Minimally Invasive Approach & Key Aspects For The Treatment of Median Arcuate Ligament Syndrome: Case Report

[eng] Background: Median arcuate ligament syndrome (MALS) is a rare condition resulting from the external compression of the celiac artery by an abnormally downward located media arcuate ligament (MAL). The aim of this video is to illustrate the key steps for minimally invasive approach for the surgical treatment of MALS. Case Description: We present the case of an 18 years old female without any important past medical history referring 1 year of postprandial epigastric pain associated with weight-loss. After normal complementary tests, computed tomography (CT) scan showed 60% celiac trunk stenosis with post-stenotic dilation. Surgical approach started with two 5 mm, one 11 mm and one 12 mm laparoscopy trocars. Opening the pars flaccida of the lesser omentum and separating the right crus from the esophagus gives access to the abdominal aorta. Additional care must be taken to avoid injury of the branches of the celiac trunk, especially the common hepatic and left gastric arteries. Careful dissection of adhesions using laparoscopic sealer and hook cautery gives access to the fibrous tissue of the MAL. Finally, as when the musculo-fibrous structure of MAL is seen it must be divided until the celiac trunk is freed completely and its branches are seen. Surgical time was 1 hour 33 minutes long with no blood loss. Post-operative was uneventful (Clavien-Dindo: 0) and the patient was discharged at 48 hours from the admission. During the follow-up, the patient presented adequate oral intake without epigastric postprandial pain. Conclusions: Minimally invasive approach for MAL release is feasible, effective and safe following key steps and paying attention to vascular the structures near the celiac trunk. Keywords: Median arcuate ligament syndrome (MALS); minimally invasive surgical procedures; laparoscopy; case repor

Analysis of potential risk factors in the survival of patients with primary retroperitoneal liposarcoma

[eng] Introduction The present work is an observational study of a series of variables regarding overall survival and disease-free survival in patients diagnosed with primary liposarcoma. Methods The study is prospective with retrolective data collection that includes all patients with primary liposarcoma referred to Hospital Son Espases University Hospital, Palma de Mallorca, Spain from January 1990 to December 2019. Results The study includes 50 patients and the compartment surgery was performed in 18 patients (36%) of cases. The mean overall survival of the sample was 15.57 years (95% CI: 12.02-19.12) and the mean disease-free survival was 6.70 years (95% CI: 4.50-8.86). Conclusion Compartment surgery has not shown benefits in terms of overall survival and disease-free survival. The ASA classification (≥3) predicts a poor prognosis in both overall survival and disease-free survival. Resection with free margins, described on the pathological results and defined in this work as R0, show better disease-free survival

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Doble Grapado Lineal en la Anastomosis Gastroyeyunal como Prevención de Estenosis. Experiencia en Nuestro Centro

[spa] La derivación biliopancreática tiene efectos beneficiosos sobre la obesidad y las comorbilidades asociadas. Sin embargo, esta cirugía no está libre de complicaciones y posibles efectos secundarios. La estenosis gastroyeyunal es un evento adverso postoperatorio que influye en la calidad de vida de los pacientes y que puede necesitar ingresos hospitalarios, procedimientos endoscópicos e incluso reintervenciones quirúrgicas. Para prevenir estos eventos adversos, nos propusimos realizar la anastomosis gastroyeyunal mediante doble grapado lineal consecutivo y comparar las tasas de estenosis de la anastomosis respecto al grapado lineal simple. Se ha realizado una revisión retrospectiva consecutiva de pacientes sometidos a derivación biliopancreática laparoscópica por obesidad mórbida. Se incluyeron 98 pacientes, 83 pertenecientes al grupo de grapado lineal simple y 15 pacientes al doble grapado lineal doble y para homogenizar la muestra se aplicó el sistema Propensity Score Matching, obteniendo una muestra final de 45 pacientes, 30 con grapado lineal simple y 15 con doble.Tras el análisis de los datos, se objetivó que la anastomosis gastroyeyunal con grapado lineal doble obtuvo una menor incidencia de estenosis y del edema anastomótico, evidenciando una menor estancia hospitalaria y manteniendo una correcta pérdida ponderal en el seguimiento postoperatorio