Análisis de los factores de riesgo de recidiva del hepatocarcinoma en el trasplante hepático

Actualmente existe un avance imparable en el desarrollo de la biomedicina y de la ingeniería biomédica, muchas de las líneas de investigación van encaminadas al desarrollo de sustitutos mecánicos o biológicos para órganos humanos dañados como las bombas de insulina o las máquinas de diálisis cada vez más potentes. Sin embargo, el hígado sigue siendo un órgano tan complejo por sus múltiples funciones que a día de hoy es impensable un sustituto artificial. El trasplante de órganos se ha convertido por lo tanto en un recurso terapéutico excepcional y de gran importancia al ser la única opción para múltiples patologías renales, cardiacas, pulmonares y especialmente hepáticas entre otras. A nivel hepático al igual que ocurre con el resto de órganos, los donantes se asignan en España desde un organismo central llamado ONT que tiene en cuenta el deterioro de la función hepática para su asignación. El desarrollo de tratamientos médicos ha motivado que en las listas de espera de TH cada vez tenga más peso el HCC, el segundo tumor con más mortalidad a nivel internacional. Sin embargo, la recidiva se produce en el 10-15% de los casos ensombreciendo el pronóstico del tratamiento. En la actual tesis se pretende analizar los posibles factores asociados a la recidiva del HCC en el hígado trasplantado, mediante su estudio y control podría mejorarse la selección de pacientes y los resultados de los mismos. El análisis de los factores se ha dividido según se asocien al donante, al receptor, al tratamiento en lista de espera, a la inmunosupresión postcirugía, a la histología tumoral y factores relacionados con el acto quirúrgico. Para poder desarrollar este proyecto se ha diseñado un estudio de cohortes, observacional y retrospectivo sobre una base de datos prospectiva y anonimizada de los pacientes adultos trasplantados hepáticos por hepatocarcinoma en el Hospital Virgen del Rocío en el periodo comprendido entre 1992 y 2017. Los pacientes se han dividido en dos grupos según periodos cronológicos. El Hospital Universitario Virgen del Rocío es uno de los centros nacionales con mayor actividad de trasplante hepático según datos del RETH, con una media de 68 trasplantes al año supone aproximadamente un 6% de los que se realizan en territorio nacional. El análisis de la muestra obtenida para este trabajo es de 229 pacientes trasplantados hepáticos en el HUVR ha sido comparado con los datos que aporta el RETH. El HCC supone una de las principales indicaciones de trasplante hepático motivando el 23% de los TH de la serie total (332 de 1450 pacientes), pasan de una incidencia del 4% en los primeros años al 46,7% de los TH del 2018, cerca del 28,4% que figura en el RETH. La supervivencia global a 1, 3 y 5 años (88,2%, 80,1% y 73,6 respectivamente) del total de la serie se compone de un espectro temporal amplio con diferencias importantes entre los diferentes periodos que pueden actuar como factor de confusión. Las diferencias estadísticamente significativas entre las supervivencias globales por grupos son manifiestas a 1, 3 y 5 años, en la serie 1 son del 72,8 %, 63% y 55,4% respectivamente mientras que en la serie 2 es del 91,5 %, 83,4% y 79,2%. Durante el seguimiento de los pacientes se han recogido un total de 32 recidivas, el 15,2% de los pacientes trasplantados hepáticos por HCC. Tras comparar la supervivencia y el índice de recidiva de nuestra serie con los registros de la SETH y la literatura publicada, pensamos que a pesar de la controversia existente la estadificación modificada de BCLC-A y –B y los Up to 7, basada en un tumor único < 7 cm y múltiples tumores más allá de los criterios de Milán donde la suma de los tamaños no supere 7 cm y junto con el uso de TLR, podría soportar un incremento de los criterios de aceptación del HCC para poder ser trasplantado de forma controlando y asegurando un pronóstico similar a los criterios estrictos de Milán. El efecto de la expansión de los criterios de Milán en la lista de espera es una variable que depende no solo del estado histológico de los pacientes con HCC sino también de las características de cada centro de la lista de espera y de los donantes. Actualmente con la bibliografía presente se han establecido acuerdos a nivel internacional para aceptar unos criterios expandidos fruto del análisis en cada región de trasplante y de acuerdo con el principio de beneficio de supervivencia para todos los pacientes en la lista de espera. Por lo tanto, siempre que la presión de la lista de espera lo permita, debe analizarse el umbral de supervivencia aceptable ofreciendo flexibilidad a las indicaciones de TRL y TH para estos pacientes cuya última opción terapéutica curativa somos nosotros. Dentro del estudio individualizado de los factores de riesgo de recidiva de hepatocarcinoma: no se identificaron factores del donante, tratamiento inmunosupresor o técnica quirúrgica como factores de riesgo de recidiva del HCC. Los principales factores pronósticos que se han relacionado con la recidiva del HCC en la muestra analizada son el tamaño tumoral, número de nódulos, niveles de Alfa-fetoproteina (AFP), el tratamiento en lista de espera y el cumplimiento de criterios de Milán. Uno de los hallazgos más destacables que arroja la tesis es en relación a la recidiva precoz del HCC, los niveles de AFP pretrasplante constituyen un marcador pronóstico eficaz. Valores de AFP >200 ng/ml pretrasplante suponen un riesgo independiente de recidiva tumoral precoz. El tratamiento en lista de espera de los pacientes trasplantados con HCC disminuye la tasa de recidiva tumoral, y tiene impacto en la supervivencia global postrasplante

