Multi-institutional expert update on the use of laparoscopic bile duct exploration (LBDE) in the management of choledocholithiasis: lesson learned from 3950 procedures

Background: Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage man agement of choledocholithiasis. Methods: A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis. Results: A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%. Conclusion: Based on this multicenter survey, LBDE is a safe and effective ap proach when performed by experienced teams. The generalization of LBDE will be based on developing training programs

Controlled attenuation parameter-insulin resistance (CIR) score to predict non-alcoholic steatohepatitis

The diagnosis of non-alcoholic steatohepatitis (NASH) requires liver biopsy. Patients with NASH are at risk of progression to advanced fibrosis and hepatocellular carcinoma. A reliable non-invasive tool for the detection of NASH is needed. We aimed at developing a tool to diagnose NASH based on a predictive model including routine clinical and transient hepatic elastography (TE) data. All subjects undergoing elective cholecystectomy in our center were invited to participate, if alcohol intake was < 30 g/d for men and < 15 g/d for women. TE with controlled attenuation parameter (CAP) was obtained before surgery. A liver biopsy was taken during surgery. Multivariate logistic regression models to predict NASH were constructed with the first 100 patients, the elaboration group, and the results were validated in the next pre-planned 50 patients. Overall, 155 patients underwent liver biopsy. In the elaboration group, independent predictors of NASH were CAP value [adjusted OR (AOR) 1.024, 95% confidence interval (95% CI) 1.002-1.046, p = 0.030] and HOMA value (AOR 1.847, 95% CI 1.203-2.835, p < 0.001). An index derived from the logistic regression equation to identify NASH was designated as the CAP-insulin resistance (CIR) score. The area under the receiver operating characteristic curve (95%CI) of the CIR score was 0.93 (0.87-0.99). Positive (PPV) and negative predictive values (NPV) of the CIR score were 82% and 91%, respectively. In the validation set, PPV was 83% and NPV was 88%. In conclusion, the CIR score, a simple index based on CAP and HOMA, can reliably identify patients with and without NASH.J.M. is recipient of an intensification grant from Consejería de Salud, Junta de Andalucía (grant number: A1-0060-2021). J.A.P. is recipient of an intensification grant from the Instituto de Salud Carlos III (grant number: I3SNS). A.G.S. is recipient of a Miguel Servet Research Contract from the Instituto de Salud Carlos III (CP18/00146). A.C.G. has received a Río Hortega grant from the Instituto de Salud Carlos III (grant number CM19/00251) and a research extension grant from Acciones para el refuerzo con recursos humanos de la actividad investigadora en las Unidades Clínicas del Servicio Andaluz de Salud 2021, acción B (Clínico-Investigadores) (grant number B-0061-2021).This work has been partially funded by the Instituto de Salud Carlos III (grant no: PI18/00606); co-funded by ERDF "A way to make Europe" and Consejería de Salud de la Junta de Andalucía (PI-0001/2017).Peer reviewe

Estudio experimental del comportamiento y cicatrización de las anastomosis intestinales (colónicas) efectuadas en condiciones de isquemia con especial atención a la influencia de la pentoxifilina en el proceso cicatricial

