Análisis evolutivo de morbimortalidad en cirugía de urgencias durante la pandemia: comparación retrospectiva entre primera y segunda ola de COVID-19 / Evolutionary analysis of patient's morbidity and mortality in emergency surgical care during the pandemic: Retrospective comparison between first and second wave of COVID-19

Introducción: Desde el comienzo de la pandemia, la morbimortalidad en la atención urgente al paciente quirúrgico ha sido objeto de estudio. Sin embargo, la mayoría de los estudios compararon dicha variable con la propia de la época pre-COVID, obviando la evolución de la misma durante la propia pandemia. Con el objetivo de analizar este posible cambio, realizamos un estudio comparativo de morbimortalidad en cirugía de urgencias entre la primera y segunda ola de la pandemia en nuestro centro. Material y métodos: Estudio retrospectivo longitudinal que incluyó a todos los pacientes mayores de 18 años ingresados y/o intervenidos quirúrgicamente de forma urgente en los dos periodos de máxima incidencia (PMI) de infección por COVID-19 (1.er: 22/03/2020-31/05/2020; 2.° PMI: 26/08/2020-30/11/2020). Se analizó la incidencia de infección por SARS-CoV-2, el tratamiento recibido, la morbimortalidad precoz y los posibles factores de riesgo de complicaciones. Resultados: Se analizaron 173 pacientes (1.er: 66; 2.° PMI: 107). La incidencia de COVID-19 fue mayor en el segundo periodo (14,95% vs. 4,54%). La infección por SARS-CoV-2 se asoció a una mayor tasa de complicaciones, sin embargo, no se observaron diferencias estadísticamente significativas en la morbimortalidad general (p = 0,746) ni en la de los pacientes COVID positivos (p = 0,582) entre ambos periodos. El tratamiento quirúrgico se asoció con una menor tasa de complicaciones tanto en la primera (p = 0,006) como en la segunda ola (p = 0,014). Dicho tratamiento quirúrgico fue más frecuente en el segundo PMI (70,1 vs. 57,6%) aunque no se alcanzó la significación estadística al respecto de esta afirmación (p = 0,065).(AU)

Introduction: Since the beginning of the pandemic, morbidity and mortality in emergency care of surgical patients have been the subject of several studies. However, most of these have compared this variable with that of the pre-COVID period, ignoring its evolution during the pandemic itself. In order to analyze this possible change, we performed a comparative study of morbidity and mortality in emergency surgery between the first and second waves of the pandemic in our center. Material and methods: Retrospective longitudinal study including all patients over the age of 18 admitted and/or operated in the emergency setting in the two maximum incidence periods (MIP) of COVID-19 infection (1st MIP: 22/03/2020–31/05/2020; 2nd MIP: 26/08/2020–30/11/2020). The incidence of SARS-CoV-2 infection, treatment received, early morbidity and mortality and possible risk factors for complications were analyzed. Results: A total of 173 patients were analyzed (1st MIP: 66; 2nd MIP: 107). The incidence of COVID-19 was higher in the second period (14.95% vs. 4.54%). SARS-CoV-2 infection was associated with a higher rate of complications, however, no statistically significant differences were observed in morbimortality rate, either in the total sample (p = 0.746) or in patients with a positive COVID-19 test (p = 0.582) between both periods. Surgical treatment was found to be associated with a lower complication rate in both the first (p = 0.006) and second wave (p = 0.014), and it was more frequent in the second PMI (70.1 vs. 57.6%) although statistical significance was not reached (p = 0.065). (AU)

Evolutionary analysis of patient's morbidity and mortality in emergency surgical care during the pandemic: Retrospective comparison between first and second waves of COVID-19.

