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Resumen Introduccion Los parametros clinicos y analiticos de la apendicitis aguda (AA) son la base diagnostica. Se analiza la diferencia de sus valores segun la histologia para distinguir las AA simples de las complicadas. Metodos Analisis observacional retrospectivo que incluye pacientes (> 14 anos) que ingresan con diagnostico de AA desde el 1 abril 2014 al 31 julio 2016. Histopatologicamente se dividen en AA complicada (perforada y/o gangrenada) y AA no complicada (flemonosa). Entre los 2 grupos se compara sexo, edad, temperatura al ingreso, duracion de sintomatologia, recuento leucocitario preoperatorio (WBC), porcentaje de neutrofilos, volumen plaquetario medio (VPM), indice de distribucion de plaquetas (PDW), proteina C-reactiva (PCR) y estancia hospitalaria. Resultados Se analizan 335 pacientes y se incluyen 284, de los cuales 194 (68,3%) tienen AA no complicada (AAnc) y 90 (31,7%) AA complicada (AAc). La edad, la duracion de sintomatologia, el porcentaje de neutrofilos, la PCR y la estancia hospitalaria son mayores en la AAc (p Conclusiones El modelo predice la posibilidad de desarrollar AAc, pero debe validarse de manera prospectiva.

Post-operative morbidity of pancreatectomies occurs in up to 40-50% of patients, even in modern series. There is a need to find a simple scale in order to identify patients with increased risk of developing major post-operative complications after pancreatic resections. Many studies have been published on sarcopenia and surgical outcomes. Aspects of sarcopenia are presented, along with a systematic review using PRISMA guidelines, in order to search for articles about sarcopenia and pancreatic surgery. The impact of sarcopenia on morbidity and mortality in pancreatic resections is still unclear. The studies presented have been carried out over long periods of time, and many of them compare patients with different diseases. There are also different definitions of sarcopenia, and this can influence the results, as some of the reviewed articles have already shown. It is necessary to unify criteria, both in the definition and in the cut-off values. Prospective studies and consensus on sarcopenia diagnosis should be achieved.

Combined hepatic and inferior vena cava (IVC) resection is the only potentially curative treatment for patients with colorectal liver metastases (CRLM) involving the IVC. Most of the existing data come from case reports or small case series. In this paper, a systematic review based on the PICO strategy was performed in accordance with the PRISMA statement. Papers from January 1980 to December 2022 were searched in Embase, PubMed, and the Cochrane Library databases. Articles considered for inclusion had to present data on simultaneous liver and IVC resection for CRLM and report surgical and/or oncological outcomes. From a total of 1175 articles retrieved, 29, including a total of 188 patients, met the inclusion criteria. The mean age was 58.3 ± 10.8 years. The most frequent techniques used were right hepatectomy ± caudate lobe for hepatic resections (37.8%), lateral clamping (44.8%) for vascular control, and primary closure (56.8%) for IVC repair. The thirty-day mortality reached 4.6%. Tumour relapse was reported in 65.8% of the cases. The median overall survival (OS) was 34 months (with a confidence interval of 30–40 months), and the 1-year, 3-year, and 5-year OS were 71.4%, 19.8%, and 7.1%, respectively. In the absence of prospective randomized studies, which are difficult to perform, IVC resection seems to be safe and feasible.

