Implementación del protocolo ERAS en ancianos sometidos a resección hepática / Implementation of an ERAS protocol on elderly patients in liver resection

Introducción: El aumento en la calidad de vida, la mejora en los cuidados perioperatorios, la aplicación del concepto de fragilidad y un mayor desarrollo de técnicas quirúrgicas permite a pacientes ancianos el acceso a la cirugía hepática. Sin embargo, la edad sigue siendo limitante para la implementación de protocolos ERAS en este grupo. El objetivo del estudio es evaluar la implementación del protocolo ERAS en pacientes ancianos (≥70años) sometidos a resecciones hepáticas. Métodos: Estudio de cohorte prospectivo que incluye pacientes intervenidos de resección hepática durante diciembre de 2017 a diciembre de 2019 sometidos a un programa ERAS, comparando los resultados de pacientes ≥70años (G≥70) frente a <70años (G<70). La fragilidad se midió con el score Physical Frailty Phenotype. Resultados: Se incluyeron 101 pacientes, de los que 32 (31,6%) correspondieron a G≥70. El 90% de ambos grupos verificaron realizar >70% del ERAS. Se encontraron diferencias a favor del G<70 en el inicio de tolerancia y la movilización activa el primer día postoperatorio. La estancia postoperatoria fue superponible (3,07días vs 2,7días). La morbimortalidad fue similar; ClavienI-II (G≥70: 41% vs G<70: 30,5%) y ≥III (G≥70: 6% vs G<70: 8,5%), al igual que los reingresos. La mortalidad global fue <1%. El cumplimiento del ERAS se asoció a un descenso en las complicaciones (ERAS <70%: 80% vs ERAS >90%: 20%; p=0,02) y de la gravedad de las mismas en la serie global y en ambos grupos a estudio. El 6% del G≥70 presentó fragilidad; el único paciente fallecido alcanzó un índice de fragilidad de 4. Conclusión: Los pacientes ancianos son candidatos a entrar en protocolo ERAS obteniendo una rápida recuperación, sin aumentar la morbimortalidad ni los reingresos. (AU)

Background: The increase of quality of life, the improvement in the perioperative care programs, the use of the frailty index, and the surgical innovation has allowed to access of complex abdominal surgery for elderly patients like liver resection. Despite of this, in patients aged 70 or older there is a limitation for the implementation ERAS protocols. The aim of this study is to evaluate the implementation ERAS protocol on elderly patients (≥70years) undergoing liver resection. Methods: A prospective cohort study of patients who underwent liver resection from December 2017 to December 2019 with an ERAS program. We compare the outcomes in patients ≥70years (G≥70) versus <70years (G<70). The frailty was measured with the Physical Frailty Phenotype score. Results: A total of 101 patients were included; 32 of these (31.6%) were patients ≥70years. 90% of the both groups had performed >70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were quicker in <70years group. The hospital stay was similar in both groups (3.07days/2.7days). Morbidity and mortality were similar; ClavienI-II (G≥70: 41% vs G<70: 30.5%) and Clavien ≥III (G≥70: 6% vs G<70: 8.5%), like hospital readmissions. Mortality was <1%. ERAS protocol compliance was associated with a decrease in complications (ERAS <70%: 80% vs ERAS >90%: 20%; p=0.02) and decrease in severity of complications in both study groups. Frailty was found in 6% of the elderly group; the only patient who died had a frailty index of 4. Conclusion: Implementation of ERAS protocol for elderly patients is possible, with major improvements in perioperative outcomes, without an increase in morbidity, mortality neither readmissions. (AU)

Implementation of an ERAS protocol on elderly patients in liver resection.