INTRODUCTION: Since the beginning of the pandemic, morbidity and mortality in emergency care of surgical patients have been the subject of several studies. However, most of these have compared this variable with that of the pre-COVID period, ignoring its evolution during the pandemic itself. In order to analyze this possible change, we performed a comparative study of morbidity and mortality in emergency surgery between the first and second waves of the pandemic in our center. METHODS: Retrospective longitudinal study including all patients over the age of 18 admitted and/or operated in the emergency setting in the two maximum incidence periods (MIP) of COVID-19 infection (1st MIP: 22/03/2020-31/05/2020; 2nd MIP: 26/08/2020-30/11/2020). The incidence of SARS-CoV-2 infection, treatment received, early morbidity and mortality and possible risk factors for complications were analyzed. RESULTS: A total of 173 patients were analyzed (1st MIP: 66; 2nd MIP: 107). The incidence of COVID-19 was higher in the second period (14.95% vs. 4.54%). SARS-CoV-2 infection was associated with a higher rate of complications; however, no statistically significant differences were observed in morbimortality rate, either in the total sample (P = .746) or in patients with a positive COVID-19 test (P = .582) between both periods. Surgical treatment was found to be associated with a lower complication rate in both the first (P = .006) and second waves (P = .014), and it was more frequent in the second MIP (70.1% vs 57.6%), although statistical significance was not reached (P = .065). CONCLUSIONS: No significant differences were observed in morbidity and mortality of patients admitted and/or operated in the emergency setting in the two periods of maximum incidence of SARS-CoV-2 at our center. Surgical treatment was associated with lower morbidity and mortality rates, and it was more frequent in the second MIP.

Resident training in colorectal laparoscopic surgery: A retrospective morbidity, mortality and survival analysis of 408 cases in our environment.

INTRODUCTION: Colorectal cancer has a growing incidence in our society. However, the performance of laparoscopic interventions in this field is still not included in the National Training Program. Given the lack of references, our objective was to analyze the resident's participation in laparoscopic colorectal surgery and its possible effect on morbidity and mortality and oncological prognosis. METHODS: A retrospective longitudinal single-center study that included all laparoscopic colorectal surgical procedures performed by residents (R group) and by attending surgeons (A group) between 01/01/2009 and 12/31/2017, maintaining follow-up until 12/31/2018. Postoperative morbidity and mortality, overall survival (OS) and disease- free survival (DFS), as well as their relationship with the resident involvement as first surgeon were analyzed. RESULTS: 408 patients were analyzed, of which 138 (33.8%) were operated by a supervised resident and 270 (66.2%) by the attending surgeon. No differences were detected in the rate of postoperative complications between both groups (OR: 1.536; 95% CI: 0.947-2.409; p = 0.081). Furthermore, resident participation had no influence on tumor recurrence rate (R Group: 14.2% vs. A Group: 16.9%; p = 0.588) or on overall (p = 0.562) or disease-free survival (p = 0.305). CONCLUSION: Resident involvement in laparoscopic colorectal surgery had no influence on morbidity and mortality or oncological prognosis in our center. Conducting prospective studies in this regard will provide greater knowledge, enabling a progressive improvement of the training program.

Upfront surgery versus self-expanding metallic stent as bridge to surgery in left-sided colonic cancer obstruction: A multicenter observational study.

BACKGROUND: Oncological outcomes of self-expanding metallic stent used as a bridge to surgery in potential curative patients with left-sided colonic cancer obstruction remain unclear. The aim of this study was to investigate perioperative and mid-term oncological outcomes of 2 of the currently most commonly performed treatments in left-sided colonic cancer obstruction. METHODS: This is a retrospective multicenter study including patients with left-sided colonic cancer obstruction treated with curative intent between 2013 and 2017. The presence of metastasis at diagnosis was an exclusion criterion. The primary outcome was to evaluate the noninferiority, in terms of overall survival, of bridge to surgery strategy compared with emergency colonic resection. The secondary outcomes were perioperative morbimortality, disease free survival, local recurrence, and distant recurrence. RESULTS: A total of 564 patients were included, 320 in the emergency colonic resection group and 244 in the bridge to surgery group. Twenty-seven patients of the bridge-to-surgery group needed urgent operation. Postoperative morbidity rates were statistically higher in the emergency colonic resection group (odds ratio [95% confidence interval] 0.37 [0.24-0.55], P < .001). There was no difference in 90-day mortality between groups (odds ratio [95% confidence interval] 0.85 [0.36-1.99], P = .702). The median follow-up was 3.80 years (2.29-4.92). The results show the noninferiority of bridge to surgery versus emergency colonic resection in terms of overall survival (hazard ratio [95% confidence interval) 0.78 [0.56-1.07], P = .127). There were no differences in disease free survival, distant recurrence, and local recurrence rates between bridge to surgery and emergency colonic resection groups. CONCLUSION: Self-expanding metallic stent as bridge to surgery might not lead to a negative impact on the long-term prognosis of the tumor compared with emergency colonic resection in expert hands and selected patients.

Resident training in colorectal laparoscopic surgery: A retrospective morbidity, mortality and survival analysis of 408 cases in our environment. / Formación del residente en cirugía laparoscópica en coloproctología: análisis retrospectivo de morbimortalidad y pronóstico oncológico sobre 408 pacientes en nuestro centro.

INTRODUCTION: Colorectal cancer has a growing incidence in our society. However, the performance of laparoscopic interventions in this field is still not included in the National Training Program. Given the lack of references, our objective was to analyze the resident's participation in laparoscopic colorectal surgery and its possible effect on morbidity and mortality and oncological prognosis. METHODS: A retrospective longitudinal single-center study that included all laparoscopic colorectal surgical procedures performed by residents (R group) and by attending surgeons (A group) between 01/01/2009 and 12/31/2017, maintaining follow-up until 12/31/2018. Postoperative morbidity and mortality, overall survival (OS) and disease-free survival (DFS), as well as their relationship with the resident involvement as first surgeon were analyzed. RESULTS: 408 patients were analyzed, of which 138 (33.8%) were operated by a supervised resident and 270 (66.2%) by the attending surgeon. No differences were detected in the rate of postoperative complications between both groups (OR: 1.536; 95% CI: 0.947-2.409; p=0.081). Furthermore, resident participation had no influence on tumor recurrence rate (R Group: 14.2% vs. A Group: 16.9%; p=0.588) or on overall (p = 0.562) or disease-free survival (p = 0.305). CONCLUSION: Resident involvement in laparoscopic colorectal surgery had no influence on morbidity and mortality or oncological prognosis in our center. Conducting prospective studies in this regard will provide greater knowledge, enabling a progressive improvement of the training program.

Upper gastrointestinal bleeding due to hepatic artery aneurysm: Case report and literature review.

INTRODUCTION: Aneurysm of the hepatic artery is most of the time a rare and asymptomatic pathology, but in case of complication it shows high morbidity and mortality requiring in many cases an urgent treatment. PRESENTATION OF CASE: A 92-year-old male presented at the emergency department with high gastrointestinal bleeding and abdominal pain. Gastroscopy showed a submucosal lesion with active bleeding that was controlled through this approach. The study was expanded with a CT angiogram and a complicated hepatic aneurysm with duodenal fistulization was observed. DISCUSSION: After reviewing the case, surgical treatment is proposed as the first option but it is rejected by the patient. Thus, aneurysm embolization with coils and thrombin is performed, without further complications. CONCLUSION: Selective embolization of the hepatic artery aneurysm is a therapeutic alternative in cases that implies large comorbidities, being an increasingly used technique.

Recidiva de tumor Phyllodes sarcomatoide en una mujer joven: a propósito de un caso / Recurrence of sarcomatoide phyllodes tumor in a young

Resumen Introducción: El tumor Phyllodes mamario es una entidad muy poco frecuente, con tendencia a la recidiva local y una tasa de malignización de 5-10%. La base de su tratamiento es la resección quirúrgica. Material y Métodos: Mujer de 32 años diagnosticada de un tumor Phyllodes maligno en mama derecha sometida en otro centro a cirugía conservadora con colocación de expansor y a dos tumorectomías posteriores por recidiva local. Fue referida a nuestro Hospital al presentar una nueva recidiva de gran tamaño (9,2 cm) para valoración de intervención quirúrgica. Resultados: Se realizó exéresis del tumor (remanente de tejido mamario y músculo pectoral mayor) y retirada del expansor con reconstrucción mamaria con colgajo de dorsal ancho en el mismo tiempo quirúrgico. En el momento actual la paciente se encuentra pendiente de iniciar tratamiento radioterápico. Conclusiones: El tumor Phyllodes maligno es una entidad poco frecuente y cuyo manejo terapéutico se basa en la resección quirúrgica con márgenes. De forma adyuvante se puede administrar quimiorradioterapia. Es de gran importancia realizar un manejo multidisciplinar e individualizado de cada caso para ofrecer el mejor pronóstico.

Introduction: Phyllodes tumor is a rare entity, with a high tendency to local recurrence and a malignancy rate of 5-10%. The basis of its treatment is the surgical resection. Materials and Method: We report a 32-year-old woman who was diagnosed of a malignant Phyllodes tumor who had previously underwent conservative breast surgery and expander placement in another center. Two subsequent lumpectomies due to local recurrences were necessary. She was referred to our Hospital for she presented a new large-sized recurrence (9.2 cm) at the retroarelor area for assessment of new surgical treatment. Results: Surgical resection of the tumor (remnant of mammary tissue and pectoralis major muscle) and removal of the expander with immediate breast reconstruction with latissimus dorsi flap was performed. At the present time, the patient is pending radiotherapeutic treatment. Conclusions: Malignant Phyllodes tumor is a rare entity whose therapeutic management is based on margin-free surgical excision. Adjuvant chemoradiotherapy might be administered. It is very important to carry out a multidisciplinary and individualized management of each case to offer the best possible forecast.

Case report: Diverticulitis complicating a giant Meckel's divertuculum.

INTRODUCTION: In this paper, we discuss a unique case of diverticulitis in which the patient presented a giant Meckel's diverticulum. PRESENTATION OF CASE: The patient was a 44 year old male whose medical history included a laparoscopic gastric bypass four years before the finding, and chronical high blood pressure. The patient came to the emergency department with an abdominal pain and elevated acute-phase reactants. An abdominal CT revealed a 17 cm long Meckel's diverticulum with signs of severe inflammation. The patient was then taken to the operating room, and subjected to a 4 cm ileum resection, including the entire diverticulum, with a manual end-to-end anastomosis. DISCUSSION: Although Meckel's diverticulum is the most common congenital abnormality of the intestinal tract, it is unusual for it to cause symptoms in adults. However, when a patient arrives at the emergency department with a complicated Meckel's diverticulum, an early diagnosis is essential to prevent serious complications, such as perforation of the diverticulum and subsequent peritonitis. The presence of a giant diverticulum is an extremely rare condition. There are few publications to date, but these diverticula are associated with more complications, presenting a higher risk of torsion, volvulus or intestinal obstruction. This paper include a bibliographic review of existing studies on etiopathogenesis, and the diagnosis and treatment of complicated Meckel's diverticulum, particularly in its giant variant. CONCLUSION: Although Meckel's diverticulitis is a rare entity, it can appear as an acute abdomen. An early diagnosis and treatment to prevent subsequent complications is essential to ensure an optimal recovery.

De Garengeot's hernia: Case report and literature review.

INTRODUCTION: De Garengeot's Hernia is a rare type of femoral hernia in which the appendix is located inside the herniated sac. Diagnosis of the condition is challenging and its treatment must be performed without delay. PRESENTATION OF CASE: We present the case of a 75-year-old patient with a femoral hernia in which an appendix with signs of inflammation was found. An appendectomy followed by hernia repair was performed under an open preperitoneal approach according to Nyhus technique. The patient did not present any complications and was discharged on the second postoperative day. DISCUSSION: This type of hernia is often unexpected and its preoperative diagnosis is difficult to perform. In most cases the clinical picture is indistinguishable from a common incarcerated hernia. Contrast-enhanced CT is the most useful complementary test, although it is not as accurate as desirable, so the diagnosis is frequently found intraoperatively. There is a wide variety of surgical options and there is no consensus on the most appropriate one. The preperitoneal approach enables the performance of an appendectomy and subsequent hernia reparation. The use of prosthesis should be considered if there are no signs of perforation or abscess. CONCLUSION: De Garengeot's hernia is a very rare entity. The diagnosis and subsequent surgical treatment must be early to prevent the disease progression. The preperitoneal approach should be considered as the first choice technique, as it allows the exploration of the herniated sac and the performance of surgical procedures on its content.