Days of symptoms and days of hospital admission before surgery do not influence the results of cholecystectomy in moderate acute calculous cholecystitis-Cholecystectomy remains the best treatment.

BACKGROUND AND AIMS: early cholecystectomy is the gold-standard treatment for acute calculous cholecystitis (ACC), although many surgeons still prefer delayed cholecystectomy for grade II to avoid surgical complications. The aim of this study was to analyze the postoperative morbidity and mortality of Tokyo Guidelines grade-II ACC as treated with cholecystectomy, taking into account the days of symptoms and days since hospital admission. MATERIALS AND METHODS: a unicenter, retrospective study was performed based on a prospective database. Patients with grade-II ACC treated with cholecystectomy were selected. Patients were analyzed according to days of symptoms (DS) and days of hospital admission (DHA) until cholecystectomy. Patients were subdivided into 3 groups: < 3 days, 3-5 days, and > 5 days. Univariate and multivariate analyses were performed for morbidity and mortality. Categorical variables were compared using the Chi-squared or Fischer's exact test. Continuous variables were compared using the Mann-Whitney U-test. The level of statistical significance was set at p < 0.05. RESULTS: a total of 998 patients with ACC diagnosis were included; 567 with grade-II ACC and 368 treated with cholecystectomy. Nearly 90 % were treated laparoscopically and 48.1 % underwent surgery the same day of emergency admission. With regard to DS and DHA, there were no statistical differences for severe postoperative complications, although a greater number of complications were detected in the > 5 DS group (p: 0.32) and > 5 DHA group (p: 0.00). Statistically significant differences were found in DS for mortality (p: 0.04). Postoperative length of stay was longer for > 5 DHA group cholecystectomies (p > 0.05). There were no differences with regard to hospital readmission. CONCLUSION: with regard to DS or DHA until cholecystectomy, there were no statistically significant differences related to severe postoperative complications, length of stay, or mortality.

Risk factors for suboptimal laparoscopic surgery in rectal cancer patients.

PURPOSE: Laparoscopic surgery for rectal cancer is technically complex. This study aimed to identify risk factors for suboptimal laparoscopic surgery (involved margins, incomplete mesorectal excision, and/or conversion to open surgery) in patients with rectal cancer. METHODS: We included patients undergoing laparoscopic anterior resection for rectal cancer between June 2009 and June 2018. We defined the outcome variable suboptimal laparoscopic surgery as conversion to open surgery or inadequate histopathological specimens (margins < 1 mm or involved and/or poor-quality mesorectal excision). To identify independent predictors of suboptimal laparoscopic surgery, we analyzed 15 prospectively recorded demographic, clinical, and anthropometric variables obtained from our rectal cancer unit's database. Subanalyses examined the same variables with respect to conversion and to inadequate histopathological specimens. RESULTS: Of the 323 patients included, 91 (28.2%) had suboptimal laparoscopic surgery. In the multivariate analysis, the independent factors associated with all suboptimal laparoscopic surgery were tumor location ≤ 5 cm from the anal verge (OR = 2.95, 0.95% CI 1.32-6.60; p = 0.008) and the intertuberous distance (OR = 0.79, 0.95% CI 0.65-0.96; p = 0.019). In the subanalyses, the promontorium-retropubic axis was an independent predictor of conversion (OR 0.70, 0.95% CI 0.51-0.96; p = 0.026), and tumor location ≤ 5 cm from the anal verge (OR 3.71, 0.95% 1.51-9.15; p = 0.004) was an independent predictor of inadequate histopathological specimens. CONCLUSIONS: Predictive factors for suboptimal laparoscopic anterior resection for rectal cancer were tumor location and the intertuberous distance. These results could help surgeons decide whether to use other surgical approaches in complex cases. TRIAL REGISTRATION: The study was registered at Clinicaltrials.org (No. NCT03107650).

A randomized clinical trial comparing the initial vascular approach to the inferior mesenteric vein versus the inferior mesenteric artery in laparoscopic surgery of rectal cancer and sigmoid colon cancer.

BACKGROUND: The inferior mesenteric artery approach with a selective lateral splenic flexure mobilization is the most widely used initial step in laparoscopic rectal and left colon surgery. Surgery started through the inferior mesenteric vein (IMV) with systematic medial mobilization (MM) has some theoretical advantages that have never been analyzed in a clinical trial. The aim of this study was to compare the two techniques with regards to surgical technique variables (conversion, surgical time, bleeding, morbidity, and mortality) and pathological outcomes. METHODS: A single-blinded, randomized, controlled trial of patients operated electively by laparoscopic with curative intention for rectal or sigmoid cancer was performed at a single, specialized colorectal surgery department from April 2016 to October 2017. RESULTS: 49 patients were included in each group. There were no statistical differences in patient demographics between the two approaches. Pathological outcomes did not differ between the two groups. Intra-operative characteristics showed a higher conversion rate in patients in which the inferior mesenteric artery was dissected first (p = 0.031). The artery approach also increased intra-operative bleeding (p = 0.049), but there were no differences regarding operative time. On multivariate analysis, the artery approach was associated with a higher risk of conversion (OR 8.68; p = 0.050). Post-operatory complications did not differ between artery and vein dissection. CONCLUSIONS: In our study, the initial approach by the IMV with a systematic MM of the splenic flexure has allowed us to reduce the conversion rate without increasing complications or the surgical time. No differences were observed in the pathological results. Both approaches seem to be safe and effective and well-trained laparoscopic surgeons should have the two techniques available to them for use as needed.

