Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study

Introduction: A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis. Objetive: The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO. Materials and methods: This is a post hoc study of the SPRiMACC study. It ́s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC. Outcomes: 1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC. Conclusion: Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome

HIPEC στον καρκίνο του στομάχου

Ο καρκίνος του στομάχου αποτελεί την τρίτη συνηθέστερη κακοήθεια παγκοσμίως και την τρίτη αιτία θανάτου από κακοήθη νόσο και συχνά συνοδεύεται από συγχρονη ή μετάχρονη περιτοναϊκή νόσο. Εμφανίζει δε διαφορετικά επιδημιολογικά χαρακτηριστικά ανάλογα με την περιοχή, τη φυλή και το φύλο και συνδέεται με καλά τεκμηριωμένους παράγοντες κινδύνου. Το στάδιο της νόσου είναι αυτό που καθορίζει την πρόγνωση και τις θεραπευτικές επιλογές. Οι ασθενείς με περιτοναϊκή νόσο από καρκίνο του στομάχου αντιμετωπίζονται παραδοσιακά αποκλειστικά με συστηματική χημειοθεραπεία. Ωστόσο, λόγω των ανατομικών και φυσιολογικών ιδιαιτεροτήτων του περιτοναίου, οι περιτοναϊκές εμφυτεύσεις δεν ανταποκρίνονται καλώς στη συστηματική χημειοθεραπεία. Έτσι, τις τελευταίες δεκαετίες έχει προταθεί μια διαφορετική θεραπευτική προσέγγιση για επιλεγμένους ασθενείς, η οποία αποτελείται από κυτταρομειωτική χειρουργική και ενδοπεριτοναϊκή χορήγηση χημειοθεραπείας. Τόσο η κυτταρομειωτική χειρουργική όσο και η ενδοπεριτοναϊκή χημειοθεραπεία διέπονται από συγκεκριμένες αρχές και απαιτούν η καθεμία συγκεκριμένο σχεδασμό. Ο σκοπός της εργασίας αυτής είναι να μελετήσει την προσέγγιση αυτή με αφετηρία κλινικές μελέτες που έχουν διεξαχθεί την τελευταία δεκαετία με ιδιαίτερη επικέντρωση στο όφελος που προσφέρει στην επιβίωση ο συνδυασμός κυτταρομείωσης και διεγχειρητικής χορήγησης υπέρθερμης ενδοπεριτοναϊκής χημειοθεραπείας (HIPEC). Φαίνεται ότι ο επιθετικότερος θεραπευτικός σχεδιασμός μπορεί να βελτιώσει την ολική και την ελεύθερη νόσου επιβίωση σε επιλεγμένες ομάδες ασθενών. Βασικούς προγνωστικούς παράγοντες αποτελούν η έκταση της περιτοναϊκής νόσου (PCI score) και η παραμονή υπολλειμματικής νόσου μετά την κυτταρομείωση (CC score). Οι παράγοντες αυτοί επηρεάζουν την πρόγνωση των ασθενών και καθοδηγούν το σχεδιασμό των θεραπευτικών πρωτοκόλλων στις κλινικές μελέτες. Έχουν προταθεί εκτεταμένα θεραπευτικά πρωτόκολλα αντιμετώπισης της περιτοναϊκής νόσου από γαστρικό καρκίνο, στα οποία εντάσσονται συνδυαστικά η νεοεπικουρική θεραπεία, η κυτταρομείωση, οι διάφορες μορφες ενδοπεριτοναϊκής θεραπείας και η επικουρική χημειοθεραπεία. Οι αναδυόμενες αυτές τεχνικές αποτελούν αντικείμενο εν εξελίξει τυχαιοποιημένων κλινικών μελετών, όπως είναι η GASTRICHIP, η GASTRIPEC, η DRAGON II και η PERISCOPE II. Η περιτοναϊκή νόσος πρέπει πλέον να αντιμετωπίζεται εξατομικευμένα από πολυτομεακές ομάδες σε εξειδικευμένα κέντρα.Gastric cancer constitutes the third most common malignancy worldwide and the third most common cause of death due to malignancy. The incidence of the disease differs depending on the area, the race and the gender. The prognosis as well as the treatment options depend largely on the stage of the disease. Patients with peritoneal carcinomatosis due to gastric cancer were traditionally treated solely with systemic chemotherapy. However, the cancer deposits in the peritoneal cavity do not respond well to systemic chemotherapy. This traces back to the cavity not being readily accessible to the systemically administered chemotherapeutic agents, due to its anatomical and physiological characteristics. Experts proposed during the last few decades a different approach consisting of cytoreductive surgery and intraperitoneal chemotherapy. Both the cytoreductive surgery and the intraperitoneal chemotherapy have their own unique principles and require specific design. The purpose of this study is to contemplate this approach, using the clinical studies conducted in the last decade as a starting point. It especially focuses on the survival benefit of the combination of cytoreductive surgery and intraoperative administration of Hyperthermic Intraperitoneal Chemotherapy (HIPEC). As it seems, this more aggressive therapeutic design may have a positive impact on survival, when considering carefully chosen subgroups of patients. The extent of the peritoneal disesase (PCI score) and the completeness of cytoreduction (CC score) constitute the most important prognostic factors and guide clinical decisions and the design of the treatment protocols. Such protocols for combating peritoneal disease in patients with gastric cancer have been proposed by many experts. They incorporate neoadjuvant chemotherapy, cytoreduction, different forms of intraperitoneal chemotherapy and advuvant therapy. These emerging therapeutic approaches are being investigated in evolving randomized clinical trials, such as GASTRICHIP, GASTRIPEC, DRAGON II and PERISCOPE II trials. Peritoneal disease should be individualized according to the patient characteristics by multidisciplinary teams in specialized centres

Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study

BackgroundLess invasive alternatives than early cholecystectomy (EC) for acute calculous cholecystitis (ACC) treatment have been spreading in recent years. We still lack a reliable tool to select high-risk patients who could benefit from these alternatives. Our study aimed to prospectively validate the Chole-risk score in predicting postoperative complications in patients undergoing EC for ACC compared with other preoperative risk prediction models.MethodThe S.P.Ri.M.A.C.C. study is a World Society of Emergency Surgery prospective multicenter observational study. From 1st September 2021 to 1st September 2022, 1253 consecutive patients admitted in 79 centers were included. The inclusion criteria were a diagnosis of ACC and to be a candidate for EC. A Cochran-Armitage test of the trend was run to determine whether a linear correlation existed between the Chole-risk score and a complicated postoperative course. To assess the accuracy of the analyzed prediction models-POSSUM Physiological Score (PS), modified Frailty Index, Charlson Comorbidity Index, American Society of Anesthesiologist score (ASA), APACHE II score, and ACC severity grade-receiver operating characteristic (ROC) curves were generated. The area under the ROC curve (AUC) was used to compare the diagnostic abilities.ResultsA 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. Chole-risk was validated, but POSSUM PS was the best risk prediction model for a complicated course after EC for ACC (in-hospital mortality: AUC 0.94, p < 0.001; 30-day mortality: AUC 0.94, p < 0.001; in-hospital major morbidity: AUC 0.73, p < 0.001; 30-day major morbidity: AUC 0.70, p < 0.001). POSSUM PS with a cutoff of 25 (defined in our study as a 'Chole-POSSUM' score) was then validated in a separate cohort of patients. It showed a 100% sensitivity and a 100% negative predictive value for mortality and a 96-97% negative predictive value for major complications.ConclusionsThe Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action.Trial Registration: ClinicalTrial.gov NCT04995380