Εμφάνιση παγκρεατικού συριγγίου μετά από παγκρεατο-δωδεκαδακτυλεκτομή και επίδραση στην επιβίωση. Μελέτη βιβλιογραφίας και αναδρομική μελέτη σειράς χειρουργικών ασθενών από το Πανεπιστημιακό Γενικό Νοσοκομείο Αττικόν.

Περίληψη Εισαγωγή Η παγκρεατοδωδεκαδαλεκτομή θεωρείται μια από τις απαιτητικότερες και δύσκολες χειρουργικές επεμβάσεις και εκτελείται με σκοπό συνήθως την αφαίρεση καλόηθων ή κακόηθων όγκων του παγκρέατος ή του χολικού δέντρου καθώς και σε περιπτώσεις τραύματος. Αυτό το περίπλοκο χειρουργείο έχει συχνά πολλαπλές επιπλοκές, δυνητικά καταστροφικές για την επιβίωση των ασθενών. Μια από τις συχνές επιπλοκές είναι η εμφάνιση παγκρεατικού συριγγίου (postoperative pancreatic fistula, POPF), γεγονός που σύμφωνα με τους περισσότερους συγγραφείς - ερευνητές επιπλέκει πολύ την μετεγχειρητική πορεία των ασθενών και πολλές φορές σημαίνει αυξημένη θνητότητα. Μεγάλες κλινικές μελέτες έχουν σχεδιαστεί για να αποδείξουν την αυξημένη νοσηρότητα και θνητότητα στην ομάδα ασθενών με POPF καθώς και πολλαπλές προσπάθειες έχουν γίνει ώστε να βρεθεί η καλύτερη χειρουργική τεχνική για να αποφευχθεί η εμφάνιση POPF και οι ασθενείς να έχουν καλύτερη πρόγνωση. Υλικό και μεθοδολογία Πρόκειται για αναδρομική μελέτη της εμφάνισης της επιπλοκής του παγκρεατικού συριγγίου σε μία σειρά ασθενών που υποβλήθηκαν σε επέμβαση παγκρεατοδωδεκαδακτυλεκτομής στο Πανεπιστημιακό Γενικό Νοσοκομείο Αττικόν από 01/01/2013 έως 31/12/2018. Η παγκρεατοδωδεκαδακτυλεκτομή έγκειται στη χρησιμοποίηση μίας έλικα λεπτού εντέρου (short) Roux-en-Y με αναστομώσεις του στομάχου και του παγκρέατος με την αναστόμωση του χοληφόρου δέντρου να γίνεται στον μακρύ βραχίονα του λεπτού εντέρου. Η βασική ιδέα πίσω από την προσέγγιση είναι να επιτευχθεί αρκετή απόσταση της παγκρεατονηστιδικής αναστόμωσης από τα ενεργοποιημένα γαστρικά υγρά και το χολικό χυμό, καθώς ένα από τα σενάρια που εξηγεί την διάσπαση της παγκρεατονηστιδικής αναστόμωσης είναι η ενεργότητα των παγκρεατικών ενζύμων. Αποτελέσματα Μελετήθηκαν 126 ασθενείς (n=126) με διάμεση ηλικία τα 66.1 έτη (58.7, 74). Από το δείγμα της μελέτης αυτής, παγκρεατικό συρίγγιο παρουσίασε το 13.5% (17 ασθενείς) εκ των οποίων το 8.7% χαρακτηρίζεται ως biochemical leak και το υπόλοιπο 4.8% ως παγκρεατικό συρίγγιο B και C. Οι ασθενείς μελετήθηκαν σε δύο ομάδες ως προς την εμφάνιση παγκρεατικού συριγγίου (ομάδα Α, ασθενείς που δεν παρουσίασαν παγκρεατικό συρίγγιο και ομάδα Β, ασθενείς που παρουσίασαν παγκρεατικό συρίγγιο). Παράγοντες κινδύνου για εμφάνιση παγκρεατικού συριγγίου ανεδείχθησαν ο αυξημένος δείκτης μάζας σώματος (BMI) (p=0.01), η μετεγχειρητική αιμορραγία (p=0.03), ενώ το παγκρεατικό συρίγγιο συσχετίσθηκε με παράταση ημερών νοσηλείας (p<0.001), χολική διαφυγή (p<0.001), ανεπάρκεια οργάνου (p<0.001) και μειωμένη επιβίωση σε μήνες (p=0.02). Ο προεγχειρητικός ίκτερος (p=0.001) και η μετεγχειρητική νοσηλεία σε Μονάδα Εντατικής Θεραπείας (ΜΕΘ) (p=0.013) φαίνεται να επηρεάζουν αρνητικά τη θνητότητα. Συμπεράσματα Το χειρουργικό κέντρο ΠΓΝ ΑΤΤΙΚΟΝ έχει ασχοληθεί εκτεταμένα με την πρόληψη του παγκρεατικού συριγγίου καθώς έχει αναγνωριστεί η σημασία της επιπλοκής σε σχέση με την νοσηρότητα και την θνητότητα. Η διαφορά στην επέμβαση κατά Whipple έγκειται στο σύστημα αναστομώσεων και σύμφωνα με τα ποσοστά εμφάνισης παγκρεατικού συριγγίου, πιθανότατα δημιουργεί μια στεγανότερη αναστόμωση χωρίς ενεργά παγκρεατικά ένζυμα. Η υπεροχή της τροποποιημένης επέμβασης της παγκρεατοδωδεκαδακτυλεκτομής χρήζει επιβεβαίωσης με μια νέα μελέτη που θα συγκρίνει τις δύο τεχνικές και τα αποτελέσματά τους.Abstract Introduction Pancreaticoduodenectomy is one of the most complex and challenging surgical procedures, still holding a significant number of postoperative complications. The occurrence of pancreatic fistulae, a complication connected to higher mortality and prolonged hospital stay, remains quite common. Plenty of techniques have been proposed in an effort to improve these rates. Materials and Methods This retrospective study presents a series of pancreaticoduodenectomy cases from a surgical team in Greece (from 01/01/2013 to 31/12/2018) in comparison with rates from high volume centers abroad. The difference in Whipple surgery lies in the anastomoses and concerns a modification in the intestinal loop in which the pancreas and stomach are anastomosed in sequence (loop Y) with the Roux loop draining the bile salts. The premise behind modifying anastomoses is to activate pancreatic enzymes away from anastomoses. Results A total of 126 patients with median age 66.1 years were included in the study. Pancreatic fistula was found in 13.5 % of patients and specifically, the incidence of biochemical leak was 8.7% and grade B and C POPF was 4.8%. Patients were studied in two groups for the occurrence of pancreatic fistula (group A, patients without pancreatic fistula and group B, patients with pancreatic fistula). Risk factors for pancreatic fistula were increased BMI (p = 0.01), postoperative bleeding (p = 0.03), while pancreatic fistula was associated with prolongation of hospitalization days (p <0.001) biliary leakage (p<0.001), organ failure (p <0.001) and reduced survival in months (p = 0.02). Significant correlation with mortality was observed when patients had preoperative jaundice (p = 0.001) or were in need of postoperative hospitalization in the Intensive Care Unit (p = 0.013). Conclusion The surgical center ATTIKON has dealt extensively with the prevention of pancreatic fistula as the importance of the complication in relation to morbidity and mortality has been recognized. The difference in Whipple surgery lies in the anastomosis system and according to the rates of pancreatic fistula occurrence, it probably creates a secure anastomosis without active pancreatic enzymes. The superiority of modified pancreatoduodenectomy needs to be confirmed with a new study comparing the two techniques and their results