Background: Hepatocellular carcinoma is the most common type of primary liver cancer and is the third cause of cancer related deaths; 80% of the HCC are associated with cirrhotic livers or chronic liver diseases, which constitute the main risk factor. Chronic inflammation, necrosis and regeneration due to these conditions produce genetic mutation and development of tumor cells. Yet, 10% develop in non-cirrhotic healthy livers without precipitating factors. Material and methods: We conducted a retrospective analysis of the characteristics and survival of patients with diagnosis of hepatocellular carcinoma in non-cirrhotic liver and absence of a history of liver cirrhosis or chronic liver disease undergoing surgery in two hepato-pancreato-biliary units between January 2007 and January 2016. Results: Mean age was 65 years and 13 patients were men. Abdominal pain was the most common clinical presentation. Liver panel was normal in 60% of the cases and alpha-fetoprotein was elevated in only 16%. The diagnosis was made by imaging tests in 61% of the cases. Mean tumor size was 110.6 cm. All the patients underwent surgery. Complications were observed in 36.8% of the patients and survival at 5 years was 62.3%. Conclusion: hepatocellular carcinoma is usually diagnosed as a large lesion in imaging tests ordered due to abdominal pain. Surgery provides curative treatment, and large resections can be safely performed, with low perioperative morbidity and mortality and low incidence of postoperative liver failure,since the liver remnant is healthy and liver function is maintained.

Postoperative complications represent a basic quality indicator for measuring outcomes at surgical units. At present, however, they are not systematically measured in all surgical procedures. A more accurate assessment of their impact could help to evaluate the real morbidity associated with different surgical interventions, establish measures for improvement, increase efficiency and identify benchmarking services. The Clavien-Dindo Classification is the most widely used system worldwide for assessing postoperative complications. However, the postoperative period is summarized by the most serious complication without taking into account others of lesser magnitude. Recently, two new scoring systems have emerged, the Comprehensive Complication Index and the Complication Severity Score, which include all postoperative complications and quantify them from 0 (no complications) to 100 (patient’s death), These allow the comparison of results. It is important to train surgical staff to report and classify complications and to record 90-d morbidity rates in all patients. Comparisons with other services must take into account patient comorbidities and the complexity of the particular surgical procedure. To avoid subjectivity and bias, external audits are necessary. In addition, ensuring transparency in the reporting of the results is an urgent obligation.

OBJECTIVE To validate the Comprehensive Complication Index (CCI) via an assessment of its relation to postoperative costs. BACKGROUND The CCI summarizes all the postoperative complications graded by the Clavien-Dindo classification (CDC) on a numerical scale. Its relation to hospital costs has not been validated to date. METHODS Prospective observational cohort study, including all patients undergoing surgery at a general surgery service during the 1-year study period. All complications graded with the CDC and CCI and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. The surgeries were classified according to their Operative Severity Score (OSS) and in 4 groups of homogeneous surgeries. All postoperative costs were recorded. RESULTS In all, 1850 patients were included, of whom 513 presented complications (27.7%). The CDC and the CCI were moderately to strongly correlated with overall postoperative costs (OPCs) in all OSS groups (rs = 0.444-0.810 vs 0.445-0.820; P < 0.001), homogeneous surgeries (rs = 0.364-0.802 vs 0.364-0.813; P < 0.001), prolongation of postoperative stay (rs = 0.802 vs 0.830; P < 0.001), and initial operating room costs (rs = 0.448 vs 0.451; P < 0.001). This correlation was higher in emergency surgery. With higher CDC grades, the OPC tended to increase an upward trend. In the multivariate analysis, CDC, CCI, age, and duration of surgery were all associated with OPC (P < 0.001). CONCLUSIONS In our environment, the CCI presented associations with OPC. This demonstration of its economic validity enhances its clinical validity.

Introduction We performed a study of the top 100 most cited articles in the five general surgery journals with the highest impact according to Journal Citation Report. Methods We selected the five journals with the highest impact in 2015: Annals of Surgery, British Journal of Surgery, JAMA Surgery, Surgery, and Journal of the American College of Surgeons. In January 2017, using the Web of Science application, we performed a search of all articles published by these journals and identified the 100 most cited articles (top 100). We evaluated the number of citations, year of publication, type of article, country and hospital of the article, area of interest and number of authors. Results The median number of citations per top 100 paper was 490. Twenty percent of the top 100 papers have been published since 2000. Overall, 70% are original papers, 8% randomized control trials, 11% reviews, 1% meta-analyses and 11% other subtypes. There are 13% proceedings papers. Sixty-one percent are from the US. The most frequently discussed topic is hepato-pancreato-biliary surgery (33%). Conclusions The top 100 most cited articles tend to be original articles describing studies carried out in the US, reporting significant surgical breakthroughs. Hepato-pancreato-biliary surgery is the most common subject area. Annals of Surgery had twice as many citations as the other journals studied. The archetypal article of the Top15 most cited is an original paper published in the twentieth century, with an average of 2000 citations.

