Evaluation of the knowledge of the critical view of safety and recognition of the transoperative complexity during the laparoscopic cholecystectomy.

INTRODUCTION: Since the establishment of the Critical view of safety (CVS), different strategies have been created such as bailout procedures (SC, subtotal cholecystectomy), classifications for preoperative and intraoperative complexity (The Parkland grading scale, PGS) and objective evaluation of the CVS (doublet score, DS) to establish a "Culture of Safety in Cholecystectomy, COSIC"; to avoid complications. METHODS: A multiple choice questionnaire was applied to residents and graduated surgeons from different Hospitals in Mexico during different national meetings; evaluating the knowledge of this different concepts (CVS, SC, PGS, DS), univariate logistic regression was used to assess the association of the knowledge with adverse events (AE) like the Bile duct injury. RESULTS: A total of 744 questionnaires were evaluated; 284 (38.17%) women and 460 (61.83%) men; 436 (58.6%) were residents and 308 (41.4%) graduated surgeons. 708 (95.16%) reported knowing the CVS; however, only (51.98%, p ≤ 0.001) defined the concept correctly, while 136 (18.28%) reported knowing the DS, but only 44 (5.91%) defined it correctly. Regarding the PGS, 398 (53.49%) mentioned knowing it, but only 262 defined it correctly. The concept of SC 642 (86.29%) reported knowing it; however, only (56.7%, p ≤ 0.001) correctly defined the techniques, being the reconstituting technique the preferred one (42.37% vs 34.89%). In this survey, the correct knowledge of the CVS (OR 0.47, p < 0.001), the subtotal techniques (OR 0.71 p = 0.07), the DS (OR 0.48 p < 0.001) and of the PGS (OR 0.28, p < 0.001) decreased the risk of presenting BDI. CONCLUSION: Despite the COSIC and the timing of publication of the CVS; the percentage of people who can correctly define basic safety concepts is low among residents and licensed surgeons. Therefore, it is important to emphasize the dissemination of these concepts to obtain safe LC and thus reduce the incidence of complications.

Intraoperative complexity and risk factors associated with conversion to open surgery during laparoscopic cholecystectomy in eight hospitals in Mexico City.

BACKGROUND: The conversion to open surgery (COS) during the Laparoscopic Cholecystectomy (LC) is reported to occur at a rate of 10-15%. Some preoperative risk factors (RF) have been postulated; however, few studies have evaluated these factors and the intraoperative complexity with the COS rate. The aim of the study was to evaluate the preoperative RF and intraoperative complexity using the Parkland grading scale (PGS) with the COS rate in LC. METHODS: A retrospective study was done evaluating the demographic and surgical variables from the patients and LC videos from 8 different hospitals of Mexico City from December 2018 to January 2020. The evaluation of the PGS was done by 2 surgeons (one MI and one HPB surgeon); the PGS was also categorized as Non-Complex LC (nCLC, PGS1-2) and Complex LC (CLC, PGS 3-5). Logistic regression was used to evaluate the association of this factors with the COS rate. RESULTS: 430 LC were analyzed; 358 (78.61%) were women, 261 (60.7%) were elective and 169(39.3%) urgent LC, the mean age was 44.06 (SD ± 13.16) years. 21 (4.8%) LC were COS; the mean age of this group was 55 (SD ± 12.95), 3 (0.7%) were nCLC and 18 (4.19%) CLC, mean PGS of 3.76 (SD ± 1.09), the mean time to COS was 48.67 (SD ± 41.9), the estimated blood loss (EBL) was 258 (SD ± 260.22) and 6 (1.4%) intraoperative BDI were recognized on this group. Univariate analysis showed a significant association with the COS with male sex, older age, age > 45 years, presence of comorbidities, a higher PGS, a CLC, higher EBL and possible BDI; multivariate analysis produced a model using male sex, age, presence of comorbidities and a CLC with a 0.809 area under the ROC curve. CONCLUSION: The recognition of the associated RF and a CLC can guide the surgeon to establish preoperative and bailout strategies during the procedure, recognizing a higher risk of COS and its higher morbidity.

[Hyperbilirrubinemia as a predictive factor of perforated appendicitis]. / Hiperbilirrubinemia como factor predictivo de apendicitis perforada.

BACKGROUND: Recent studies considered hyperbilirubinemia as a marker to identify the presence of perforated appendix. The aim of the study is to verify that the presence of hyperbilirubinemia is a useful marker to identify the presence of perforated appendix before surgery, and thereby, provide early treatment to avoid progression of the disease and its complications. METHODS: This is a retrospective study, which identified 225 patients, who met the inclusion and exclusion criteria, from January 2012 to October 2014 at the IMSS General Hospital 29, taking into account laboratory results and postoperative, performing a univariate, bivariate and multivariate analysis. RESULTS: 56.9% showed bilirubin < 1, from which 16.4% presented perforation, while 43.1% showed bilirubin > 1, 62.88% presented perforated appendicitis. Hyperbilirubinemia increases 17 times the risk of perforated appendix (RMP: 17.63; IC 95%: 6.882-45.207; p < 0.001) which is statistically significant. CONCLUSIONS: Considering the limitations of this study, it can be inferred that hyperbilirubinemia is present in a great number of patients with perforated appendicitis, so it could be considered a relevant laboratory test to include within the protocol of appendicitis, which in turn, may determine a better planning for the surgical approach.

Introducción: en estudios recientes se considera la hiperbilirrubinemia como un marcador para identificar la presencia de apendicitis perforada. El objetivo del estudio es comprobar que la presencia de hiperbilirrubinemia es un marcador útil para identificar preoperatoriamente a los pacientes con presencia de perforación apendicular, y de esta manera proporcionar un tratamiento oportuno evitando la progresión de la patología y sus complicaciones. Métodos: estudio retrospectivo, con 225 pacientes, los cuales contaban con los criterios de inclusión y exclusión, del periodo de enero de 2012 a octubre del 2014 en el HGZ 29 del IMSS, tomando en cuenta resultados de laboratorio y posquirúrgico, realizando análisis univariado, bivariado y multivariado. Resultados: el 56.9% presentó bilirrubina < 1, de los cuales el 16.4% presentó perforación, mientras que el de 43.1% con bilirrubina > 1, el 62.88% presentó apendicitis perforada. La hiperbilirrubinemia incrementa 17 veces más el riesgo de presentar apendicitis perforada (RMP: 17.63; IC 95%: 6.882-45.207; p < 0.001), lo que resulta estadísticamente significativo. Conclusiones: considerando las limitaciones de este estudio, se puede inferir que la hiperbilirrubinemia está presente en un mayor número de pacientes con apendicitis perforada, por lo cual podría ser considerado como un estudio de laboratorio relevante para incluir dentro del protocolo de apendicitis, lo cual, a su vez, puede determinar una mejor planeación para el abordaje quirúrgico.