Litiasic acute cholecystitis: application of Tokyo Guidelines in severity grading.

BACKGROUND: Acute calculous cholecystitis (AC) is one of the most frequent surgical emergencies in our field. Laparoscopic cholecystectomy is considered the treatment of choice, although not sufficiently widespread. OBJECTIVE: To analyze the application of the Tokyo Guidelines in the management of AC and to determine the influence of the degree of severity on management and prognosis. METHOD: Prospective, observational study of patients with a primary diagnosis of AC between 2010 and 2015.. Exclusion criteria: AC recurrence; AC as a secondary diagnosis; acalculous cholecystitis; concurrent biliary pathology. Severity was classified according Tokyo 2013 Guidelines. RESULTS: 998 patients were included: 338 (33.9%) mild AC, 567 (56.8%) moderate AC, and 93 (9.3%) severe AC. A total of 582 (58.3%) patients were operated on. Postoperative complications Dindo-Clavien grade ≥ II 12.6%: mild AC 3.6%; moderate AC 12.2%; severe AC 49.0% (p < 0.001). Overall mortality 2%: mild AC 0%; moderate AC 0.5%; severe AC 18.0% (p < 0.001). CONCLUSION: Urgent laparoscopic cholecystectomy remains the treatment of choice for mild and moderate AC. In patients with severe AC, the risks and benefits of surgery should be assessed, given the high degree of complications and associated mortality.

ANTECEDENTES: La colecistitis aguda litiásica (CA) es una de las urgencias quirúrgicas más frecuentes en nuestro medio. La colecistectomía laparoscópica se considera el tratamiento de elección, aunque sigue sin ser una realidad su práctica generalizada. OBJETIVO: Analizar la aplicación de las Guías de Tokio en el manejo de la CA y determinar la influencia de la gravedad en el manejo y el pronóstico. MÉTODO: Estudio prospectivo, observacional, de pacientes con diagnóstico primario de CA entre 2010 y 2015. Criterios de exclusión: recidiva de CA, CA como diagnóstico secundario, CA alitiásica u otra patología biliar concomitante. Se ha clasificado la gravedad según las Guías de Tokio de 2013. RESULTADOS: Se incluyen 998 CA: 338 (33.9%) leves, 567 (56.8%) moderadas y 93 (9.3%) graves. Se operaron 582 pacientes (58.3%), y posteriormente 15 precisaron rescate. Complicaciones posoperatorias Dindo-Clavien ≥ 12,6%: CA leve 3,6%, CA moderada 12,2%, CA grave 49% (p < 0.001). Mortalidad global 2%: CA leve 0%, CA moderada 0.5%, CA grave 18% (p < 0.001). CONCLUSIÓN: La colecistectomía laparoscópica sigue siendo el tratamiento de elección para la CA leve y moderada. En pacientes con CA grave debe valorarse el riesgo-beneficio de la cirugía, dadas las complicaciones y la mortalidad asociadas.

The teaching of liaison psychiatry.

OBJECTIVE: To document performance and satisfaction of medical students in a short course on liaison psychiatry. METHODS: The emphasis in this optional course is placed on the discussion of clinical cases, bed-side clinical teaching, and a research-oriented part. The "Innovative Teaching Plan" (ITP) is intended to train student-leaders to guide small groups (SG) of students. Trainee performance was assessed by the marks in the final examination, and a reliable and valid tool, the Medical Teaching Quality Questionnaire (MTQQ) was used to document trainee satisfaction. The results of four academic courses are presented in this report. RESULTS: External experts consulted assured that the content of the course was adequate. It has been completed by more than 200 medical students, and high marks have been obtained by most. Above average scores (AA, "high" or "very high") were given by substantial proportions of students in most items, related to the "relevance" of the subject, the "usefulness of the clinical cases" or the "enhancement of student-teacher interaction". Compared to the first academic course, students' satisfaction has improved. "Enhancement of a researcher's mind" was rated AA by 61.1% of students in the last academic course, and "global satisfaction" by 88.8%. CONCLUSIONS: Good performance and high satisfaction of medical students was documented in a course on liaison psychiatry. Lessons may be drawn to inform about efficient and effective ways of teaching and learning this subject.