El principal problema causante de morbi-mortalidad al que se enfrenta el cirujano digestivo viene dado por las complicaciones relacionadas con las dehiscencias anastomóticas, y de modo particular las que afectan al colon y recto. Existen numerosos factores citados como causantes de la aparición de una fuga anastomótica. La mayoría de las causas señaladas, sin embargo, conducen finalmente a un cierto grado de isquemia o hipoperfusión, y, en el peor de los casos, a un evento de lesión por isquemia y reperfusión. La pentoxifilina tiene un acreditado efecto terapéutico mejorando la hemorreología y la microcirculación de los tejidos, así como reduciendo las lesiones por reperfusión y actuando como inmunomodulador. Con estas premisas, diseñamos un estudio con tres grupos de 31 ratas Wistar en cada uno de ellos. En el grupo A (grupo control) los animales fueron sometidos a una resección de un centímetro de colon de la unión rectosigmoidea preservando la vascularización colónica por completo y realizando a continuación una anastomosis colorrectal. El grupo B (grupo isquemia) fue a una devascularización parcial, tras la resección colónica. Por último, el grupo C (grupo tratamiento) fue sometido a una lesión isquemiante idéntica a la del grupo B, siendo tratado a continuación con una dosis diaria intraperitoneal de 50mg/Kg de pentoxifilina. Todos los animales fueron sacrificados al octavo día para el examen de su anastomois. La comparación de los grupos A y B evidenció que el modelo de isquemia diseñado producía un incremento de la tasa de dehiscencias anastomósis (45.2% en el grupo de isquemia frente a un 9,7% en el grupo control). La resistencia anastomótica disminuyéndose la presión de estallido desde 191,84 mmHg hasta los 118,19 mmHg tras la devascularización. El examen microscópico mostró un significativo descenso del infiltrado neutrófilo en el grupo de isquemia, y una disminución de la fibrosis en el grupo B con respecto al A, además una marcada tendencia, no significativa, al menor desarrollo de neovascularización. El estudio comparativo de los grupo A y B demostró, en resumen, que la devascularización inducida provocaba una aumento de la tasa fugas anastomóticas y reducía la resistencia de la anastomosis y reducía la resistencia de la anastomosis debido a un defecto de formación de tejido de granulación, validando el modelo de anastomosis de alto riesgo. Analizamos los mismos parámetros, comparando el grupo B de isquemia con el grupo C tratado con pentoxifilina, observamos como todos los efectos que parecieron con la devascularización selectiva fueron parcialmente revertidos con la administración del fármaco. Las dehiscencia anastomóticas fueron reducidas desde el mencionado 45,2% del grupo B hasta un 16,1% en el grupo C. La resistencia a la presión intraluminal se incrementó hasta los 205,55 mmHg en los animales tratados con pentoxifilina, mientras que la presión del estallido del grupo de isquemia solo alcanzó los 118,18 mmhg. El estudio microscópico demostró que la pentoxifilina estimuló el desarrollo de tejido de granulación, sobre todo de fibrosis, esto es, de colágeno, a nivel de la anastomosis. El estudio de las células inflamatorias evidenció una mayor presencia de nuetrófilos y una menor infiltración por células gigantes en el grupo tratado. Por tanto, puede afirmarse que el tratamiento con pentoxifilina de los animales con anastomosis parcialmente devascularizadas tiene un potente efecto protector para la aparición de dehiscencias anastomóticas mediante el estímulo cicatricial y la producción y mantenimiento de un adecuado tejido de granulación, logrado a través de la mejoría del aporte microvascular y de una inmunomodulación afectiva.Premio Extraordinario de Doctorado U

Influence of surgical site infection on oncological prognosis after curative resection for colorectal cancer: An observational single-institution study

Background: An exacerbated inflammatory response to post-operative infection could favor an environment in which residual viable tumor cells present in the surgical bed, bloodstream, or occult micrometastases can survive and progress to produce local or distant recurrence. In this regard, a surgical site infection (SSI) could be an important risk factor for disease progression. This study aimed to investigate the impact of SSI on long-term survival and recurrence of colorectal cancer. Methods: Patients who underwent curative-intent resection for colorectal carcinoma between 2011 and 2013 were retrospectively analyzed. Overall and disease-free survival (DFS) and local recurrence rate for patients with and without SSI were analyzed. Results: One hundred and thirty-eight patients were included in the study. Fifty-one (37%) patients showed SSI but revealed no differences in recurrence rate and overall survival compared with non-infected patients. However, the stratified analysis revealed that patients with an intra-abdominal abscess or an organ-space-infection showed a higher recurrence rate and a decreased 5-year overall and DFS. Conclusions: SSI may have an influence on the oncological prognosis and, therefore, could be considered a recurrence factor. Further multi-institutional studies are necessary to conclude a causal association.Antecedentes: Una respuesta inflamatoria exacerbada por una infección postoperatoria podría favorecer un entorno en el que células tumorales residuales viables presentes en el lecho quirúrgico, torrente sanguíneo o micrometástasis ocultas puedan sobrevivir y progresar para producir una recurrencia local o a distancia. En este sentido, una infección del sitio quirúrgico (ISQ) podría ser un factor de riesgo de progresión de la enfermedad. Este estudio tuvo como objetivo investigar el impacto de la ISQ en la supervivencia y recurrencia del cáncer colorrectal. Método: Todos los pacientes con carcinoma colorrectal sometidos a resección con intención curativa entre 2011 y 2013 fueron analizados retrospectivamente. Se analizó supervivencia global y libre de enfermedad y la tasa de recurrencia local en pacientes con cáncer colorrectal con y sin ISQ. Resultados: Se incluyeron 138 pacientes. 51 (37%) sufrieron ISQ pero no mostraron diferencias en la tasa de recurrencia y supervivencia global respecto a los pacientes no infectados. Sin embargo, el análisis estratificado reveló que los pacientes con un absceso intraabdominal o una infección órgano-espacio mostraron una tasa de recurrencia más alta y una disminución en la supervivencia global y libre de enfermedad. Conclusiones: La ISQ, en función de la gravedad y la respuesta inflamatoria que genera, puede influir en el pronóstico oncológico y, por lo tanto, podría considerarse un factor de recurrencia. Futuros estudios multicéntricos son necesarios para demostrar una posible asociación

Long-term outcome of patients with biliary pancreatitis not undergoing cholecystectomy. A retrospective study.

most acute pancreatitis cases are of biliary origin and cholecystectomy is recommended to prevent recurrence. However, some patients will never be referred for surgery. In this study, the long-term follow-up of this group of patients was reviewed. all new cases of biliary pancreatitis from January 2015 to December 2017 that did not undergo cholecystectomy were analyzed. Epidemiologic data and Charlson's comorbidity index (CCI) were recorded. Recurrent episodes of pancreatitis or biliary events and mortality during the follow-up period were recorded. a total of 104 patients were included in the study (30.4 % of all biliary pancreatitis cases) and the median age was 82 years (range, 27-96). Average CCI was 5 (range, 0-18) and the median follow-up period was 37 months (range, 1-70). A total of 41 patients (39.4 %) had gallstone-related complications. Twenty-three patients (22,1 %) had recurrent pancreatitis and 34 (32,7 %) developed biliary events. Twenty-five patients died during follow-up (24 %) but only in 6 (5,8 %) was death due to gallstone-related complications. Non-related mortality was 15.5 % in patients who refused surgery and 25 % in multiple-comorbidity patients. patients who did not undergo cholecystectomy were at high risk for biliary events and pancreatitis recurrence. Conservative treatment and surgical abstention should be individualized and reserved for patients with multiple comorbidities with a short life expectancy

PEComa hepático: un tumor inusual en una localización infrecuente.

Perivascular epithelioid cell neoplasms (PEComas) are a tumor family defined as such just a couple of decades ago. They make an unusual group of neoplasms, which can appear in different locations of the organism. PEComas are usually considered to be benign tumors, but there are some histological features that make some subgroups suspicious of malignancy. The treatment of these tumors consist in their surgical resection, with no current effective complementary oncological treatment known. We present the clinical case of a woman that underwent surgery for a resection of a hepatic lesion labeled afterwards as a PEComa with malignant features

Controlled attenuation parameter-insulin resistance (CIR) score to predict non-alcoholic steatohepatitis

The diagnosis of non-alcoholic steatohepatitis (NASH) requires liver biopsy. Patients with NASH are at risk of progression to advanced fibrosis and hepatocellular carcinoma. A reliable non-invasive tool for the detection of NASH is needed. We aimed at developing a tool to diagnose NASH based on a predictive model including routine clinical and transient hepatic elastography (TE) data. All subjects undergoing elective cholecystectomy in our center were invited to participate, if alcohol intake was < 30 g/d for men and < 15 g/d for women. TE with controlled attenuation parameter (CAP) was obtained before surgery. A liver biopsy was taken during surgery. Multivariate logistic regression models to predict NASH were constructed with the first 100 patients, the elaboration group, and the results were validated in the next pre-planned 50 patients. Overall, 155 patients underwent liver biopsy. In the elaboration group, independent predictors of NASH were CAP value [adjusted OR (AOR) 1.024, 95% confidence interval (95% CI) 1.002–1.046, p = 0.030] and HOMA value (AOR 1.847, 95% CI 1.203–2.835, p < 0.001). An index derived from the logistic regression equation to identify NASH was designated as the CAP-insulin resistance (CIR) score. The area under the receiver operating characteristic curve (95%CI) of the CIR score was 0.93 (0.87–0.99). Positive (PPV) and negative predictive values (NPV) of the CIR score were 82% and 91%, respectively. In the validation set, PPV was 83% and NPV was 88%. In conclusion, the CIR score, a simple index based on CAP and HOMA, can reliably identify patients with and without NASH

Multi-institutional expert update on the use of laparoscopic bile duct exploration in the management of choledocholithiasis: Lesson learned from 3950 procedures.

Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage management of choledocholithiasis. A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis. A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%. Based on this multicenter survey, LBDE is a safe and effective approach when performed by experienced teams. The generalization of LBDE will be based on developing training programs