomplicated diverticulitis (AUD) has recently been questioned. OBJECTIVE: The aim of this study is to examine the safety and efficacy of treatment regimens without antibiotics compared with that of traditional treatments with antibiotics in selected patients with AUD. DATA SOURCES: PubMed, Medline, Embase, Web of Science, and the Cochrane Library. METHODS: A systematic review was performed according to PRISMA and AMSTAR guidelines by searching through Medline, Embase, Web of Science, and the Cochrane Library for randomized clinical trials (RCTs) published before December 2022. The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. STUDY SELECTION: RCTs on treating AUD without antibiotics published in English before December 2022 were included. INTERVENTION: Treatments without antibiotics were compared with treatments with antibiotics. MAIN OUTCOME MEASURES: The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. RESULTS: The search yielded 1163 studies. Four RCTs with 1809 patients were included in the review. Among these patients, 50.1% were treated conservatively without antibiotics. The meta-analysis showed no significant differences between nonantibiotic and antibiotic treatment groups with respect to rates of readmission [odds ratio (OR)=1.39; 95% CI: 0.93-2.06; P =0.11; I2 =0%], change in strategy (OR=1.03; 95% CI: 0.52-2,02; P =0.94; I2 =44%), emergency surgery (OR=0.43; 95% CI: 0.12-1.53; P =0.19; I2 =0%), worsening (OR=0.91; 95% CI: 0.48-1.73; P =0.78; I2 =0%), and persistent diverticulitis (OR=1.54; 95% CI: 0.63-3.26; P =0.26; I2 =0%). LIMITATIONS: Heterogeneity and a limited number of RCTs. CONCLUSIONS: Treatment for AUD without antibiotic therapy is safe and effective in selected patients. Further RTCs should confirm the present findings.

Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study.

BACKGROUND: Less invasive alternatives than early cholecystectomy (EC) for acute calculous cholecystitis (ACC) treatment have been spreading in recent years. We still lack a reliable tool to select high-risk patients who could benefit from these alternatives. Our study aimed to prospectively validate the Chole-risk score in predicting postoperative complications in patients undergoing EC for ACC compared with other preoperative risk prediction models. METHOD: The S.P.Ri.M.A.C.C. study is a World Society of Emergency Surgery prospective multicenter observational study. From 1st September 2021 to 1st September 2022, 1253 consecutive patients admitted in 79 centers were included. The inclusion criteria were a diagnosis of ACC and to be a candidate for EC. A Cochran-Armitage test of the trend was run to determine whether a linear correlation existed between the Chole-risk score and a complicated postoperative course. To assess the accuracy of the analyzed prediction models-POSSUM Physiological Score (PS), modified Frailty Index, Charlson Comorbidity Index, American Society of Anesthesiologist score (ASA), APACHE II score, and ACC severity grade-receiver operating characteristic (ROC) curves were generated. The area under the ROC curve (AUC) was used to compare the diagnostic abilities. RESULTS: A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. Chole-risk was validated, but POSSUM PS was the best risk prediction model for a complicated course after EC for ACC (in-hospital mortality: AUC 0.94, p < 0.001; 30-day mortality: AUC 0.94, p < 0.001; in-hospital major morbidity: AUC 0.73, p < 0.001; 30-day major morbidity: AUC 0.70, p < 0.001). POSSUM PS with a cutoff of 25 (defined in our study as a 'Chole-POSSUM' score) was then validated in a separate cohort of patients. It showed a 100% sensitivity and a 100% negative predictive value for mortality and a 96-97% negative predictive value for major complications. CONCLUSIONS: The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action. TRIAL REGISTRATION: ClinicalTrial.gov NCT04995380.

[Analysis of the broadcasting and perceived utility through the implementation of a virtual training platform during the pandemic]. / Análisis de la difusión y utilidad percibida a través de la implementación de una plataforma de formación virtual durante la pandemia por COVID-19.

Introduction: The SARS-CoV-2 pandemic has affected training opportunities for healthcare professionals partly because face to face courses were cancelled. This study analyzes the results of participation and satisfaction of the AEC Virtual Classroom sessions during the first year. Methods: The AEC Virtual Classroom includes a combined format of weekly Webinar broadcast live that can be viewed on a delayed basis in a virtual platform. In this study, the results in its first year are evaluated considering the number of live participants, the delayed views and the global reach; as well as the results of the satisfaction survey in each of the sessions (0-10). Results: From 16/04/2020 to 15/04/2021, 50 sessions of the Virtual Classroom AEC were held. The average scope of the sessions was 509 ± 288 views with a range between 196 and 149. At the times of highest incidence of cases during the pandemic, a decrease in live participants was observed 275 ± 135 vs. 391 ± 233 (p = 0.032). The mean score on the format was 8.46 ± 0.31/10. The best-scored sessions were those of the subject related to coloproctology with a statistically significant difference in the mean score 8.79 ± 0.42 vs. 8.39 ± 0.27 (p = 0.035). 90% of users considered the sessions useful. 97.2% of respondents believe that the sessions should be maintained after the pandemic. Conclusions: The AEC Virtual Classroom has a very good results in the first year, proving to be a useful surgical teaching tool that will foreseeably survive once the pandemic is over.

Analysis of the broadcasting and perceived utility through the implementation of a virtual training platform during the pandemic.

INTRODUCTION: The SARS-CoV-2 pandemic has affected training opportunities for healthcare professionals partly because face to face courses were cancelled. This study analyzes the results of participation and satisfaction of the AEC Virtual Classroom sessions during the first year. METHODS: The AEC Virtual Classroom includes a combined format of weekly Webinar broadcast live that can be viewed on a delayed basis in a virtual platform. In this study, the results in its first year are evaluated considering the number of live participants, the delayed views and the global reach; as well as the results of the satisfaction survey in each of the sessions (0-10). RESULTS: From 16/04/2020 to 15/04/2021, 50 sessions of the Virtual Classroom AEC were held. The average scope of the sessions was 509 ± 288 views with a range between 196 and 149. At the times of highest incidence of cases during the pandemic, a decrease in live participants was observed 275 ± 135 vs. 391 ± 233 (P = 0.032). The mean score on the format was 8.46 ± 0.31/10. The best-scored sessions were those of the subject related to coloproctology with a statistically significant difference in the mean score 8.79 ± 0.42 vs. 8.39 ± 0.27 (P = 0.035). 90% of users considered the sessions useful. 97.2% of respondents believe that the sessions should be maintained after the pandemic. CONCLUSIONS: The AEC Virtual Classroom has had very good results in the first year, proving to be a useful surgical teaching tool that will foreseeably survive once the pandemic is over.

Impact of Change in Body Composition during Follow-Up on the Survival of GEP-NET.

Background: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are heterogeneous rare diseases causing malnutrition and cachexia in which the study of body composition may have an impact in prognosis. Aim: Evaluation of muscle and fat tissues by computed tomography (CT) at the level of the third lumbar (L3 level) at diagnosis and at the end of follow-up in GET-NET patients and their relationships with clinical and biochemical variables as predictors of survival. Methodology: Ninety-eight GEP-NET patients were included. Clinical and biochemical parameters were evaluated. Total body, subcutaneous, visceral and total fat areas and very low-density, low-density, normal density, high-density, very high-density and total muscle areas were obtained from CT images. Results: Body composition measures and overall mortality correlated with age, ECOG (Eastern Cooperative Oncology Group performance status) metastases, lactate dehydrogenase (LDH), albumin and urea levels. Although there was no relationship between body composition variables at diagnosis and overall and specific mortality, an increase in low-density muscle and a decrease in normal-density muscle during follow-up were independently correlated to overall (p <0.05) and tumor-cause mortality (p < 0.05). Conclusion: Although body composition measures obtained by CT at diagnosis did not impact survival of GEP-NET patients, a loss of good quality muscle during follow-up was associated with an increased overall and tumor-related mortality. Nutritional status should therefore be supervised by nutrition specialists and an increase in good quality muscle could improve prognosis.

Applicability and reproducibility of the validated intraoperative bleeding severity scale (VIBe scale) in liver surgery: A multicenter study.

BACKGROUND: Bleeding is an intraoperative and postoperative complication of liver surgery of concern, and yet evidence to support utility and reproducibility of bleeding scales for liver surgery is limited. We determined the reproducibility of the clinician-reported validated intraoperative bleeding severity scale and its clinical value of implementation in liver surgery. METHODS: In this descriptive and observational multicenter study, we assessed the performance of liver surgeons instructed on the clinician-reported intraoperative bleeding severity scale using training videos that covered all 5 grades of bleeding severity. Surgeons were stratified according to years of surgical experience and number of surgeries performed per year based on a median split in low and high values. Intraobserver and interobserver agreement was assessed using Kendall's coefficient of concordance (Kendall's W). RESULTS: Forty-seven surgeons from 10 hospitals in Spain participated in the study. The overall intraobserver concordance was 0.985, and the overall interobserver concordance was 0.929. For "high experience" surgeons, the intraobserver and interobserver agreement values were 0.990 and 0.941, respectively. For "low experience" surgeons, the intraobserver and interobserver agreement was 0.981 and 0.922, respectively. Regarding the annual number of surgeries, intraobserver and interobserver agreement values were 0.995 and 0.940, respectively, for surgeons performing >35 surgeries per year, with 0.979 and 0.923, respectively, for surgeons who perform ≤35 surgeries year. CONCLUSION: The clinician-reported intraoperative bleeding severity scale shows high interobserver and intraobserver concordance, suggesting it is a useful tool for assessing severity of bleeding during liver surgery; years of surgical experience and number of annual procedures performed did not affect the applicability of the clinician-reported intraoperative bleeding severity scale.

Long-Term Outcomes of Perioperative Versus Neoadjuvant Chemotherapy for Resectable Colorectal Liver Metastases: An International Multicentre Propensity-Score Matched Analysis with Stratification by Contemporary Risk-Scoring.

BACKGROUND: There is still debate regarding the principal role and ideal timing of perioperative chemotherapy (CTx) for patients with upfront resectable colorectal liver metastases (CRLM). This study assesses long-term oncological outcomes in patients receiving neoadjuvant CTx only versus those receiving neoadjuvant combined with adjuvant therapy (perioperative CTx). METHODS: International multicentre retrospective analysis of patients with CRLM undergoing liver resection between 2010 and 2015. Characteristics and outcomes were compared before and after propensity score matching (PSM). Primary endpoints were long-term oncological outcomes, such as recurrence-free survival (RFS) and overall survival (OS). Furthermore, stratification by the tumour burden score (TBS) was applied. RESULTS: Of 967 patients undergoing hepatectomy, 252 were analysed, with a median follow-up of 45 months. The unmatched comparison revealed a bias towards patients with neoadjuvant CTx presenting with more high-risk patients (p = 0.045) and experiencing increased postoperative complications ≥Clavien-Dindo III (20.9% vs. 8%, p = 0.003). Multivariable analysis showed that perioperative CTx was associated with significantly improved RFS (hazard ratio [HR] 0.579, 95% confidence interval [CI] 0.420-0.800, p = 0.001) and OS (HR 0.579, 95% CI 0.403-0.834, p = 0.003). After PSM (n = 180 patients), the two groups were comparable regarding baseline characteristics. The perioperative CTx group presented with a significantly prolonged RFS (HR 0.53, 95% CI 0.37-0.76, p = 0.007) and OS (HR 0.58, 95% CI 0.38-0.87, p = 0.010) in both low and high TBS patients. CONCLUSIONS: When patients after resection of CRLM are able to tolerate additional postoperative CTx, a perioperative strategy demonstrates increased RFS and OS in comparison with neoadjuvant CTx only in both low and high-risk situations.

