Nueva escala simplificada basada en el sistema Possum para la predicción del riesgo quirúrgico en cirugía digestiva urgente

La complejidad de las auditorías médico-quirúrgicas radica en la dificultad para definir objetivos y estándares que permitan comparar resultados. Debido a la composición de cada casuística, las cifras crudas de morbi-mortalidad deben corregirse y ajustarse al riesgo. La escala POSSUM (compuesta por 18 variables, 12 fisiológicas y 6 operatorias) agrupa a los pacientes quirúrgicos en base al riesgo de morbilidad y mortalidad y podría ser una herramienta útil para realizar auditorías quirúrgicas.. Para emplear un sistema de predicción de riesgo fuera del contexto original en el que se desarrolló, es necesario validar sus prestaciones en la nueva población diana. En el presente estudio, se aplicó la escala POSSUM en un Servicio de Cirugía General y del Aparato Digestivo de un hospital terciario, y se comprobó que sobreestima el riesgo de morbilidad en la cirugía gastrointestinal. A continuación, se comparó el comportamiento de la escala entre la cirugía gastrointestinal programada y urgente. POSSUM estimó adecuadamente el riesgo de morbilidad de la cirugía gastrointestinal programada. Sin embargo, sobreestimó ese riesgo en la cirugía gastrointestinal de urgencias, donde los resultados observados fueron mejores que los esperados. La cirugía urgente engloba tanto a aquellos pacientes que ingresaban de forma urgente por patología adquirida en la comunidad (urgencias comunitarias), como a aquellos que habiendo sido ya intervenidos sufren durante el mismo ingreso una complicación en el postoperatorio que requiere una reintervención quirúrgica urgente (urgencias nosocomiales). En el siguiente capítulo se decidió descartar las urgencias nosocomiales y centrar el estudio en las urgencias comunitarias, ya que representan una importante proporción de todas las intervenciones de un servicio de Cirugía General y del Aparato Digestivo. Por ello, el siguiente objetivo consistió en definir unas nuevas fórmulas basadas en la escala POSSUM para predecir el riesgo de morbilidad en la cirugía gastrointestinal urgente. Se diseñó un estudio descriptivo prospectivo centrado en 2361 pacientes que recibieron una intervención quirúrgica urgente por patología adquirida en la comunidad. Las primeras 1000 cirugías consecutivas constituyeron la cohorte de desarrollo del nuevo modelo; las siguientes 1000 cirugías constituyeron la cohorte de primera validación; y los 361 casos restantes, pertenecientes a otro hospital, constituyeron la cohorte de segunda validación externa. Primero, se desarrolló una escala POSSUM modificada incluyendo las mismas variables que la original. A continuación, se crearon dos nuevas escalas que llamamos LUCENTUM (aLicante sUrgical Community Emergencies New Tool for the enUmeration of Morbidities): 1) LUCENTUM Regression Logística (RL), seleccionó 5 variables: edad, sodio, leucocitos, hemoglobina y complejidad quirúrgica; y 2) LUCENTUM CHAID (Chi-Square Automatic Interaction Detector), incluyó 4 variables: fallo cardiaco, sodio, complejidad quirúrgica y exudado peritoneal. Con la nueva escala POSSUM modificada se obtuvieron mejores resultados de predicción que los estimados por la escala original. Las nuevas escalas LUCENTUM estimaron mejor el riesgo de morbilidad de la cirugía gastrointestinal de urgencias en las tres cohortes del estudio. En conclusión, una nueva escala POSSUM modificada y dos nuevas escalas LUCENTUM, estiman adecuadamente el riesgo de morbilidad en la cirugía gastrointestinal de urgencias adquiridas en la comunidad

Textbook outcome in oncological gastric surgery: a systematic review and call for an international consensus

Abstract Background Textbook outcome (TO) is a multidimensional measure used to assess the quality of surgical practice. It is a reflection of an “ideal” surgical result, based on a series of benchmarks or established reference points that may vary depending on the pathology in question. References to TO in the literature are scarce, and the few reports that are available were all published very recently. In the case of gastric surgery, there is no established consensus on the parameters that should be included in TO, a circumstance that prevents comparison between series. Aim To present a review of the literature on TO in gastric surgery (TOGS) and to try to establish a consensus on its definition. Material and methods Following the PRISMA guide, we performed an unlimited search for articles on TOGS in the MEDLINE (PubMed), EMBASE and Cochrane, Latindex, Scielo, and Koreamed databases, without language restriction, updated on December 31, 2022. The inclusion criterion was any type of study assessing TO in adult patients after oncological gastric surgery. Selected studies were assessed, and TOGS was measured. The parameters used to assess the achievement of TOGS in selected studies were also recorded. Results Twelve articles were included, comprising a total of 44,581 patients who had undergone an oncological gastric resection. The median rate of TOGS was 38.6%. All the publications but one included mortality as a TO variable, showing statistically significant differences in favor of the group in which TOGS was achieved. All articles included the number of nodes examined in the surgical specimen, with the assessment of fewer than 15 being associated with a low rate of TOGS achievement in five studies (41.7%). The variable postoperative complications according to the Clavien-Dindo score was the most important cause of failure to achieve TOGS in four studies (33.3%). Seven articles (58.3%) found a significant increase in long-term survival in patients who obtained TO. Advanced age, elevated ASA, and Charlson score had a negative impact on obtaining TOGS. Conclusions The standardization of TOGS is necessary to be able to establish comparable results between groups

Surgical outcomes of gallbladder cancer: the OMEGA retrospective, multicentre, international cohort study

Background Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC).Methods The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity.Findings On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84-1.29], p = 0.711 and HR 1.18 [0.95-1.46], p = 0.13 respectively) or OS (HR 0.96 [0.79-1.17], p = 0.67 and HR 1.48 [1.16-1.88], p = 0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02-1.74], p = 0.037) and OS (HR 1.26 [1.03-1.53], p = 0.022). Furthermore, EBDR (OR 2.86 [2.3-3.52], p < 0.0010), resection of additional organs (OR 2.22 [1.62-3.02], p < 0.0010) and major hepatectomy (OR 3.81 [2.55-5.73], p < 0.0010) were all associated with increased morbidity and mortality. Compared to LMIC, patients in HIC were associated with poorer RFS (HR 1.18 [1.02-1.37], p = 0.031) but not OS (HR 1.05 [0.91-1.22], p = 0.48). Adjuvant and neoadjuvant treatments were infrequently used.Interpretation In this large, multicentre analysis of GBC surgical outcomes, liver resection was not conclusively associated with improved survival, and extended resections were associated with greater morbidity and mortality without oncological benefit. Aggressive upfront resections do not benefit higher stage GBC, and international col-laborations are needed to develop evidence-based neoadjuvant and adjuvant treatment strategies to minimise surgical morbidity and prioritise prognostic benefit.Funding Cambridge Hepatopancreatobiliary Department Research Fund.Copyright & COPY; 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)