Diversity and ethics in trauma and acute care surgery teams: results from an international survey

Background Investigating the context of trauma and acute care surgery, the article aims at understanding the factors that can enhance some ethical aspects, namely the importance of patient consent, the perceptiveness of the ethical role of the trauma leader, and the perceived importance of ethics as an educational subject. Methods The article employs an international questionnaire promoted by the World Society of Emergency Surgery. Results Through the analysis of 402 fully filled questionnaires by surgeons from 72 different countries, the three main ethical topics are investigated through the lens of gender, membership of an academic or non-academic institution, an official trauma team, and a diverse group. In general terms, results highlight greater attention paid by surgeons belonging to academic institutions, official trauma teams, and diverse groups. Conclusions Our results underline that some organizational factors (e.g., the fact that the team belongs to a university context or is more diverse) might lead to the development of a higher sensibility on ethical matters. Embracing cultural diversity forces trauma teams to deal with different mindsets. Organizations should, therefore, consider those elements in defining their organizational procedures. Level of evidence Trauma and acute care teams work under tremendous pressure and complex circumstances, with their members needing to make ethical decisions quickly. The international survey allowed to shed light on how team assembly decisions might represent an opportunity to coordinate team member actions and increase performance

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p &lt; 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Use of polyvinylidene fluoride (PVDF) meshes for ventral hernia repair in emergency surgery

[Purpose] The implantation of non-absorbable meshes is the gold standard technique for ventral hernia (VH) repairs. However, emergency surgeries are often related to contaminated/infected fields, where the implantation of prosthetic materials may not be recommendable. Our aim was to evaluate the results of polyvinylidene fluoride (PVDF) meshes used for contaminated and/or complicated VH repairs in the acute setting.[Methods] We conducted a retrospective analysis of patients with VH who underwent emergency surgery involving PVDF meshes, in a tertiary hospital (from November 2013 to September 2019). We analyzed postoperative complications and 1-year recurrence rates. We evaluated the relationships between contamination grade, mesh placement, infectious complications, and recurrences. [Results] We gathered data on 123 patients; their mean age was 62.3 years, their mean BMI was 31.1 kg/m2, and their mean CeDAR index was 51.6. 96.4% of patients had a grade 2–3 ventral hernia according to the Rosen index. The mean defect width was 8 cm (IQR 2–18). 93 cases (75.6%) were described as contaminated or dirty surgeries. A PVDF mesh was placed using an IPOM technique in 56.3% of cases, and via interposition location in 39.9%. The one-month recurrence rate was 5.7% and recurrence after one year was 19.1%. The overall mortality rate was 27.6%. Risk of recurrence was related to patients with a Rosen score over 2 (p < 0.001), as well as with postoperative SSI (p = 0.045). Higher recurrence rates were not related to PVDF mesh placement. [Conclusion] The use of PVDF meshes for emergency VH repairs in contaminated surgeries seems safe and useful, with reasonable recurrence rates, and acceptable infectious complication rates, similar to those published in the literature

Manejo urgente de los abscesos perianales. Una tarea aún pendiente.

The aim of the study was to evaluate urgent care practice with regard to anorectal abscesses (AA) in a tertiary-level referral hospital. this was retrospective and unicentric study. Patients who underwent surgery for AA between 2016 and 2017 were included in the study. Demographic variables were analyzed as well as the treatment performed, the need for hospitalization, use of antibiotics, and referral to the coloproctology outpatient department (COD). The recurrence risk factors were also evaluated. A total of 220 evaluations under anesthesia were performed, corresponding to 190 patients, 129 males (mean age 46 ± 14.9 years). The most frequent treatment in the emergency department (ED) was simple drainage (75.8%). Antibiotic therapy was prescribed in 62.9% of the cases. A total of 41.1% of the patients were referred to a specialized COD. The only risk factor associated with recurrence was the presence of an associated anal fistula. Anorectal abscesses are very frequent in the ED. There is great clinical variability regarding the taking of cultures, prescription of antibiotics, and referral criteria to a specialized coloproctology outpatient department, without clear impact of any of them on the recurrence of the abscess

Surgeons' perspectives on artificial intelligence to support clinical decision-making in trauma and emergency contexts: results from an international survey

Background: Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons' knowledge and perception of using AI-based tools in clinical decision-making processes. Methods: An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society's website and Twitter profile. Results: 650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust. Discussion: The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI

Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey

Background Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons. Methods Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society’s website, and shared on the society’s Twitter profile. Results A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly. Discussion Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions