Need for a targeted perioperative antibiotic treatment protocol for patients with preoperative biliary drainage undergoing pancreaticoduodenectomy.

PURPOSE: To evaluate the bacterobilia in patients undergoing pancreaticoduodenectomy (PD) based on whether they carry a preoperative biliary drainage or not and to analyse if a targeted perioperative antibiotic treatment based on the expected microbiology leads in no differences in Surgical Site Infections (SSI) between the groups. METHODS: Retrospective observational single-center study of patients undergoing pancreaticoduodenectomy with preoperative biliary stent (group P, Prosthesis) and without stent (group NP, No Prosthesis). Postoperative complications including SSI and its subtypes were analyzed after applying a targeted perioperative antibiotic treatment protocol with cefotaxime and metronidazole (group NP) and piperacillin-tazobactam (group P). RESULTS: Between January 2014 and December 2021, 127 patients were treated (84 in group NP and 43 in group P). Intraoperative cultures were positive in 16.7% (group NP) vs 76.7% (group P, p < 0.01). Microorganisms isolated in group NP included Enterobacterales (10.7%) and Enterococcus spp. (7.1%) with no Candida detected. In group P: Enterobacterales (51.2%), Enterococcus spp. (48.8%), and Candida (16.3%) were higher (p < 0.01%). No differences in morbidity and mortality were observed between the groups. SSI rate was 17.8% in group NP and 23.2% in group P (ns). CONCLUSION: Bacterobilia differs in patients with biliary drainage, showing a higher presence of Enterobacterales, Enterococcus spp., and Candida. There were no differences in SSI incidence after applying perioperative antibiotic treatment tailored to the expected microorganisms in each group. This raises the need to reconsider conventional surgical prophylaxis in patients with biliary stent.

Intraoperative goal-directed hemodynamic therapy through fluid administration to optimize the stroke volume: A meta-analysis of randomized controlled trials.

OBJECTIVE: To evaluate the clinical impact of optimizing stroke volume (SV) through fluid administration as part of goal-directed hemodynamic therapy (GDHT) in adult patients undergoing elective major abdominal surgery. METHODS: This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered in the PROSPERO database in January 2024. The intervention was defined as intraoperative GDHT based on the optimization or maximization of SV through fluid challenges, or by using dynamic indices of fluid responsiveness, including stroke volume variation, pulse pressure variation, and plethysmography variation index compared to usual fluid management. The primary outcome was postoperative complications. Secondary outcome variables included postoperative acute kidney injury (AKI), length of stay (LOS), intraoperative fluid administration, and 30-day mortality. RESULTS: A total of 29 randomized controlled trials (RCTs) met the inclusion criteria. There were no significant differences in the incidence of postoperative complications (RR 0.89; 95% CI, 0.78-1.00), postoperative AKI (OR 0.97; (95% IC, 0.55-1.70), and mortality (OR 0.80; 95% CI, 0.50-1.29). GDHT was associated with a reduced LOS compared to usual care (SMD: -0.17 [-0.32; -0.03]). The subgroup in which hydroxyethyl starch was used for hemodynamic optimization was associated with fewer complications (RR 0.79; 95% CI, 0.65-0.94), whereas the subgroup of patients in whom crystalloids were used was associated with an increased risk of postoperative complications (RR 1.08; 95% CI, 1.04-1.12). CONCLUSIONS: In adults undergoing major surgery, goal-directed hemodynamic therapy focused on fluid-based stroke volume optimization did not reduce postoperative morbidity and mortality.

Laparoscopic vs open approach for acute cholecystitis in octogenarians. A prospective multicenter observational nationwide study.

BACKGROUND: The world population is aging, with octogenarians expected to reach over 400 million by 2050. Acute cholecystitis is a serious complication in the elderly. Age is not a contraindication for emergency cholecystectomy, an option that can both save lives and preserve quality of life. METHODS: The present study aimed to compare open and laparoscopic surgical approaches. Over six months, 38 emergency surgery units enrolled all consecutive octogenarians with acute cholecystitis undergoing cholecystectomy. Postoperative outcomes were compared after propensity score matching analysis. RESULTS: The study included 212 patients (84 years [81-86], 47.2% women). The open approach was used in 32.1% of patients, and the laparoscopic approach in 67.9%. After propensity score matching, a decrease in hospital stays (open, 8 days [6-13]; laparoscopic, 5 days [4-8]; P < .001), 30-day morbidity (open, 48.5%; laparoscopic, 26.5%; P = .01), and 30-day mortality (open, 13.2%, laparoscopic, 1.5%; P = .02) was found. Among the specific postoperative complications, a decrease in septicemia (open, 14.7%; laparoscopic, 0%; P = .001) was observed. CONCLUSIONS: Laparoscopic approach was used in two out of three octogenarians. After propensity score matching, octogenarians undergoing laparoscopic approach had shorter length of hospital stay, fewer 30-day postoperative complications, fewer episodes of septicemia, and less 30-day mortality than octogenarians undergoing open approach. These findings suggest that the laparoscopic approach may be the preferred choice for octogenarians with acute cholecystitis undergoing cholecystectomy.

Risk factors for complications in total hip arthroplasty. / Factores de riesgo para complicaciones en artroplastia total de cadera.

INTRODUCTION AND OBJECTIVE: Hip arthroplasty represents a significant advancement in the treatment of refractory chronic joint pain, improving quality of life and functionality. The objective of this study is to identify the risk factors associated with local and systemic complications in patients treated with total hip arthroplasty. METHODS: Observational, analytical, retrospective cohort study, which included 304 participants treated with total hip replacement. Comparison of variables between two groups was performed; 38 participants in the group with complications and 266 participants in the group without complications. RESULTS: The mean age in the complication group was 66 years (SD 18.7) and in the uncomplicated group it was 67,1 years (SD 15.1) (p 0,686). Female sex was observed in 73.3% of the group with complications and 65% in the group without complications. (p 0.292). Risk factors were: hip fracture as an indication for arthroplasty RR 1.33 [95% CI 1.004;1.775 p 0.047], coronary heart disease RR 1.31 [95% CI 1.067;1.616 p 0.010] and surgical bleeding equal to or greater than 400 cc RR 1.11 [95% CI 1.012;1.218 p 0.028]. CONCLUSIONS: The risk factors for complications in total hip arthroplasty were: hip fracture as the indication for arthroplasty, coronary artery disease, and surgical bleeding equal to or greater than 400 cc.

The textbook outcome for cholecystectomy: Is it a good quality tool for a low-morbidity procedure?

INTRODUCTION: Cholelithiasis is the most common hospital diagnosis of the digestive system, and its treatment, if symptomatic, is laparoscopic cholecystectomy. There is a growing need for comprehensive determination of postoperative outcomes and the efficiency of healthcare facilities. The "textbook outcome"(TO) indicates the quality of care commonly used in oncological procedures, obtained by adding several postoperative parameters, which informs whether a perfect result has been obtained. The main objective of this study is to determine the TO for cholecystectomy and to see the factors that influence its achievement. METHODS: Retrospective observational unicentric cohort study on patients who underwent cholecystectomy between 2018-2020. We defined TO as those patients who met the following premises: Clavien-Dindo complications < III, postsurgical stay less than the 75th percentile (<3 days), and no readmissions or mortality in the first ninety days. Perioperative characteristics were analyzed, and the patients were divided into two groups according to whether or not they achieved TO. We defined criteria for difficult cholecystectomy according to the operative report. RESULTS: The percentage of TO was 72% (342/475) (82.6% in elective surgery and 60.5% in urgent surgery). The univariate analysis showed that the following factors are associated with achieving TO: female sex, age <63 years, ASA risk < III, elective surgery, laparoscopic approach, and not difficult cholecystectomy. After multivariate analysis ASA < III (OR 2.39 CI95% 1.37-4.16), elective surgery (OR 2.77 CI95% 1.64-4.67), laparoscopic approach (OR 5.71 CI95% 2.89-11.30) and not to be difficult cholecystectomy (OR 0.42 CI95% 0.259-0.71) remained statistically significant. CONCLUSIONS: The TO is a healthcare quality tool that is simple to perform, easily interpretable, and helpful for evaluating quality in healthcare and comparing centers. It applies not only to oncological procedures but also to cholecystectomy.

Comparison and combination of three data sources from patient medical records to determine optimal quantification of postoperative morbidity according to the Clavien Dindo Classification and the Comprehensive Complication Index. A prospective study.

INTRODUCTION: It is currently unknown which data sources from the clinical history, or combination thereof, should be evaluated to achieve the most complete calculation of postoperative complications (PC). The objectives of this study were: to analyze the morbidity and mortality of 200 consecutive patients undergoing major surgery, to determine which data sources or combination collect the maximum morbidity, and to determine the accuracy of the morbidity reflected in the discharge report. METHODS: Observational and prospective cohort study. The sum of all PC found in the combined review of medical notes, nursing notes, and a specific form was considered the gold standard. PC were classified according to the Clavien Dindo Classification and the Comprehensive Complication Index (CCI). RESULTS: The percentage of patients who presented PC according to the gold standard, medical notes, nursing notes and form were: 43.5%, 37.5%, 35% and 18.7% respectively. The combination of sources improved CCI agreement by 8%-40% in the overall series and 39.1-89.7 % in patients with PC. The correct recording of PC was inversely proportional to the complexity of the surgery, and the combination of sources increased the degree of agreement with the gold standard by 35 %-67.5% in operations of greater complexity. The CDC and CCI of the discharge report coincided with the gold-standard values in patients with PC by 46.8% and 18.2%, respectively. CONCLUSIONS: The combination of data sources, particularly medical and nursing notes, considerably increases the quantification of PC in general, most notably in complex interventions.

10 years of prehabilitation: From theory to clinical practice.

In recent years, prehabilitation has generated high expectations as an innovative preoperative strategy to enhance clinical outcomes following surgery. Several studies have demonstrated that multimodal programs are effective in improving patients' health status and cardiopulmonary reserve, allowing them to undergo surgery in better conditions and, consequently, reducing the incidence of postoperative complications. Most publications describe proof-of-concept studies, and literature about their implementation is more limited. The implementation of these programs requires new resources and significant organizational effort. In this paper, we share our experience implementing a multimodal prehabilitation program as a mainstream service at a tertiary hospital. Although there are still many unknowns regarding the optimal selection of patients, as well as the duration and components of the program, this article describes our journey in this field, aiming to provide insight for teams interested in developing a similar project.

Estado nutricional preoperatorio y complicaciones en cirugía digestiva oncológica: un estudio retrospectivo en un centro de cáncer chileno

Introducción: La desnutrición es una condición frecuente en pacientes oncológicos y puede estar presente en un 40-80% de éstos. En cirugía gastrointestinal, es ampliamente conocida la relación entre la desnutrición preoperatoria y las complicaciones. El objetivo de este estudio es conocer la asociación entre el estado nutricional preoperatorio según el índice de masa corporal (IMC), la valoración global subjetiva (VGS) y la frecuencia de complicaciones postoperatorias en pacientes sometidos a cirugía oncodigestiva electiva. Metodología: Estudio observacional de cohorte retrospectiva. Se incluyeron pacientes sometidos a cirugía digestiva entre abril de 2019 y abril de 2020. Se excluyeron aquellos pacientes con enfermedad fuera de alcance terapéutico curativo. Los pacientes fueron categorizados según el tipo de cáncer, la cirugía realizada, el tratamiento neoadyuvante, los parámetros nutricionales (IMC y VGS) y la albumina preoperatoria. Se registraron las complicaciones postoperatorias de acuerdo con la clasificación de Clavien-Dindo (III-V). Resultados: Se incluyeron 201 pacientes sometidos a cirugía digestiva. El 83,6% calificó en la categoría B o C según VGS. Diecinueve pacientes (9,5%) presentaron complicaciones postoperatorias. Tener una VGS de categoría C se asoció con un mayor riesgo de complicaciones postoperatorias. Otras variables significativas para desarrollar complicaciones fueron recibir tratamiento neoadyuvante combinado (QT + RT) y ser intervenido por una cirugía de alto riesgo nutricional. Conclusión: Tener un estado nutricional deteriorado previo a una cirugía oncológica según VGS, someterse a una cirugía de alto riesgo nutricional y/o someterse a un tratamiento neoadyuvante combinado presentan un mayor riesgo de desarrollar complicaciones postoperatorias. Se destaca la importancia de incorporar protocolos de evaluación y soporte nutricional como parte del tratamiento multimodal impartido desde el diagnóstico oncológico.

Introduction: Malnutrition is a frequent condition in cancer patients and may be present in 40-80% of them. In gastrointestinal surgery, the relationship between preoperative malnutrition and complications has been widely studied, due to the increased risk of postoperative complications. The aim of this study is to determine the association between preoperative nutritional status, according to body mass index (BMI), subjective global assessment (SGA) and the frequency of postoperative complications in patients undergoing elective oncological digestive surgery. Methodology: Observational retrospective cohort study. Patients undergoing elective surgery between April 2019 and April 2020 were included. Patients with disease outside the curative therapeutic scope were excluded. Patients were categorized by type of cancer, surgery performed, neoadjuvant treatment, nutritional parameters (BMI and SGA) and albumin prior to surgery. Postoperative complications were recorded according to the Clavien-Dindo classification (III-V). Results: A total of 201 patients undergoing digestive surgery were included. 83.6% qualified in category B or C according to VGS. Nineteen patients (9.5%) presented postoperative complications. Having a SGA category C is associated with a higher risk of postoperative complications. Other significant variables for developing complications were receiving combined neoadjuvant treatment (CT + RT) and undergoing high nutritional risk surgery. Conclusion: Having a deteriorated nutritional status prior to oncological surgery according to SGA, undergoing high nutritional risk surgery, and/or undergoing combined neoadjuvant treatment significantly increases the risk of developing postoperative complications. The importance of incorporating nutritional assessment and support protocols as part of the multimodal treatment given to the patient from the moment of cancer diagnosis stands out.

Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey.

BACKGROUND: The methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown. The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. METHODS: Using a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. RESULTS: The survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population. Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients' discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. CONCLUSIONS: This study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.

Postsurgical complications of aortic valve replacement in middle-aged people: an exploratory review of the literature / Complicaciones postquirúrgicas de reemplazo de válvula aórtica en personas de mediana edad: una revisión exploratoria de literatura

Introduction: Cardiovascular Disease (CVD) is the world's leading cause of death, claiming the lives of approximately 18 million people each year, 80% of them in low- and middle-income countries . We say that it is the most difficult intervention because of its cardiac and vascular anatomical composition. Its injury would be extremely dangerous because it would compromise the circulatory and respiratory system, which would generate an aggravation of the patient or his death. That is why the WHO in 2016 calculated the number of deaths attributed to cardiovascular diseases for Colombia at 83,987, added to the post-surgical complications derived from them. The causes that affect the heart and especially the aortic valve range from circulatory difficulty to mechanical failure, so we know that every year more people die from cardiovascular diseases (CVD) than from any other cause. This means the high need and demand for a surgical intervention; indispensable to safeguard the life of patients, for this reason we wonder what are the post-surgical complications of aortic valve replacement surgery in middle-aged people? Objective: To identify the types of post-surgical complications of aortic valve replacement in middle-aged people in the first six months after surgery. Methodology: PRISMA protocol for exploratory literature reviews and its extension for exploratory literature reviews. Methodological quality was assessed with PEDro, and study characteristics were extracted independently. Result: 28 studies included in the review, with scores between 6 and 9, of good and excellent methodological quality. The most frequent post-surgical complications were surgical reintervention, post-surgical bleeding, thrombosis or thromboembolism. Conclusion: Complications of aortic valve replacement are frequent in the middle-aged population.

Introducción: Las Enfermedades Cardiovasculares (ECV) son la principal causa mundial de muerte, y cobran la vida de aproximadamente 18 millones de personas cada año, el 80% de ellas en países de ingresos bajos y medios . Decimos que es la intervención con mayor dificultad por su compuesto anatómico cardiaco y vascular. Su lesión sería sumamente peligrosa porque comprometería el sistema circulatorio y respiratorio, lo cual generaría un agravamiento del paciente o su fallecimiento. Por eso la OMS en el 2016 calculó el número de muertes atribuidas a enfermedades cardiovasculares para Colombia en 83.987, sumado a las complicaciones postquirúrgicas derivadas de ellas. Las causas que afectan al corazón y especialmente la válvula aórtica van desde una dificultad circulatoria hasta una falla mecánica, por lo que sabemos que cada año mueren más personas por enfermedades cardiovasculares (ECV) que por cualquier otra causa. Lo que significa la alta necesidad y demanda de una intervención quirúrgica, la cual es indispensable para salvaguardar la vida de los pacientes, por esta razón nos preguntamos ¿cuáles son las complicaciones postquirúrgicas de una cirugía de reemplazo de válvula aórtica en personas de mediana edad en el primer semestre post cirugía? Objetivo: Identificar los tipos de complicaciones postquirúrgicas de reemplazo de válvula aórtica en personas de mediana edad en el primer semestre post cirugía Metodología: Protocolo PRISMA para revisiones exploratorias de literatura y su extensión para revisiones exploratorias de literatura. Se evaluó la calidad metodológica con PEDro, y se extrajeron de forma independiente las características de los estudios. Resultado: 28 estudios incluidos en la revisión, con puntuaciones entre 6 y 9, de calidad metodológica buena y excelente. Las complicaciones postquirúrgicas más frecuentes fueron: reintervención quirúrgica, hemorragias post cirugía, trombosis o tromboembolismo. Conclusión: Las complicaciones por reemplazo de válvula aortica son frecuentes entre la población de mediana edad.

Introdução: A doença cardiovascular é a principal causa de morte no mundo, causando a morte de cerca de 18 milhões de pessoas a cada ano, 80% dos quais em países de baixa e média renda. Dizemos que é a intervenção mais difícil devido à sua composição anatômica cardíaca e vascular. Sua lesão seria extremamente perigosa porque comprometeria o sistema circulatório e respiratório, o que geraria um agravamento do paciente ou sua morte. É por isso que a OMS calculou em 2016 o número de mortes atribuídas a doenças cardiovasculares para a Colômbia em 83.987, acrescido das complicações pós-cirúrgicas derivadas delas. As causas que afetam o coração e especialmente a válvula aórtica variam de dificuldade circulatória a falha mecânica, por isso sabemos que a cada ano mais pessoas morrem de doenças cardiovasculares (CVD) do que de qualquer outra causa. Isto significa a alta necessidade e demanda de uma intervenção cirúrgica; indispensável para salvaguardar a vida dos pacientes, por esta razão nos perguntamos quais são as complicações pós-cirúrgicas da cirurgia de substituição da válvula aórtica em pessoas de meia-idade? Objectivo: Identificar os tipos de complicações pós-cirúrgicas da substituição da válvula aórtica em pessoas de meia-idade nos primeiros seis meses após a cirurgia. Metodologia: Protocolo PRISMA para a revisão da literatura exploratória e sua extensão para as revisões exploratórias da literatura. A qualidade metodológica foi avaliada com PEDro, e as características do estudo foram extraídas de forma independente. Resultado: 28 estudos incluídos na revisão, com pontuações entre 6 e 9, de boa e excelente qualidade metodológica. As complicações pós-cirúrgicas mais frequentes foram reintervenção cirúrgica, hemorragia pós - cirurgia, trombose ou tromboembolismo. Conclusão: As complicações da substituição da válvula aórtica são frequentes na população de meia-idade.