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

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

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 < 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)

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Giant Intracystic Papillary Carcinoma of the Breast Report of a Case and Review of the Literature

Background: Intracystic papillary carcinoma (IPC) is a distinctive variant of a papillary ductal neoplasm confined to a dilated cystic space. This rare mammary tumor typically appears as a discrete solitary mass in the central region of the breast in a postmenopausal woman. This article presents the case of a female patient with a giant IPC. Relevant literature is briefly reviewed. Case: A 65-year-old woman was admitted for the management of a palpable mass of the left breast. On clinical examination, it was noted that the entire left breast was replaced by an extremely large, irregularly shaped, relatively mobile lesion. The mass was almost fixed to surrounding tissues including skin and pectoral muscle. Due to the size of the tumor the patient underwent a left modified radical mastectomy. Results: The final histopathologic diagnosis was defined as an IPC. Concomitant vascular invasion or metastasis to 19 removed lymph nodes were not noted. Conclusions: Because of its relevant growth pattern and indolent clinical behavior, IPC is conventionally regarded as a variant of intraductal papillary carcinoma with an absence of myoepithelial cells. There have been several cases that indicated a slow evolution of the mass, verifying the perception that IPC is associated with a favorable clinical outcome. Differential diagnoses include colloid or medullary carcinoma, invasive ductal carcinoma, hematoma, benign cyst, or adenofibroma. Axillary lymph-node metastases and markers related to invasion have been documented. Due to the rarity of the tumor and variability observed in treatment strategies, only a few surveys have assessed the significance of lymph-node status and the role of adjuvant treatment. (J GYNECOL SURG 2017:1

Severity of Pancreatic Leak in Relation to Gut Restoration After Pancreaticoduodenectomy

Background:. Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients’ outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients’ outcome. Methods:. The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed. Results:. Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C). Conclusion:. Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH