Análisis de la influencia de los factores clínicos, analíticos, radiológicos y terapéuticos en el desarrollo de la diverticulitis aguda recurrente

INTRODUCCIÓN: La mayoría de los pacientes con diverticulitis aguda no complicada se recupera con medidas conservadoras y entre el 50-70% no sufre más episodios. Muchos autores recomendaban la resección del segmento afecto de forma electiva después del segundo episodio diverticular, debido al riesgo de complicaciones en los pacientes con recurrencias. Actualmente, esta actitud es cuestionada. OBJETIVOS: Describir y determinar qué factores clínicos, analíticos, radiológicos y terapéuticos han influido en el desarrollo de un episodio de diverticulitis aguda recurrente tras un episodio inicial, estableciendo las bases para el desarrollo de un protocolo hospitalario que facilite la elección terapéutica tras el primer episodio de diverticulitis aguda. MATERIAL Y MÉTODOS: Se ha realizado un estudio retrospectivo a partir de una base que recoge los datos de 164 pacientes que fueron ingresados y tratados en los Servicios de Cirugía General, Aparato Digestivo, y Medicina Interna del Hospital General San Jorge de Huesca con los diagnósticos de diverticulitis aguda izquierda (colon descendente y sigma) no complicada y complicada, desde Enero de 2007 hasta Diciembre de 2017. Hemos comparado el grupo de recurrencias (n=49) con el grupo de no recurrencias (n=115) en cuanto a las variables clínicas, analíticas, radiológicas y terapéuticas definidas, después del primer episodio. Todos los pacientes fueron diagnosticados (del episodio inicial y del recurrente) mediante una prueba de imagen radiológica. Se han empleado medidas de frecuencia para la descripción de variables cualitativas y medidas de tendencia central para las cuantitativas, mientras que para la estadística inferencial se usaron los test estadísticos correspondientes en función del tipo de variable. RESULTADOS: Al comparar ambos grupos (pacientes con recurrencia y sin ella) hemos hallado diferencias estadísticamente significativas en el tabaquismo (p=0.001), la diverticulitis no complicada (p=0.050), la perforación del colon (p=0.006), la PCR elevada (tanto en el análisis cuantitativo como en el cualitativo, p=0.004 y p=0.012 respectivamente) y tendencia a la significación en las variables edad (p=0.080), inmunosupresión (p=0.099), neoplasia concomitante (p=0.059) y tratamiento conservador (p=0.060). CONCLUSIONES: Aunque nuestra tasa de recurrencias y nuestros resultados son comparables a los de la literatura, es preciso un estudio más exhaustivo para establecer pautas de selección terapéutica para evitar recurrencias. BACKGROUND: Most patients with uncomplicated acute diverticulitis recover with conservative treatment and 50-70% do not suffer more episodes. Many authors recommended elective colonic resection after the second inflammatory episode, due to the risk of complications in patients with recurrences. Currently, this therapeutic attitude is questioned. OBJECTIVES: To describe and to define which clinical, analytical, radiological and therapeutic factors have influence in the development of recurrent episodes of acute diverticulitis after the first episode, establishing the basis for the development of an action protocol that facilitates the therapeutic choice after the first episode of acute diverticulitis. METHODS: We performed a retrospective study based on a database with 164 patients who were admitted and treated in the Hospital General San Jorge of Huesca (Departments of General and Digestive Surgery, Gastroenterology, and Internal Medicine), with the diagnosis of uncomplicated and complicated acute left diverticulitis (descending and sigmoid colon), from January 2007 to December 2017. We compared the group of recurrences with the group of non-recurrences in terms of clinical, analytical, radiological and therapeutic variables defined after the first inflammatory episode. All patients were diagnosed (for the initial episode and the recurrent episode) with a radiological imaging test. For descriptive analysis of qualitative variables we used measures of frequency, while for quantitative variables we calculated measures of central tendency. For statistical inferential analysis, statistical tests were used according to the type of variable. RESULTS: When comparing both groups (patients with recurrence and without it) we found statistically significant differences in smoking (p=0.001), uncomplicated diverticulitis (p=0.050), colonic wall perforation (p=0.006), elevated CRP (both in quantitative and qualitative analysis, p=0.004 and p=0.012 respectively) and tendency to significance in age (p=0.080), immunosuppression (p=0.099), concomitant neoplasia (p=0.059) and conservative treatment (p=0.060). CONCLUSIONS: Although our recurrence rate and our results are comparable to those of the literature, we need a more exhaustive study to develop therapeutic selection guidelines to avoid recurrences.<br /

Resultados a corto y largo plazo en los pacientes intervenidos de metástasis hepáticas sincrónicas de adenocarcinoma colorrectal en un hospital de tercer nivel

Las metástasis hepáticas son los tumores más frecuentes del hígado, el cual constituye el compromiso metastático más frecuente del cáncer de colon, por detrás de los ganglios linfáticos, de forma que entre el 50-70% de los pacientes presentan o presentarán metástasis hepáticas de cáncer colorrectal en el momento del diagnóstico o a lo largo de su evolución (generalmente antes de los 3 primeros años) y 2/3 de estos pacientes fallecerán como consecuencia de las mismas. Las metástasis hepáticas del cáncer colorrectal se presentarán como sincrónicas en el 10-30% de los casos. Los objetivos del presente trabajo van a ser: - Comprobar si se cumplen los estándares de calidad actuales en el tratamiento quirúrgico de los pacientes con metástasis sincrónicas en nuestra unidad de cirugía hepática. Comparar en los pacientes con metástasis sincrónicas si la cirugía simultánea del carcinoma colorrectal primario y de las metástasis hepáticas presenta resultados a corto plazo (morbilidad y mortalidad del postoperatorio inmediato) y a largo plazo (supervivencia global y supervivencia libre de enfermedad) solapables a los de la cirugía diferida. Determinar qué características han diferenciado a los pacientes con metástasis sincrónicas en los que se realizó una cirugía simultánea respecto de los que tuvieron una cirugía diferida. Para ello hemos realizado un estudio retrospectivo a partir de una base de datos completada de forma prospectiva con los datos de 250 pacientes intervenidos quirúrgicamente de metástasis hepáticas, de los cuales seleccionamos los pacientes con metástasis hepáticas sincrónicas (n=125) dividiendo la muestra en 2 cohortes de pacientes en función de si la cirugía fue simultánea (resección en un mismo tiempo del cáncer colorrectal primario y de las metástasis hepáticas sincrónicas o diferida). En base a los resultados obtenidos, concluimos que en nuestra unidad de cirugía hepática se cumplen los estándares de calidad actuales en el tratamiento quirúrgico de los pacientes con metástasis hepáticas sincrónicas, presentando unos resultados a corto plazo y a largo plazo solapables a los de la cirugía diferida

Análisis de los diferentes abordajes oncoquirúrgicos sobre los resultados a corto y largo plazo en los pacientes intervenidos de metástasis hepáticas sincrónicas de adenocarcinoma colorrectal en un hospital de tercer nivel

Entre las funciones hepáticas se encuentran la depuración y eliminación de productos del catabolismo proteico, la síntesis de factores que participan en la coagulación, y otras funciones como la digestiva o la inmunológica. Existen procesos primarios que afectan al hígado, como son las infecciones, los tumores, o los traumatismos y procesos secundarios como por ejemplo la emigración de células tumorales procedentes de otras regiones del organismo, de forma que se trata de uno de los órganos donde más frecuentemente metastatizan los tumores primarios. Es en este punto donde se va a centrar este trabajo, específicamente, en las metástasis hepáticas cuyo origen primario es el cáncer colorrectal. Actualmente, tenemos la experiencia suficiente para considerar que la resección hepática es el tratamiento de elección o gold standard de las metástasis hepáticas del cáncer colorrectal (MHCCR), pues es el único tratamiento capaz de aumentar la supervivencia a largo plazo en estos pacientes e incluso conseguir su curación. De este modo se preconiza la centralización de la cirugía hepática en centros especializados19, de forma que está contraindicada en los centros que no puedan realizar un estadiaje preoperatorio correcto y que carezcan de los medios y de la experiencia necesaria para llevarla a cabo. Hasta fechas recientes, las resecciones hepáticas presentaban unos elevados porcentajes de morbi-mortalidad (morbilidad del 20-40% y mortalidad del 5-15%) pero actualmente estas cifras han descendido drásticamente, evidenciando una morbilidad menor al 20% y una mortalidad inferior al 5% en centros con gran casuística. En este sentido, los factores que más han contribuido a la mejora de la morbimortalidad son los siguientes: mejor selección de los pacientes; mejores técnicas de imagen; nuevas líneas de quimioterapia (QT) neo y adyuvante (con menor hepatotoxicidad); mejora de la técnicas radiológicas intervencionistas, quirúrgicas y anestésicas; mejor conocimiento de la anatomía quirúrgica del hígado; mayor experiencia de los equipos gracias al trasplante hepático; desarrollo de nuevos aspectos técnicos (maniobra de Pringle, exclusión vascular total, ligadura extrahepática de grandes vasos, técnicas de oclusión portal); desarrollo de nuevo instrumental auxiliar (ecografía intraoperatoria, bisturí ultrasónico, coagulador monopolar), mejores cuidados perioperatorios de los pacientes; etc. En los últimos años hemos asistido a un cambio en los criterios “clásicos” de selección de los enfermos con MHCCR, evolucionando hacia unos criterios menos restrictivos o “ampliados” (sin centrarse exclusivamente en el número, tamaño, localización, sincronicidad, ni la presencia de enfermedad extrahepática) con el objetivo de rescatar a los pacientes con lesiones inicialmente rresecables. De esta forma, la decisión sobre la resecabilidad de las MHCCR dependerá de un equipo multidisciplinar. En este contexto, hemos pretendido ampliar los resultados ya publicados por nuestro grupo, exponiendo nuestra experiencia de diez años en el manejo de pacientes con MHCCR sincrónicas. Como se expondrá posteriormente, hemos evaluado comparativamente el efecto a corto y largo plazo de los distintos abordajes o estrategias oncoquirúrgicas planteadas en estos pacientes (abordaje clásico, combinado e inverso), comprobando si se han cumplido los estándares de calidad actuales en términos de supervivencia y morbimortalidad en una unidad de referencia de cirugía hepática como la nuestra

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study.

UNLABELLED: Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either early (within 14 d of intubation) or late (more than 14 d after intubation). DESIGN: International multi-institute retrospective cohort study. SETTING: Thirteen hospitals in Bolivia, Brazil, Spain, and the United States. PATIENTS: Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, -16 to -8; p \u3c 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, -23 to -9 d; p \u3c 0.001) and 22 days (95% CI, -31 to -12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8-5.2). Differences in 90-day post-admission survival were not identified. CONCLUSIONS: COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study

Objectives:. Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either “early” (within 14 d of intubation) or “late” (more than 14 d after intubation). Design:. International multi-institute retrospective cohort study. Setting:. Thirteen hospitals in Bolivia, Brazil, Spain, and the United States. Patients:. Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021. Interventions:. Not applicable. Measurements and Main Results:. A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, −16 to −8; p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, −23 to −9 d; p < 0.001) and 22 days (95% CI, −31 to −12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8−5.2). Differences in 90-day post-admission survival were not identified. Conclusions:. COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit