INDURG TRIAL Protocol: A Randomized Controlled Trial Using Indocyanine Green during Cholecystectomy in Acute Cholecystitis.

INTRODUCTION: Laparoscopic cholecystectomy is one of the most common gastrointestinal surgeries, and bile duct injury is one of its main complications. The use of real-time indocyanine green fluorescence cholangiography allows the identification of extrahepatic biliary structures, facilitating the procedure and reducing the risk of bile duct lesions. A better visualization of the bile duct may help to reduce the need for conversion to open surgery, and may also shorten operating time. The main objective of this study was to determine whether the use of indocyanine green is associated with a reduction in operating time in emergency cholecystectomies. Secondary outcomes are the postoperative hospital stay, the correct intraoperative visualization of the Calot's Triangle structures with the administration of indocyanine green, and the intraoperative complications, postoperative complications and morbidity according to the Clavien-Dindo classification. METHODS: This is a randomized, prospective, controlled, multicenter trial with patients diagnosed with acute cholecystitis requiring emergency cholecystectomy. The control group will comprise 220 patients undergoing emergency laparoscopic cholecystectomy applying the standard technique. The intervention group will comprise 220 patients also undergoing emergency laparoscopic cholecystectomy for acute cholecystitis with prior administration of indocyanine green. CONCLUSION: Due to the lack of published studies on ICG in emergency laparoscopic cholecystectomy, this study may help to establish procedures for its use in the emergency setting.

How to Learn a Complex Endoscopic Procedure: Knots in Transanal Endoscopic Surgery: Different Skill Among Surgeons.

PURPOSE: The intrarectal suture is considered a high technically complex procedure. The study's objectives were to assess the feasibility of making an intrarectal knot, through an in vitro study and assessing whether the video tutorial facilitates learning. MATERIALS AND METHODS: A detailed description of the technique. A comparative observational cross-sectional study in surgeons with no previous experience in intrarectal knots. RESULTS: Twenty-one of these 32 participants passed the intrarectal knot test without video tutorial (T1) (65.6%), and 26 (81.2%) after the video tutorial (T2) (P=0.26). The mean time taken to tie the knot fell from 74 seconds (SD=46) in T1 to 41 seconds (SD=41) in T2 (P<0.001). At T1, 26 participants (81.3%) described the technique as difficult, but only 7 (21.9%) at T2 (P<0.001). CONCLUSIONS: Performing the intrarectal knot suture is feasible. Despite the technical difficulty, the video tutorial is sufficient for surgeons to learn the technique.

Consecuencias de la toma de decisiones terapéuticas con base en el resultado del FAST en pacientes politraumáticos con fractura pélvica / Consequencies of therapeutic decision-making based on FAST results in trauma patients with pelvic fracture

Introducción: La exactitud del FAST disminuye notablemente en los pacientes politraumáticos con fractura pélvica. El objetivo es analizar las consecuencias de tomar decisiones terapéuticas basadas en el resultado del FAST en los pacientes politraumáticos con fractura de pelvis. Métodos: Estudio descriptivo de pacientes con politraumatismos mayores de 16 años que han ingresado en el área de críticos o que han fallecido previamente, con fractura pélvica. El resultado del FAST ha sido comparado con un valor realmente positivo o negativo según el resultado de la laparotomía o de la tomografía computarizada.Resultados: En 13 años, se ha incluido a 263 pacientes politraumáticos con fractura pélvica (ISS medio de 31; mortalidad 19%). El FAST tenía una sensibilidad del 65,2%, una especificidad del 69%, una tasa de falsos negativos del 34,8% y una tasa de falsos positivos del 30,9%. Los pacientes hemodinámicamente inestables tenían el doble de mortalidad que los pacientes estables (27% vs. 14%, p <0,05). Los pacientes con un FAST positivo tenían mayor mortalidad que los pacientes con FAST negativo (43% vs. 26%); 4 de 10 pacientes hemodinámicamente inestables con un FAST falsamente positivo que se sometieron a laparotomía exploradora innecesaria murieron por shock hipovolémico. La mortalidad se redujo del 60 al 20% asociando un packing preperitoneal. Conclusiones: La reducida eficacia del FAST en pacientes con fractura de pelvis nos obliga a cuestionarnos las consecuencias de la toma de decisiones terapéuticas con base en sus resultados. Los pacientes con FAST falsamente positivo tienen una mortalidad mayor, que se puede reducir aplicando un packing preperitoneal. (AU)

Introduction: FAST is essential to decide if trauma patients need laparotomy, but has a notably decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture. Methods: Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who were fallecimiento. FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables. Results: Over the 13–year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs. 14%, p <0.05). Patients with positive FAST died more than negative FAST (43% vs. 26%); and 4 of 10 hemodynamically unstable patients who underwent non therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis. Conclusion: FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduce notably applying a preperitoneal packing. (AU)

Consequencies of therapeutic decision-making based on FAST results in trauma patients with pelvic fracture.

INTRODUCTION: FAST is essential to decide whether trauma patients need laparotomy, but it has a notable decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture. METHODS: Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who died. The FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables. RESULTS: Over the 13-year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs 14%, P < .05). Patients with positive FAST died more than negative FAST (43% vs 26%); and 4 out of 10 hemodynamically unstable patients who underwent non-therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis. CONCLUSION: FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduced notably by applying preperitoneal packing.

Morbidity after transanal endoscopic microsurgery: risk factors for postoperative complications and the design of a 1-day surgery program.

BACKGROUND: Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure with low morbidity. The definition of risk factors for postoperative complications would help to identify the patients likely to require more care and surveillance in an ambulatory or 1-day surgery (A-OdS) program. The main endpoints are overall 30-day morbidity and relevant morbidity. The secondary objectives are to detect risk factors for complications, rehospitalization, and the time of occurrence of the postoperative complications, and to describe the adverse effects following hospitalization that the A-OdS program would avoid. METHODS: This is an observational study of consecutive patients undergoing TEM between June 2004 and December 2016. Overall and relevant morbidity based on the Clavien-Dindo (Cl-D) classification were recorded, as were demographic, preoperative, surgical, and pathology variables. Univariate and multivariate analyses of the risk factors were carried out. RESULTS: Six hundred and ninety patients underwent surgery, of whom 639 were included in the study. Overall morbidity rate was 151/639 patients (23.6%); the clinically relevant morbidity rate was 36/639 (Cl-D > II) (5.6%) and mortality 2/639 (0.3%). The most frequent complication was rectal bleeding, recorded in 16.9% (108/639 patients) and grade I in 86/108 patients (78. 9%). The period with the greatest risk of complications was the first 2 days. The rehospitalization rate after 48 h was 7%. The risk factors for complications were as follows: tumor size > 6 cm (OR 3.2, 95% CI 1.3-7.8), anti-platelet medication (OR 2.3, 95% CI 1.1-5.1), and surgeon's experience < 150 procedures (OR 2.0, 95% CI 1-4.1). CONCLUSIONS: TEM is a safe procedure. The low rates of morbidity, re-hospitalization, and postoperative complications in the first 2 days after surgery make the procedure suitable for A-OdS.

Aplicación del Shock Index como predictor de hemorragia en el paciente politraumático / The use of the Shock Index as a predictor of active bleeding in trauma patients

INTRODUCCIÓN: Las constantes vitales detectan la presencia de hemorragia al perder grandes cantidades de sangre, lo que comporta una gran morbimortalidad. El Shock Index (SI) es un parámetro que detecta el sangrado con puntos de corte de 0,9. El objetivo de este estudio es valorar si un punto de corte de ≥ 0,8 es más sensible para detectar sangrado oculto, permitiendo iniciar maniobras terapéuticas más precoces. MÉTODOS: Estudio analítico de validación del SI que incluye pacientes politraumatizados graves mayores de 16 años. Se registran constantes vitales y escalas predictivas de sangrado: SI, Assessment of Blood Consumption score y Pulse Rate Over Pressure score. Se analiza la relación del SI con 5 marcadores predictivos de sangrado: necesidad de transfusión masiva, embolización angiográfica, control del sangrado quirúrgico, muerte por shock hipovolémico y "sangrado activo" (presencia de al menos uno de los 4 marcadores anteriores en un paciente). RESULTADOS: Recogida prospectiva de datos de 1.402 pacientes politraumatizados durante 10 años. El Injury Severity Score medio fue de 20,9 (DE 15,8). Hubo una mortalidad del 10%. El SI medio fue de 0,73 (DE 0,29). En total presentaron "sangrado activo" el 18,7% de la serie. El SI medio en los pacientes con "sangrado activo" fue de 0,87, mientras que las constantes vitales estaban dentro de la normalidad. El área bajo la curva ROC del SI para el "sangrado activo" fue de 0,749. CONCLUSIONES: El SI con un punto de corte ≥ 0,8 es más sensible que aquel con el punto de corte ≥ 0,9 y permite iniciar maniobras de reanimación más precoces en los pacientes con sangrado oculto

INTRODUCTION: Vital signs indicate the presence of bleeding only after large amounts of blood have been lost, with high morbidity and mortality. The Shock Index (SI) is a hemorrhage indicator with a cut-off point for the risk of bleeding at 0.9. The aim of this study is to assess whether a cut-off of ≥ 0.8 is more sensitive for detecting occult bleeding, providing for early initiation of therapeutic maneuvers. METHODS: SI analytical validation study of severe trauma patients older than 16 years of age. Vital signs were recorded, and scales for predicting bleeding included: SI, Assessment of Blood Consumption score, and Pulse Rate Over Pressure score. The relationship between the SI and 5 markers for bleeding was analyzed: need for massive transfusion, angiographic embolization, surgical bleeding control, death due to hypovolemic shock, and the overall predictor "active bleeding" (defined as the presence of at least one of the 4 markers above). RESULTS: Data from 1.402 trauma patients were collected prospectively over a period of 10 years. The mean Injury Severity Score was 20.9 (SD 15.8). The mortality rate was 10%. The mean SI was 0.73 (SD 0.29). "Active bleeding" was present in 18.7% of patients. The SI area under the ROC curve for "active bleeding" was 0.749. CONCLUSIONS: An SI cut-off point ≥ 0.8 is more sensitive than ≥ 0.9 and allows for earlier initiation of resuscitation maneuvers in patients with occult active bleeding

The use of the Shock Index as a predictor of active bleeding in trauma patients. / Aplicación del Shock Index como predictor de hemorragia en el paciente politraumático.

INTRODUCTION: Vital signs indicate the presence of bleeding only after large amounts of blood have been lost, with high morbidity and mortality. The Shock Index (SI) is a hemorrhage indicator with a cut-off point for the risk of bleeding at 0.9. The aim of this study is to assess whether a cut-off of≥0.8 is more sensitive for detecting occult bleeding, providing for early initiation of therapeutic maneuvers. METHODS: SI analytical validation study of severe trauma patients older than 16 years of age. Vital signs were recorded, and scales for predicting bleeding included: SI, Assessment of Blood Consumption score, and Pulse Rate Over Pressure score. The relationship between the SI and 5 markers for bleeding was analyzed: need for massive transfusion, angiographic embolization, surgical bleeding control, death due to hypovolemic shock, and the overall predictor «active bleeding¼ (defined as the presence of at least one of the 4 markers above). RESULTS: Data from 1.402 trauma patients were collected prospectively over a period of 10 years. The mean Injury Severity Score was 20.9 (SD 15.8). The mortality rate was 10%. The mean SI was 0.73 (SD 0.29). «Active bleeding¼ was present in 18.7% of patients. The SI area under the ROC curve for «active bleeding¼ was 0.749. CONCLUSIONS: An SI cut-off point≥0.8 is more sensitive than≥0.9 and allows for earlier initiation of resuscitation maneuvers in patients with occult active bleeding.