Management of incidentally discovered appendiceal neuroendocrine tumors after an appendicectomy.

Appendiceal neuroendocrine tumors (aNETs) are an uncommon neoplasm that is relatively indolent in most cases. They are typically diagnosed in younger patients than other neuroendocrine tumors and are often an incidental finding after an appendectomy. Although there are numerous clinical practice guidelines on management of aNETs, there is continues to be a dearth of evidence on optimal treatment. Management of these tumors is stratified according to risk of locoregional and distant metastasis. However, there is a lack of consensus regarding tumors that measure 1-2 cm. In these cases, some histopathological features such as size, tumor grade, presence of lymphovascular invasion, or mesoappendix infiltration must also be considered. Computed tomography or magnetic resonance imaging scans are recommended for evaluating the presence of additional disease, except in the case of tumors smaller than 1 cm without additional risk factors. Somatostatin receptor scintigraphy or positron emission tomography with computed tomography should be considered in cases with suspected residual or distant disease. The main point of controversy is the indication for performing a completion right hemicolectomy after an initial appendectomy, based on the risk of lymph node metastases. The main factor considered is tumor size and 2 cm is the most common threshold for indicating a colectomy. Other factors such as mesoappendix infiltration, lymphovascular invasion, or tumor grade may also be considered. On the other hand, potential complications, and decreased quality of life after a hemicolectomy as well as the lack of evidence on benefits in terms of survival must be taken into consideration. In this review, we present data regarding the current indications, outcomes, and benefits of a colectomy.

Development of a prediction model of pancreatic fistula after duodenopancreatectomy and soft pancreas by assessing the preoperative image.

BACKGROUND: Pancreatic consistency is one of the most widely accepted risk factors of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatectoduodenectomy (PD). The present study aims to identify preoperative characteristics from the preoperative computed tomography (CT) associated with an increased risk. METHODS: Retrospective observational cohort study of patients who underwent PD surgery (January 2010-2019) were enrolled. All patients with available preoperative imaging were included; 103 met the inclusion criteria. Several parameters were measured on preoperative abdominal CT: retrorenal adipose tissue; abdominal perimeter; total adipose tissue, visceral and subcutaneous; skeletal muscle mass; main pancreatic duct (MPD) diameter; pancreatic thickness; remnant pancreatic volume; pancreatic attenuation (pancreas-to-spleen ratio). Primary endpoints were the association of radiological variables with soft pancreatic consistency and POPF development. All variables possibly associated with POPF and soft pancreas were subsequently included into a multivariable logistic regression model. RESULTS: Soft pancreas consistency was found in 43 patients (41.7%) and CR-POPF was higher (51.2% vs. 18%, p < 0.001). Multivariable analysis identified MPD ≤ 3 mm (OR = 7.2, 95%CI 2.3-23, p = 0.001), a remnant pancreatic volume ≥ 20 cm3 (OR = 6.4, 95%CI 2-21, p = 0.041), pancreas-to-spleen < 0.8 (OR = 3.2, 95%CI 1.2-8.4, p = 0.039), and retrorenal adipose tissue ≥ 12 cm3 (OR = 5.3, 95%CI 1.8-15.7, p = 0.013). Multivariable analysis showed MPD ≤ 3 mm (OR = 8.25, 95%CI 2.2-30.8, p = 0.002) and total adipose tissue ≥ 190 cm3 (OR = 3.2, 95%CI 1.1-9.1, p = 0.0027) were independent predictors of CR-POPF. CONCLUSION: The preoperative assessment of MPD, remnant pancreatic volume, pancreas-to-spleen ratio, total adipose tissue, and retrorenal adipose tissue are associated with soft pancreas texture and the risk of CR-POPF.