BACKGROUND: The increase of quality of life, the improvement in the perioperative care programs, the use of the frailty index, and the surgical innovation has allowed to access of complex abdominal surgery for elderly patients like liver resection. Despite of this, in patients aged 70 or older there is a limitation for the implementation ERAS protocolos. The aim of this study is to evaluate the implementation ERAS protocol on elderly patients (≥70 years) undergoing liver resection. METHODS: A prospective cohort study of patients who underwent liver resection from December 2017 to December 2019 with an ERAS program. We compare the outcomes in patients ≥70 years (G ≥ 70) versus <70 years (G < 70). The frailty was measured with the Physical Frailty Phenotype score. RESULTS: A total of 101 patients were included. 32 of these (31.6%) were patients ≥70 years. 90% of the both groups had performed >70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were quicker in <70 years group. The hospital stay was similar in both groups (3.07days/2.7days). Morbidity and mortality were similar; Clavien I-II(G ≥ 70:41% vs G < 70:30,5%) and Clavien ≥ III (G ≥ 70:6% vs G < 70:8.5%), like hospital readmissions. Mortality was <1%. ERAS protocol compliance was associated with a decrease in complications (ERAS < 70%:80% vs ERAS > 90%:20%; p = 0.02) and decrease in severity of complications in both study groups. Frailty was found in 6% of the elderly group; the only patient who died had a frailty index of 4. CONCLUSION: Implementation of ERAS protocol for elderly patients is possible, with major improvements in perioperative outcomes, without an increase in morbidity, mortality neither readmissions.

Treatment of acute intraoperative Budd-Chiari syndrome by placement of silicone prosthesis.

Complete liver mobilization for major resections sometimes causes liver tilting due to the release of the suspensory elements of the liver. Rarely this may take to a liver abnormal position with acute obstruction to venous flow at the suprahepatic level (Budd-Chiari syndrome). To avoid this complication, techniques such as post-operative stent implantation have been described. The case of a patient who underwent a complete mobilization of the liver for resection of the inferior venous cava and a right renal tumor, was reported. After that, an acute Budd-Chiari Syndrome was observed caused of the liver malposition, which was solved with the placement of two silicone prostheses in the liver cell.

Right and Left Colorectal Cancer: Differences in Post-Surgical-Care Outcomes and Survival in Elderly Patients.

(1) There is evidence of the embryological, anatomical, histological, genetic and immunological differences between right colon cancer (RCC) and left colon cancer (LCC). This research has the general objective of studying the differences in outcome between RCC and LCC. (2) A longitudinal analytical study with prospective follow-up of the case-control type was conducted from 1 January 2010 to 31 December 2017 including 398 patients with 1:1 matching, depending on the location of the tumor. Inclusion criteria: programmed colectomies, 15 cm above the anal margin, adults and R0 surgery. (3) Precisely 6.8% of the exitus occurred in the first 6 months of the intervention. At 6 months, patients with LCC presented a mean survival of 7 months higher than RCC (p = 0.028). In the first stages, it can be observed that most of the exitus are for patients with RCC (stage I p = 0.021, stage II p = 0.014). In the last stages, the distribution of the deaths does not show differences between locations (stage III p = 0.683, stage IV p = 0.898). (4) The results show that RCC and LCC are significantly different in terms of evolution, progression, complications and survival. Patients with RCC have a worse prognosis, even in the early stages of the disease, due to more advanced N stages, larger tumor size, more frequently poorly differentiated tumors and a greater positivity of lymphovascular invasion than LCC.

Infarto esplénico masivo en bazo errante: una indicación infrecuente de esplenectomía de urgencia / Massive splenic infarction in a wandering spleen: A rare indication for emergency splenectomy

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Manejo conservador en íleo biliar / Non-operative management to gallstone ileus

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Obstrucción intestinal alta secundaria a cálculo impactado en duodeno (síndrome de Bouveret) / Gastric outlet obstruction due to duodenal gallstone (Bouveret syndrome)

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Osteoartritis secundaria a eventroplastia tipo Rives-Stoppa / Osteoarthritis secondary to Rives-Stoppa incisional hernia repair

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Oclusión intestinal secundaria a pinza aorto-mesentérica / Intestinal obstruction secondary to superior mesenteric artery syndrome

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