Resumen Introduccion Llevamos a cabo un estudio de los 100 articulos mas citados en las 5 revistas quirurgicas con mayor factor de impacto segun Journal Citation Report. Metodos Seleccionamos las 5 revistas con mayor factor de impacto segun JCR en el ano 2015 (Annals of Surgery, British Journal of Surgery, JAMA Surgery, Surgery, and Journal of the American College of Surgeons). Realizamos una busqueda de todos los articulos publicados en estas cinco revistas a fecha de enero de 2017 y seleccionamos los 100 articulos mas citados segun Web of Science. Evaluamos numero de citaciones, ano de publicacion, tipo de articulo, pais y hospital de procedencia, area de interes y numero de autores. Resultados La mediana del numero de citaciones del top 100 de citaciones es de 490. El 20% se han publicado desde el ano 2000. De forma general, el 70% son originales, el 8% ensayos aleatorizados, 11% revisiones, 1% metaanalisis y el 11% otro tipo de estudios. Mas del 60% provienen de EE. UU. y el area hepatopancreatobiliar es la mas frecuentemente abordada (33%). Conclusiones El articulo incluido en el top 100 de articulos mas citados en cirugia tiende a ser un articulo original sobre el area hepatobiliopancreatica y procedente de EE. UU. La revista Annals of Surgery tiene el doble de citaciones que el resto de revistas estudiadas.

Introduccion: la cirugia radical en hidatidosis hepatica se asocia con menor morbilidad y recurrencia que la conservadora. Material y metodos: realizamos un estudio observacional retrospectivo de pacientes con cirugia de quiste hidatidico hepatico. Se incluyeron 71 pacientes con 90 quistes entre 2007 y 2017. Se realizo cirugia radical en el 69,01 %. Resultados: no hubo diferencias en morbimortalidad, fuga biliar o recurrencia segun cirugia. Los quistes complicados se asociaron con mayor estancia y morbilidad. Conclusiones: la toma de decisiones debe considerar edad/comorbilidad, caracteristicas del quiste y recursos disponibles. La cirugia radical debe ser aplicada siempre que sea factible, con mejores resultados con una adecuada seleccion de pacientes.

Recently, some surgical teams have used a laparoscopic vertical clip gastroplasty to treat morbid obesity. This approach mimics the principle of laparoscopic sleeve gastrectomy, but using a completely reversible mechanism. Displacement of the device has been reported in 7.7% of cases. The manner of its withdrawal has not been described to date. A 50-year-old woman with a body mass index (BMI) of 36.3 kg/m2 underwent a laparoscopic calibrated tubular gastroplasty at another hospital with an 38-F orogastric tube by a B-CLAMP® gastric clip on January 11, 2019. The patient came to the Emergency Department 8 months later due to complete oral intolerance, with continuous vomiting of 5 days of evolution. Physical examination: BMI 28.9 kg/m2, dehydration; depressed abdomen, with mainly supraumbilical pain and distension, and significant tympanism on palpation. No guarding or signs of peritoneal irritation. Simple abdominal x-ray showed gastric distension and gastric clip. The nasogastric tube drained 2500 cc of gastrobiliary contents. The computed tomography showed the gastric clip displaced and located medially to the esophagogastric junction, the lesser curvature, and the antropyloric region. A laparoscopic approach was performed using 4 trocars. Signs of gastric suffering in the antral region. The clip was located to the right of the lesser curvature covered by a layer of fibrosis. The clip was removed by a 12-mm trocar. There were no postoperative complications. This video demonstrates a form to extract a displaced gastric clip used to create a calibrated tubular gastroplasty using a laparoscopic approach.

To analyze whether clinical and analytical parameters differ according to histopathology in cases of acute appendicitis (AA).This is a retrospective, observational study including patients (14 years of age) admitted for suspicion of AA from 1 April 2014 to 31 July 2016. Histopathology was divided into complicated (including perforated and gangrenous AA) and uncomplicated appendicitis (phlegmonous). Sex, age, temperature of patients on admission to the Emergency Department, symptom duration, preoperative white blood cell (WBC) count, neutrophil percentage, mean platelet volume (MPV), platelet distribution width (PDW), C-reactive protein (CRP) and hospital stay were compared in the two groups.Three hundred and thirty-five patients were analyzed, and 284 were included. Appendicitis was uncomplicated in 194 (68.3%) and complicated in 90 (31.7%). Age, symptom duration, neutrophil percentage, CRP and hospital stay were higher in the complicated AA group (P.05). The mean differences between uncomplicated and complicated AA were: age 13.2 years (95% CI: 8.2-18.2), symptom duration 14.1hours (95% CI: 6.3-21.9), neutrophil percentage 5.0% (95% CI: 3.2-6.8), CRP 73.6mg/l (95% CI: 50.0-97.2) and hospital stay 2.2 days (95% CI: 1.4-3.0), with p0.05 for all these variables. A model based on the preoperative parameters (age, symptom duration, neutrophil percentage and CRP) was calculated to predict the likelihood of complicated AA. The receiver operating characteristic (ROC) of the model had an area under the curve of 0.80 (95% CI 0.75-0.85).This model is able to diagnose complicated AA without the need for imaging techniques, although it must be validated with prospective analysis.

OBJECTIVE Using clinical outcomes, to validate the comprehensive complication index (CCI) as a measure of postoperative morbidity in all patients undergoing surgery at a general surgery department. BACKGROUND The Clavien-Dindo classification (CDC) is the most widely used system to assess postoperative morbidity. The CCI is a numerical scale based on the CDC. Once validated, it could be used universally to establish and compare the real postoperative complications of each surgical procedure. METHODS Observational prospective cohort study. All patients who underwent surgery during the 1-year study period were included. All the complications graded with the CDC and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. Surgical procedures were classified according to the operative severity score (OSS) as minor, moderate, major, or major+. The clinical validation of the CCI was performed by assessing its correlation with 4 different clinical outcomes. RESULTS A total of 1850 patients were included: 513 (27.7%) presented complications and 101 (5.46%) were readmitted. In the multivariate analysis, the CCI and CDC were associated with postoperative stay, prolongation of postoperative stay, readmission, and disability in all OSS groups (P < 0.001). The CCI was superior to the CDC in all models except for prolongation of stay for OSS moderate and major+. CONCLUSIONS The CCI can be applied in all the procedures carried out at general surgery departments. It is able to determine the morbidity and allows the comparison of the outcomes at different services.

The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.

Perforation in colorectal cancer is an uncommon condition, and neoplastic invasion of the abdominal wall with local infection is even rarer. Our objective is to present the case of an 84-year-old male with right colon cancer that manifested as an inguinal abscess, and also to perform a systematic review of the literature in PubMed, EMBASE, and Web of Science. A total of 59 cases in retrospective studies were found. Median age was 64 years, thirty cases were men and twenty-nine were women (51% and 49%, respectively). The most common location was the right colon with 27 cases (46%), followed by the left colon with 18 cases (31%), 12 cases in the transverse colon (20%), and 2 cases with colonic synchronous neoplasm (3%). Surgery was performed in two or more occasions for 33 cases (60%), and on one occasion for 21 cases (38%); medical treatment alone was administered in one case (2%). The most common histological type was adenocarcinoma (64%), followed by its mucinous variant (22%). There was recurrence in 33% of cases. Mortality at follow-up was 47%. As a limitation of our study, follow-up was heterogeneous, making it impossible to interpret long-term results regarding the influence of treatment on patient survival, also difficulted by the urgent nature of the condition and its exceptional incidence. Further studies are needed with prospective data collection on the management of colorectal cancer in the emergency setting, standardizing follow-up in order to facilitate an adequate analysis of the prognosis of the disease.

Postoperative complications (PC) are a basic health outcome, but no surgery service in the world records and/or audits the PC associated with all the surgical procedures it performs. Most studies that have assessed the cost of PC suffer from poor quality and a lack of transparency and consistency. The payment system in place often rewards the volume of services provided rather than the quality of patients' clinical outcomes. Without a thorough registration of PC, the economic costs involved cannot be determined. An accurate, reliable appraisal would help identify areas for investment in order to reduce the incidence of PC, improve surgical results, and bring down the economic costs. This article describes how to quantify and classify PC using the Clavien-Dindo classification and the comprehensive complication index, discusses the perspectives from which economic evaluations are performed and the minimum postoperative follow-up established, and makes various recommendations. The availability of accurate and impartially audited data on PC will help reduce their incidence and bring down costs. Patients, the health authorities, and society as a whole are sure to benefit.

Background Liver metastases emerge during the course of colorectal cancer (CRC) in 25-50% of patients. A small proportion of patients present intrabiliary growth. The absence of large series means that little is known about intrabiliary metastasis (IBM), its radiological diagnosis, the most suitable surgical techniques, and its prognostic implications. Methods A systematic search without limits was performed. The studies selected included patients with a diagnosis of CRC and associated IBM, either synchronous or metachronous. Results Of 40 studies selected, 30 were case reports and 10 case series. The median time between diagnosis and IBM was 46.7 months (range 0-180). Most CRC metastases are CK7-/CK20+. Surgical treatment performed ranged from endoscopic resection to major hepatic resections combined with pancreatectomies. It seems that patients with IBM have a better survival than patients without this metastasis. Conclusion In a patient with a history of CRC presenting dilatation of the bile duct, IBM should be considered. More studies are needed to determine the most appropriate type of liver resection. It is also necessary to standardize the definition and terminology of this pathology, since the existing definitions may cause confusion and make it difficult to carry out case studies and case series.

espanolObjetivo: el objetivo de este estudio es evaluar los motivos y el momento de reingreso hospitalario despues de colecistectomia comparando los pacientes en base a la realizacion de una colangiopancreatografia retrograda endoscopica (CPRE) previa o no. Metodo: retrospectivamente, se revisaron todos los pacientes sometidos a colecistectomia en el Servicio de Cirugia General y del Aparato Digestivo del Hospital Universitario de Guadalajara entre enero de 2011 y diciembre de 2016. Se incluyeron pacientes sometidos a colecistectomia reingresados en cualquier servicio del hospital en los 90 dias posteriores a la cirugia. Los criterios de exclusion fueron: colecistectomia asociada a otros procedimientos, patologia oncologica activa en el momento de la colecistectomia, ingresos programados previamente por otra patologia no relacionada y presencia de histologia tumoral en la pieza de colecistectomia. Resultados: se estudiaron 1.714 pacientes, de los cuales 80 pacientes fueron readmitidos durante los 90 dias posteriores al alta de la colecistectomia. La tasa de readmision fue del 4,67%. La realizacion de CPRE previa a la cirugia se asocio a un aumento de la morbilidad postoperatoria (40% vs. 21,54%). La realizacion previa de una CPRE disminuyo la aparicion de complicaciones de tipo biliar en los 90 dias posteriores a la colecistectomia. Se observo tambien un aumento del numero de dias hasta que se produce el reingreso en estos pacientes (22 dias con CPRE vs. siete dias sin CPRE). Conclusion: en nuestra serie, los pacientes que precisaron una CPRE previa a la colecistectomia presentaron mayor morbilidad postoperatoria. Sin embargo, los pacientes que no precisaron CPRE presentaron mas complicaciones biliares y tuvieron reingresos mas tempranos. EnglishAim: the aim of this study was to assess the reasons for and the time of hospital readmissions after cholecystectomy, according to whether an endoscopic retrograde cholangiopancreatography (ERCP) was performed. Method: all patients that underwent cholecystectomy at the Service of Digestive Diseases and General Surgery of the Hospital Universitario de Guadalajara between January 2011 and December 2016 were retrospectively reviewed. Patients who underwent cholecystectomy and were readmitted to any hospital service within 90 days of surgery were included. The following cases were excluded: patients that underwent cholecystectomy in combination with other procedures, an active oncological pathology at the time of cholecystectomy, admissions previously scheduled for another unrelated pathology and those with tumor histology in the cholecystectomy specimen. Results: of a total of 1,714 patients, 80 were readmitted within 90 days of discharge after cholecystectomy, which equates to a readmission rate of 4.6%. The performance of an ERCP prior to surgery was associated with an increase in postoperative morbidity (40% vs 21.54%). A prior ERCP reduced the rate of biliary complications during the 90 days after cholecystectomy. Furthermore, there was an increase in the number of days prior to readmission in these cases, with a mean period of 22 days with ERCP vs seven days without ERCP. Conclusion: patients in our series who required an ERCP prior to cholecystectomy had a greater postoperative morbidity. However, those that did not require ERCP had more biliary complications and were readmitted earlier.

Objectives This study aimed to identify factors that explain the association of intraductal papillary mucinous neoplasms-pancreatic neuroendocrine tumors (IPMNs-PNETs), radiological characteristics, and factors that might guide therapy. Methods We performed a systematic review of the literature to search for articles on concurrent IPMN-PNET, mixed endocrine-exocrine pancreatic tumors, and/or PNET with an intraductal growth pattern. Results A review of the literature suggests that there is some confusion about association of IPMNs-PNETs. Regarding this association, the studies collected data from 32 patients. Eleven patients presented concurrent tumors, 9 mixed endocrine-exocrine tumors, and no data were available in the remaining 7. In addition, the relationship IPMN-PNET focuses not only on the coexistence of the 2 lesions, but also on the possibility of the intraductal growth of the endocrine lesion. In the literature, in 4 cases, the preoperative radiological diagnosis had been IPMN. Conclusions Intraductal papillary mucinous neoplasms and PNETs may be associated in a number of scenarios. The association may be due to the concurrent existence of independent lesions, may be a mixed endocrine-exocrine tumor, or may be due to intraductal growth of the endocrine lesion. But the literature is confusing. It is not known whether the association is accidental or whether there is an etiological reason. Further studies are needed to investigate this scenario.

To perform a retrospective analysis of a series of complicated JID (jejunoileal diverticulitis) cases surgically treated in our service during the period from 2002 to 2015.We treated 12 cases of jejunoileal complicated diverticulosis. 7 women and 5 men. The mean age was 76 years. The clinical presentation in all cases was acute abdominal pain, one with gastrointestinal bleeding. All cases had leukocytosis, neutrophilia and increased acute phase reactants. All patients underwent emergency abdominal CT.In 11 cases, there was consistency between imaging studies and surgical findings. Diverticula were located: jejunum (9) and ileum (3). Urgent exploratory laparotomy was always done and findings were: diverticular perforation with peritonitis (7 cases), diverticular perforation with abscess (4 cases) and in one case an ischemic area with diverticular perforation after embolization. Intestinal resection and anastomosis was performed in all cases. There were no patients, in which the diagnosis of diverticulosis jejunoileal was previously known. Complications were: Clavien I (2), Clavien IIIa (1), Clavien IVb (1), Clavien V (1).Jejunoileal diverticulitis is a rare entity, usually the first sign of onset of diverticular disease not previously known. Abdominal CT is of great diagnostic value. Resection of the affected segment is the treatment of choice.